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IntroductionOptical coherence tomography (OCT) aided pre-procedural measurement of lumen and vessel dimensions has the potential to enhance accurate stent sizing and improve clinical outcomes. We aimed to investigate the impact of stent sizing as per the criteria used in the ILUMIEN IV randomized trial in unselected patients undergoing coronary stenting at high volume tertiary care centres. Our secondary objective was to test if correct stent sizing also associates with lower incidence of follow-up major adverse cardiovascular events (MACE) in unselected real-world cohortsMethodsAll consecutive lesions (and cases) undergoing pre-PCI OCT in native coronary arteries (with significant, de-novo/restenotic, obstructive lesions requiring stenting) and received stent/stents between 2012 to 2018 at 5 high volume European centres were retrospectively included. Sizing analysis was performed as per the criteria used in the ILUMIEN IV randomized trial. Ideal stent size was determined from the algorithm and compared with the stent size implanted. MACE during follow-up was defined as a composite of all-cause death, myocardial Infarction, target lesion revascularization and stent thrombosis.ResultsA total of 178 patients were include with 193 treated lesions. Mean age was 65.1±11.2 years, 82.6% were male. A total of 11.8% of the included lesions were restenotic, 21.2% had a major bifurcation, while 26.4% had moderate to severe calcification; 63.7% of treated lesions were complex in nature (type B2/C). Mean number of stents/scaffolds implanted per lesion was 1.16±0.43. A total of 86.0% of lesions were stented with conventional drug eluting stents, 13.0% were stented with bioresorbable vascular/resorbable magnesium scaffolds. Maximum stent/scaffold diameter used was 3 (3.00, 3.50) mm while total stented length was 15 (15, 24) mm. Stent overlap was observed in 18.1% of lesions and 60.1% of lesions received post-dilation. 138 (71.5%) lesions also had post-intervention OCT available for stent expansion index (SEI) assessment. Amongst 193 lesions analysed for sizing: 78 (40.4%) lesions were correctly sized for stents; 68 (35.2%) lesions were undersized; 47 (24.4%) lesions were oversized. SEI was marginally higher in correctly/oversized lesions as compared to the undersized lesions (0.78±0.13 vs. 0.77±0.10, p= 0.69). At a median of 604 (234, 1,098) days MACE incidence in correctly sized group was 7.7%, in undersized group was 10.3% and in oversized group was 16.7%. Kaplan-Meier plots for cumulative MACE free log survival in three sizing groups is displayed as figure 1.Abstract 10 Figure 1Kaplan-Meier plots for cumulative MACE free log survival in three sizing groupsConclusionsThe present real-world data highlights the fact that less than half of treated lesions are being correctly sized for stents during PCIs. MACE-free survival during follow-up of correctly sized lesions seem to be marginally better highlight the potential impact of OCT based correct sizing during PCI. This warrants further investigations with larger unselected cohorts in order to establish a definitive benefit in terms of event reduction during post PCI follow-up.

BackgroundUrgent revascularisation is important in patients with ST-elevation myocardial infarction (STEMI) and is associated with better outcomes. Guidelines suggest that for patients who are likