Diabetes mellitus (DM) not only increases the probability of presenting atrial fibrillation (AF), but it is also a predictor of ischemic stroke included in scales such as CHA2DS2VASc. However, there is limited information on the association between glycated hemoglobin (HbA1c) levels and ischemic, embolic or hemorrhagic events in patients with pre-diabetes and AF. This study aimed to investigate whether the presence of pre-diabetes in patients with AF increases the risk of ischemic events, hemorrhagic events, myocardial infarction or death. We used data from the CardioCHUVI-AF registry, which included 18,285 patients with AF from a Galician health area between January 2014 and December 2019. Patients with valvular AF (n=376), with loss of follow-up (n=97), without information on baseline characteristics (n=48) and without data on HbA1c (12,473) were excluded. The final cohort consisted of 5,291 patients, 2,993 were non-diabetics (56.6%) and 2,298 with known diabetes (43.4%). This final cohort was classified according to HbA1c in diabetics if HbA1c is more than 6.5% (n= 1,546; 29.2%), pre-diabetics when HbA1c is between 5.7 and 6.4% (n =2,233; 42.2%) and non-diabetics if HbA1c was less than 5.7% (n = 1,512; 28.6%). Competing hazards regression analysis for non-fatal events (with death as the competing event) and conventional Cox regression for mortality were performed. 2,993 non-diabetic patients with AF and HbA1c data were followed for 4.1 ± 1.6 years. The mean age was 73.0 ± 9.9 years, 47.4% were women, the mean CHA2DS2VASc score was 2.9 ± 1.4 points, the mean HASBLED score was 2.5 ± 1.2 points, and 2,407 (80.4%) patients were under treatment with oral anticoagulants. In the Kaplan Meier curves, no was observed a higher rate of events in pre-diabetes patients in comparison with patients with normal glycemia. In the multivariate analysis, after adjusting for the CHA2DS2VASc and HASBLED scales, as well as for anticoagulant therapy, it was observed that pre-diabetes was not associated with an increased risk of mortality ( HR= 0.80; 95% CI, 0.60-1.08), ischemic stroke (HR= 0.99; 95% CI, 0.71-1.38), major hemorrhage (HR= 0.78; 95% CI, 0.60-1.02) or myocardial infarction (HR= 1.08; 95% CI, 0.65-1.79), compared with patients with normal glycemia. In our registry, non-diabetic patients with atrial fibrillation do not have a higher risk of events when their glycated hemoglobin is in the pre-diabetes range.

Abstract Background Atrial Fibrillation (AF) is common in elderly patients. Age ≥65 years is an independent thromboembolic risk factor in patients with AF and is an indication for the initiation of anticoagulant therapy based on CHA2DS2VASc scale. Despite this, it may be controversial to justify an arbitrary cut-off for a continuous variable to determine that risk. Objectives The primary endpoint was to assess whether the initiation of anticoagulation therapy in patients who were 65 years old prevents ischemic stroke events in low thromboembolic risk individuals at baseline (CHA2DS2VASc 0 points in male and 1 in women). Another aim was to evaluate whether there were differences in major bleeding events in this population. Methods We used data from the CardioCHUVI-AF registry that included 16202 patients with a diagnosis of AF from the Vigo Health Area between January 2014 and January 2018 Of these, 861 individuals (5.3%) had low embolic risk at baseline. Eight patients with Hypertrophic Cardiomyopathy, 26 with mechanical prostheses and 3 with mitral stenosis were excluded. Of the remaining 824 patients, 389 (2.4%) ceased to belong to this low embolic risk group due to age (≥65 years) during the follow-up period. Univariate analysis was performed with age ≥65 years to compare the incidence of ischemic stroke and major bleeding events in anticoagulated patients with those in non-anticoagulated patients. Results A total of 389 patients with a diagnosis of AF and initial low embolic risk were followed for 8.1±1.5 years (median 8.9, IQR 7.8-9.0 years). The mean age at the start of follow-up was 60.9±2.7 years. Before the age of 65, 187 patients (48.1%) were anticoagulated. A total of 261 patients were under anticoagulant treatment after turn to 65 years (67.1%, an increase of 19.0% in the rate of anticoagulation). Therefore, 32.9% of the individuals were not anticoagulated despite the fact that they had an indication at that time. In the Kaplan-Meier curves of our study population before reaching 65 years of age, no significant differences were observed in the rate of ischemic stroke events between anticoagulated and non-anticoagulated patients [HR, 1.22; 95%CI 0.41-3.64; p=0.718] or in the rate of major bleeding [HR 1.03, 95%CI 0.36-2.95; p=0.949]. However, in the same population that had already reached 65 years of age at the end of follow-up, statistically significant differences were observed in favor of anticoagulated patients in the incidence of ischemic stroke [HR 0.19, 95%CI 0.05-0.77; p=0.020] without an increase in the rate of hemorrhagic events [HR 0.85, 95%CI 0.32-2.27; p=0.745]. Conclusions Our registry highlights the dynamic nature of the CHA2DS2VASc scale based on age. Thus, patients with a CHA2DS2VASc score of 0 points (1 if they are women) who are close to 65 years should be evaluated periodically, starting anticoagulation therapy at that age.

Abstract Introduction Fibrosis-4 index (FIB-4 index), calculated by age, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and platelet count, is a simple marker to evaluate liver fibrosis. The FIB-4 index is associated with higher all-cause mortality in patients with heart failure (HF). However, the relationship between liver stiffness and atrial fibrillation remains unclear. Purpose The present study explores the impact of the FIB-4 index in the bleeding risk and heart failure hospitalizations among a large cohort of AF patients. Methods The Fibrosis-4 index (FIB-4) was applied to 10,530 patients diagnosed with AF from our health area between January 2014 and April 2020. Patients were analyzed in three regions of the Fib-4index based on the cutoff points (Group 1 F0<1.30, group 2 F1-F2:1.30–2.67 and group 3 F3-F4: >2.67). The outcome was a composite of major bleeding events and hospitalization for heart failure. The risk of the combined end-point was determined by competing risk regression. Results 4471 patients (42.5 %) were included in Group 1, 5139 (48.8 %) in Group 2 and 920 (7.4%) in Group 3. During a mean follow-up of 3.78±2.05 years, 1,834 patients died (17.49%), 2,359 had a heart failure hospitalization (22,42%) and 772 had a major bleeding (7.36%). The incidence of major bleeding and heart failure hospitalizations was significantly higher amongst group 3. In the univariate analysis, group 2 and group 3 were associated with increased risk of the combined outcome (Figure 1). Multivariate adjustment was developed including all those variables with clinical significance and those that had been associated in the univariate analysis. Group 3 was associated with higher increased risk of major bleeding and heart failure hospitalizations (sHR 1.21, 95% CI 1.05-1.39; P=0.007), whilst Group 2 not (1.06, 95% CI 0.97-1.16; P=0.169) in comparison with Group 1. Conclusions FIB4 index >2.67 was associated with higher risk of major bleeding and heart failure hospitalizations. FIB-4 index may reflect venous congestion and it could be an useful tool for predicting HF and major bleeding events in patients with AF.Figure 1

Clinical decision making on anticoagulation in patients with chronic kidney disease with atrial fibrillation (AF) is challenging. The current strategies are based on small observational studies with conflicting results. This study explores the impact of glomerular filtration rate (GFR) in the embolic-hemorrhagic balance among a large cohort of patients with AF. The study cohort included 15,457 patients diagnosed with AF between January 2014 and April 2020. The risk of ischemic stroke and major bleeding was determined by competing risk regression. During a mean follow-up of 4.29 ± 1.82 years, 3,678 patients (23.80%) died, 850 (5.50%) had an ischemic stroke, and 961 (6.22%) had a major bleeding. The incidence of stroke and bleeding increased as baseline GFR decreased. Interestingly, in GFR <30 ml/min/1.73 m2, the bleeding risk was clearly higher than the embolic risk. As GFR decreased, anticoagulation was associated with an increased bleeding risk (subdistribution hazard ratio 1.700, 95% confidence interval [CI] 1.13 to 2.54, p = 0.009 for patients with GFR 30 to 59 ml/min/1.73 m2 and 2.00, 95% CI 0.77 to 5.21, p = 0.156 for subjects with <30 ml/min/1.73 m2 compared with those with GFR >60 ml/min/1.73 m2, respectively), but it was not associated with a decrease in embolic risk in patients with GFR <30 ml/min/1.73 m2 (subdistribution hazard ratio 1.91, 95% CI 0.73 to 5.04, p = 0.189) In GFR <30 ml/min/1.73 m2, the increase of major bleeding risk was higher than the increase of ischemic stroke risk, with a negative anticoagulation balance (greater increase in bleeding than reduction in embolism).

BACKGROUND:Atrial fibrillation (AF) carries a thrombotic risk related to blood stasis in the left atrium. In patients with rheumatic valve disease and AF, the presence of severe mitral regurgitation (MR) has been shown to reduce the risk of atrial thrombosis and stroke. However, in patients without rheumatic disease, the results are controversial. AIM:To analyse the association between MR and the incidence of stroke in patients with non-rheumatic AF. METHODS:We analysed data from the retrospective CardioCHUVI-AF registry, which includes 15,720 patients with AF (without mechanical prostheses or rheumatic valvular disease) in the Vigo area of Spain, during 2014-2018. We grouped the patients according to MR grades: 0-2 (n=15,194) and 3-4 (n=526). We performed univariate and multivariable competitive risk analyses to analyse the association between MR and stroke, with death as the competitive event. RESULTS:During a median (interquartile range [IQR]) follow-up of 4.9 (2.8-4.9) years, 859 patients (5.5%) suffered a stroke. The stroke incidence was 1.3 per 100 person-years (95% confidence interval [95% CI]: 1.2-1.4), with no difference between the MR groups. In univariate analysis, no relationship was observed between MR grade and stroke (subdistribution hazard ratio [sHR]: 1.12, 95% CI: 0.79-1.60; P=0.53); likewise after multivariable analysis (sHR: 0.98, 95% CI: 0.68-1.41; P=0.90). This same relationship was evaluated in subgroups of interest (patients with and without: oral anticoagulation, CHA2DS2-VASc≥2, prior heart failure, aortic valve disease, left ventricular ejection fraction≤40%, and moderate-severe left atrial dilation), with results consistent with the overall population. CONCLUSION:In our large registry of patients with non-rheumatic AF, we did not find a protective effect of grade 3-4 MR on the risk of stroke.

Abstract Introduction Medical therapy in TakoTsubo Syndrome (TTS) remains mainly empirical, given the lack of randomized studies evaluating different pharmacological strategies. The prognostic benefit of angiotensin-converting-enzyme inhibitors and angiotensin II receptor blocker (ACEI/ARB) is not well established. The clinical data published so far are often based on small sample registries and offer opposite results, both in terms of survival and TTS recurrence. Expert recommendations seem favorable to the prescription of ACEI and ARB. Nevertheless, clinical investigation is encouraged for validating the observed results. Purpose The aim of our study was to evaluate the long-term prognostic impact of renin-angiotesin blockers (ACEI or ARB) in terms of mortality and TTS recurrence. Methods The data analyzed in this study were obtained from the nationwide registry “RETAKO”. It included TTS post-discharge survivors, between January 1, 2003, and July 31, 2018. A total of 1062 patients were included for analysis. Cox regression analysis and inverse probability weighting (IPW) propensity score analysis were performed to asses the prognostic benefit of ACEI/ARB. Primary endpoint was a composite outcome of all-cause mortality and TTS recurrence. Results A total of 1062 TTS patients were included. ACEI or ARB were used in 639 patients (60.2%). During a mean follow-up of 2.7±3.5 years, there were 101 deaths (3.9 per 100 patients/year) and 34 recurrences of TTS (1.3 per 100 patients/year). We found no significant difference in follow-up mortality or TTS recurrence in unadjusted and adjusted Cox regression analysis (Hazard Ratio [HR] 0.69, 95% Confidence Interval [CI] 0.47–1.02) between patients treated and untreated with ACEI/ARB. After performing propensity score matching, differences in long term prognosis (all-cause mortality or recurrence) remained no statistically significant (HR 0.73, 95% CI 0.45–1.18). Conclusions In this observational study, we found that ACEI and ARB therapy was not significantly associated with improved long term survival free of recurrence in post-discharged TTS patients. Funding Acknowledgement Type of funding sources: None. Incidence of primary endpoint

Abstract Introduction A protective effect of obesity has been previously reported in patients with atrial fibrillation (AF) – the so-called `obesity paradox”. Nutritional status could behave as a confounding factor, but there are no studies that analyze the interaction of malnutrition in the relationship between obesity and mortality in AF patients. Aim The objective of this study was to determine the impact of nutritional status on the relationship between body mass index (BMI) and mortality in AF patients. Methods A retrospective, multicenter, population-based cohort study of patients with diagnosis of AF from January 1, 2014 to December 31, 2017, in Vigo, Spain, was conducted. We created three separate groups according to BMI (normal-weight, overweight, and obesity) and three separate cohorts based on nutritional status according to CONUT score (good nutrition, mild malnutrition, and moderate-severe malnutrition). The primary outcome was all-cause mortality. Secondary outcomes included embolic events (systemic embolism and stroke) and major bleeding. A combined endpoint of mortality, embolic and haemorrhagic events was assessed (clinical net outcome). Results A total of 14,849 AF patients aged ≥75 years (75.6±10.3 years, 50.9% women) were followed-up during 44.4±1.8 years. Overweight and obesity was observed in 42.6% and 46.0%, respectively, whereas malnutrition was observed in 34.3%. Malnutrition rates were lower as BMI increased: from 48.1% in patients with underweight, to 36.8%, 35.1% and 33.0% in patients with normal weight, overweight, and obesity, respectively (p-value <0.001 for the trend). BMI was inversely associated with mortality (HR 0.96, 95% CI 0.95–0.97; p<0.001) in the univariate analysis; however, this association was lost when adjusted analysis by nutritional status was performed (HR 0.99, 95% CI 0.99–1.00; p=0.285). Thus, neither overweight nor obesity were predictors of mortality nor net outcome when we adjusted by nutritional status: after stratifying for presence of malnutrition, survival of patients with a BMI>25 kg/m2 was similar to that of patients with BMI ≤25 kg/m2. Regarding to nutritional status, both mild and moderate-severe malnutrition were associated with higher rates of mortality, stroke/systemic embolism and bleeding in all BMI groups (normal-weight, overweight and obesity). In this real-world observational study, we have assessed the interaction of nutritional status in the association between BMI and prognosis of AF patients. We concluded that 1) Malnutrition is common in AF patients, even among patients with overweight and obesity; 2) Malnutrition is a strong predictor of mortality in patients with AF; and 3) BMI was not associated with worse prognosis after adjusting for nutritional status. Conclusion The analysis of a large population of AF patients showed that the association between improved mortality and obesity/overweight is confounded by malnutrition status. Funding Acknowledgement Type of funding sources: None. Impact of nutrition status and weightClinical outcomes in different groups

There is an important relationship between atrial fibrillation (AF) and contrast induced nephropathy (CIN). Several hypotheses were suggested to explain this unidirectional association between CIN and AF, like influence on renin-angiotensin-aldosterone system and the inflammatory pathway, as well as the use of iodinated contrasts -due to its possible interaction at the thyroid hormone regulation-. The aim of this study was to analyze the relation between contrast volume and the subsequent development of AF in patients with acute coronary syndrome (ACS) A total of 6,133 ACS patients underwent PCI between 2010 and 2016 were analyzed. We have excluded 1,896 patients with prior history of AF, without data about contrast volume or with missing data about follow-up. The impact of contrast volume in the development of AF was assessed by Cox regression analysis. Hazard Ratios (HR) with 95% of confidence interval (CI) were reported. Maximum allowable contrast dose (MACD) was defined as 5*body weight/serum creatinine. From the total study population (4,237 patients, 64.3±12.8 years, 24.2% women), 399 (9.4%) developed AF during a mean follow-up of 3.5±2.4 years. Mean contrast volume used was 199.9±90.3 ml. Contrast volume was not associated with follow-up de novo AF (HR 0.99, 95% CI: 0.99–1.00; p=0.834). However, the ratio between contrast volume used and the maximum allowable contrast dose (CV/MACD) resulted a predictor of follow-up AF (HR 1.18, 95% CI: 1.02–1.37, p=0.027). The cumulative incidence of AF was 2.7 per 100 patients/year in patients with CV/MACD ≤1 and 4.8 per 100 patients/year in patients with CV/MACD >1. After adjusting for those variables associated with follow-up AF in the univariate analysis, the use of a contrast volume higher than MACD resulted an independent predictor of AF (HR 1.40, 95% CI: 1.03–1.89; p=0.032). Doses of contrast volume higher than the maximum allowable contrast dose were independently associated with higher rates of AF during the follow-up. Cumulative incidence of AF by groups Type of funding source: None

Abstract Introduction Information comparing left atrial appendage closure (LAAC) to direct oral anticoagulation therapy (DOAC) is scarce. Purpose Our aim is to compare the clinical outcomes between LAAC and DOACs of an elderly population (over 80 years-old). Methods We retrospectively collected 1144 patients with atrial fibrillation over 80 years old from three different tertiary hospitals. 970 patients have received DOACs and 174 patients have undergone LAAC. We have performed a propensity score matching analysis (PSM), with a caliper of 0.2. After propensity score with matching analysis, 58 patients received DOACs alone and 58 patients treated with LAAC with similar baseline risk factors, comorbidities and risk scores were selected. Outcomes of DOACs and LAAC were assessed by Cox regression. Results Both groups had similar cardiovascular risk factors with more proportion of diabetic and hypertensive patients among LAAC group (37.4% and 90.2%, respectively vs 20.3% and 70.3%). Patients undergoing LAAC had more frequently history of bleeding, anemia or previous cancer. CHA2DS2VASC score was also significantly higher in these patients. During a median follow-up of 2.0 years (range 0.9–3.5) event rate for the combined endpoint of death, bleeding and embolic events was 24.9%. 81 embolic events were recorded (27 patients had transient ischemic attacks and 52 were diagnosed of stroke and only 2 patients with pulmonary embolism and 2 more with peripheral embolic events). 131 bleedings were recorded with 1,5% of intracranial bleeding. After propensity score matching, no differences regarding the primary composite endpoint were found (HR 1.05, 95% CI 0.15–7.51; p=0.955). Bleeding events were more frequent in LAAC group, especially during the first three months, thereafter rates become similar in both groups with no statistically significant differences (HR 1.79, 95% CI 0.73–4.41; p=0.205) (Figure 1). We calculate the time to first bleeding for LAAC 0.9±1.3 vs 1.7±1.3 on DOACs. Mortality was numerically greater in patients on DOACs (31,8%) vs LAAC (26,4%). However, this finding did not reach statistical significance (HR 0.70, 95% CI 0.33–1.47; p=0.343). Conclusions LAAC has no differences in terms of embolic events, bleeding events and mortality compared to DOACS in a population of elderly patients over 80 years-old. In our population, LAAC is a strategy as safe and effective as DOACs and represents an alternative to consider in real life patients older than 80 years. Figure 1 Funding Acknowledgement Type of funding source: None

Abstract Background Tako-tsubo Syndrome (TS) seems to be associated with a catecholamine-mediated mechanism. However, the impact of beta-blockers (BB) in-hospital and after discharge still remain uncertain. Objectives: The purpose of the study was to examine whether BB use after discharge in patients with TS, was associated with lower long-term mortality and recurrence. Methods Using a national multicentre large-scale inpatient database (RETAKO Registry), we analysed patients with a definitive TS diagnosis. Results A total of 970 patients were analysed (568 with BB therapy and 402 no-BB therapy). After discharge and over a median of follow-up of 1.1 years, treatment with BB have no shown prognostic effectiveness in terms of mortality and TS recurrence in unadjusted and adjusted Cox analysis (HR 0.86; 95% CI: 0.59 to 1.27; and 0.95; 95% CI: 0.57–1.13, respectively). Conclusions This data suggests that use of beta-blockers after hospital discharge has not shown long-term prognostic benefit in patients with Tako-tsubo Syndrome. Prognostic impact of BB in TS. Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Retako webpage was funded by a non-conditioned Astrazeneca scholarship.

Abstract Introduction Peripheral artery disease (PAD) is associated with heightened ischemic and bleeding risk in patients with acute coronary syndrome (ACS). With this study from real-life patients, we try to analyze the balance between ischemic and bleeding risk during treatment with dual antiplatelet therapy (DAPT) after an ACS according to the presence or not of PAD. Methods The data analyzed in this study were obtained from the fusion of 3 clinical registries of ACS patients: BleeMACS (2004–2013), CardioCHUVI/ARRITXACA (2010–2016) and RENAMI (2013–2016). All 3 registries include consecutive patients discharged after an ACS with DAPT and undergoing PCI. The merged data set contain 26,076 patients. A propensity-matched analysis was performed to match the baseline characteristics of patients with and without PAD. The impact of prior PAD in the ischemic and bleeding risk was assessed by a competitive risk analysis, using a Fine and Gray regression model, with death being the competitive event. For ischemic risk we have considered a new acute myocardial infarction (AMI), whereas for bleeding risk we have considered major bleeding (MB) defined as bleeding requiring hospital admission. Follow-up time was censored by DAPT suspension/withdrawal. Results From the 26,076 ACS patients, 1,600 have PAD (6.1%). Patients with PAD were older, and with more cardiovascular risk factors. DAPT with prasugrel/ticagrelor was less frequently prescribed in patients with PAD in comparison with the rest of the population (8.2% vs 22.8%, p<0.001). During a mean follow-up of 12.2±4.8 months, 964 patients died (3.7%), and 640 AMI (2.5%) and 685 MB (2.6%) were reported. After propensity-score matching, we obtained two matched groups of 1,591 patients. Patients with PAD showed a significant higher risk of both AMI (sHR 2.17, 95% CI 1.51–3.10, p<0.001) and MB (sHR 1.51, 95% CI 1.07–2.12, p=0.018), in comparison with those without PAD. The cumulative incidence of AMI was 63.9 and 29.8 per 1,000 patients/year in patients with and without PAD, respectively. The cumulative incidence of MB was 55.9 and 37.6 per 1,000 patients/year in patients with and without PAD, respectively. The rate difference per 1,000 patient-years for AMI between patients with and without PAD was +34.1 (95% CI 30.1–38.1), and for MB +18.3 (16.1–20.4). The net balance between ischemic and bleeding events comparing patients with and without PAD was positive (+15.8 per 1,000 patients/year, 95% CI 9.7–22.0). Conclusions PAD was associated with higher ischemic and bleeding risk after hospital discharge for ACS treated with DAPT. However, the balance between ischemic and bleeding risk was positive for patients with PAD in comparison with patients without PAD. As summary, ACS patients with PAD had an ischemic risk greater than the bleeding risk.

Abstract Background CHA2DS2-VASc Score is widely used to predict thromboembolic risk in patients with Atrial Fibrillation (AF). We ought to study if this score predicts outcomes in elderly patients with Non ST-segment Elevation Myocardial Infarction (NSTEMI). Methods The multicenter LONGEVO-SCA prospective registry included 532 unselected patients with NSTEMI aged ≥80 years. Data to calculate CHA2DS2-VASc Score were available in 523 patients (98.3%). They were classified according to CHA2DS2-VASc Score: group 1 (score 0–4), and 2 (5–9). We studied outcomes in terms of mortality or readmission at 6 months follow-up. Results A total of 266 patients (51%) had a high CHA2DS2-VASc Score (group 2). They were more often women, with more cardiovascular risk factors like hypertension or diabetes mellitus, and history of previous stroke and cardiovascular disease and heart failure (all, p=0.001). Geriatric syndromes (Barthel Index, Lawton Brody, cognitive impairment and frailty) and Charlson index were worse in this group (all, p=0.001). They had poorer clinical status on admission, with worse Killip class and lower left ventricle ejection fraction (all, p=0.001), and developed new onset AF more often during admission (12.4% vs. 6.6%, p=0,024). At six months follow-up, patients in group 2 had higher reinfarction, all cause mortality, and mortality or readmission rates (all, p=0.001). (Table) A CHA2DS2-VASc Score >4 predicted mortality (HR 2,60 [95% CI 1,48–4,55], p<0,001) (Figure 1) and was associated with mortality or readmission at 6 months (HR 2.07 [CI 95% 1.51–2.84], p<0.001). CHADS VASC2 0–4 (n=257) CHADS >4 (n=266) p Geriatric syndromes Barthel Index 94 (13) 85 (22) 0.001 Lawton brody 6.2 (2) 4.9 (3) 0.001 Charlson Index 1.5 (1) 3.3 (2) 0.001 Cognitive impairment 0.001 No 201 (79.1) 155 (58.7) Mild 49 (19.3) 100 (37.9) Severe 4 (1.6) 9 (3.4) Nutritional risk (MNA-SF*) 122 (48) 149 (57.1) 0.040 Frailty (FRAIL scale) 0.001 Non-frail 111 (43.2) 69 (25.9) Prefrail 102 (39.7) 101 (38) Frail 44 (17.1) 96 (36.1) Outcomes at 6 months Reinfarction 26 (6.9) 16 (13.9) 0.018 Mortality or readmission 111 (28.9) 60 (50.4) 0.001 All cause mortality 38 (9.9) 24 (20.2) 0.003 Conclusions A CHA2DS2-VASc sore>4 is present in half of octogenarians with NSTEMI and is associated with a poor outcome.

Abstract Introduction Even though left ventricular ejection fraction (LVEF) is a well-documented strong predictor of mortality after an acute coronary syndrome (ACS), its differential impact on the ischemic and bleeding risk of hemorrhage and ischemia is not well established. The aim of this study was to assess the impact of LVEF, measured by echocardiography, on the risk of acute myocardial infarction (AMI) and major bleeding (MB) after hospital discharge for ACS, during treatment with dual antiplatelet therapy (DAPT). Methods The data analyzed in this study were obtained from the fusion of 3 clinical registries of ACS patients: BleeMACS (2004–2013), CardioCHUVI/ARRITXACA (2010–2016) and RENAMI (2013–2016). All 3 registries include consecutive patients discharged after an ACS with DAPT and undergoing PCI. From the initial merged data set, that contained 26,076 patients, we have excluded those without data about LVEF. So the final cohort was composed by 20,518 patients. The impact of LVEF in the ischemic and bleeding risk was assessed by a multivariable competitive risk analysis, using a Fine and Gray regression model, with death being the competitive event. All those variables with statistical (p<0.05) or clinical significance for the association with AMI and MB were included in the analysis. Follow-up time was censored by DAPT suspension/withdrawal. Results During a mean follow-up of 12.2±5.2 months, 789 patients died (3.8%), 431 had an AMI (2.1%) and 537 had a MB (2.6%). The mean of LVEF was 53.2% ± 10.7%. Only 15.5% of patients had LVEF <40% (n=3,179). As the LVEF decreased, the risk of AMI increased, whereas the behavior of the risk of MB was more heterogeneous (Figure). After a multivariable adjustment, LVEF (as continuous variable) was significantly associated with AMI (sHR 0.98, 95% CI 0.98–0.99; p=0.010), but not with MB (sHR 1.00, 95% CI 0.99–1.01; p=0.270). After stratifying by LVEF groups (≥ vs <40%), we found an association between LVEF and AMI (sHR 1.40, 95% CI 1.10–1.76; p=0.005), but not between LVEF and bleeding (HR 0.85, 95% CI 0.67–1.08; p=0.185). Conclusions After an ACS, as the LVEF decreases, there is an increase in ischemic risk, but not in bleeding risk. A LVEF <40% was independently associated with higher risk of AMI, but not with higher risk of MB.

Abstract Introduction Anemia is strongly associated with increased risk of morbidity and mortality in patients after acute coronary syndromes (ACS). The aim of our study was to determine, after matching the baseline characteristics, the bleeding-ischemic risk profile during treatment with Dual Antiplatelet Therapy (DAPT) of patients with severe anemia (hemoglobin <10 g/dL) after an ACS undergoing Percutaneous Coronary Intervention (PCI). Methods The data analyzed in this study were obtained from the fusion of 3 clinical registries of ACS patients: BleeMACS (2004–2013), CardioCHUVI/ARRITXACA (2010–2016) and RENAMI (2013–2016). All 3 registries include consecutive patients discharged after an ACS with DAPT and undergoing PCI. The merged data set contain 26,076 patients. A propensity-matched analysis was performed to match the baseline characteristics of patients according to presence or not of severe anemia (hemoglobin <10 g/dL). The impact of severe anemia in the ischemic and bleeding risk was assessed by a competitive risk analysis, using a Fine and Gray regression model, with death being the competitive event. For ischemic risk we have considered a new acute myocardial infarction, whereas for bleeding risk we have considered major bleeding defined as bleeding requiring hospital admission. Follow-up time was censored by DAPT suspension/withdrawal. Results From the 26,076 ACS patients, 630 had severe anemia (2.4%). During a mean follow-up of 12.2±4.8 months, 964 patients died (3.7%), 640 had myocardial infarction (2.5%) and 685 had major bleeding (2.6%). After propensity-score matching, we obtained two matched groups (with hemoglobin < and ≥10 g/dL) of 621 patients. In comparison with patients without severe anemia, patients with hemoglobin <10 g/dL had similar risk of myocardial infarction (sHR 1.37, 95% CI 0.82–2.31, p=0.231) with higher risk of major bleeding (sHR 1.89, 95% CI 1.18–2.72, p=0.006). After propensity score matching, the cumulative incidence of myocardial infarction was 6 and 5 per 100 patients/year in patients with and without severe anemia, respectively, during DAPT. And the cumulative incidence of major bleeding was 12 and 6 per 100 patients/year in patients with and without severe anemia, respectively. The difference between myocardial infarction rate and major bleeding rate was −6 in patients with severe anemia (more bleeding than ischemic event rates; p<0.05) and −1 in patients with hemoglobin ≥10 g/dL (similar bleeding and ischemic event rates; p>0.05), per 100 patient-years (Figure). Conclusions After an ACS underwent PCI, during DAPT, the ischemic-bleeding balance of patients with severe anemia (hemoglobin <10 g/dL) is not favorable. In those patients, a short-term DAPT (<6 months) should be recommended.

MINOCA (myocardial infarction with non-obstructive coronary arteries) has been recently redefined by the last ESC guidelines. The aim of this study is to analyze clinical profile and long-term prognosis of these patients. Retrospectively, between 1/2010 and 12/2016 all consecutive patients with the definitive diagnosis of MI in tertiary center were included in this observational study. Patients with unstable angina with non-obstructive coronary artery disease and those who died in-hospital were excluded. Patients were stratified according to the number of significant coronary vessel disease seen by coronary angiography into: 0 (MINOCA); 1; 2; ≥3 vessels. The definition of MINOCA was based on dedicated the 2016 ESC Working Group position paper. Patients with MINOCA were compared to their counterpounds (MIOCA; MI with obstructive CAD) regarding baseline clinical characteristics, on-admission and laboratory data and treatment at hospital discharge. The prognostic meaning of MINOCA vs MIOCA was ascertained by comparing the composite endpoint (re-ACS, stroke and death) rate among groups, using Kaplan-Meier and multivariate Cox regression analyses. 13.8% (n=597) pts were classified as MINOCA. They were older and more frequently women than the obstructive group. MINOCA group also had a worse cardiovascular risk profile than pts with obstructive coronary lesions. They were associated more frequently with atrial fibrillation during hospitalization (11.2% vs. 6.8%, p<0.01). Peak of troponin I was lower in the MINOCA group [median 12 (IQR: 1.4–42.0 vs 20 (2.3–95.5), p<0.01]. MINOCA pts had more frequently a previous history of depression (34.1% vs 19.3%, p<0.01), and malignancy (9.2% vs. 7.6%, p=0.18). During 15 months (IQR: 12,3–25,5), 613 (14.2) pts had a new ACS, stroke or died (251 pts developed a new ACS, 81 had stroke, and 281 died). The incidence of the composite endpoint was 4.2% in the MINOCA pts, 4.1% in pts with 1-significant coronary vessel disease, 6.3% in the 2-significant coronary vessel disease, and 9.5% in the ≥3-significant coronary vessel disease (p<0.01) (Figure). After adjusting for age, ACS type, sex, Killip class, age, HTA, DM, stroke, peripheral artery disease, smoking, prior CAD, COPD, prior malignancy, baseline hemoglobin and creatinine values, DES vs BMS, history of atrial fibrillation, and treatment at discharge, and considering MINOCA as a reference group, HR for the composite endpoint was 1.02 (0.60–1.78; p=0.93) for the 1-vessel group, 1.3 (0.7–2.2; p=0.41) for the 2-vessels group, and 1.6 (0.93–2.8; p=0.08) for the ≥3-vessels group. Figure 1. Composite endpoint In the present cohort MINOCA was approximately found in one of each 14 patients admitted with MI. These patients had worse CV risk profile and more history of depression. MINOCA pts have similar prognostic impact in terms of hospitalization for a new ACS, stroke and death than the obstructive group.

Abstract Introduction Safety and efficacy of prasugrel and ticagrelor in real-life ACS (Acute Coronary Syndrome) with renal dysfunction remain to be established. Methods Consecutive patients from RENAMI and BLEEMACS were stratified according to renal function and estimated glomerular filtration rate (eGFR<60 mL/min/1.73 m2). Myocardial infarction (MI) and BARC major bleedings (MB; BARC type 3 or 5) were the primary end-point. Independent impact of clopidogrel, prasugrel and ticagrelor were evaluated with Cox multivariate analysis. Results 19255 patients were enrolled (mean eGFR: 90±39 ml/min/1.73m2). Patients with eGFR<60 mL/min/1.73m2, constituted the 12.9% of the population (2490 pts). After a mean follow up of 13±5 months, the global incidence of re-AMI was of 5.8% and 2.9% in patients with and in those without eGFR<60 mL/min/1.73m2 (p<0.0001) respectively. MB occurred in 5.7% and 3% (p<0.0001). At Cox multivariate analysis, clopidogrel compared to prasugrel and ticagrelor was associated with increased risk of MI both in those with eGFR>60 mL/min/1.73m2 (HR=3.3: 2.4–4.4, p<0.0001) as well as in patients with eGFR<60 mL/min/1.73m2 (HR=10.04: 3.1–32.3, p<0.0001). In contrast, both prasugrel (HR=0.07: 0.01–0.54, p=0.01) and Ticagrelor (HR=0.36: 0.16–0.81, p=0.01) were associated with decreased risk of MI in the latters. DAPT with ticagrelor or prasugrel did not increased risk of MB in patients with eGFR<60 mL/min/1.73m2, while in patients with eGFR>60 mL/min/1.73m2, ticagrelor was associated to a slightly higher risk of MB (HR=1.43: 1.09–1.89, p=0.009). Conclusion In ACS patients with eGFR<60 mL/min/1.73m2, prasugrel and ticagrelor are associated with lower risk of recurrent MI without significant increase in the risk of MB.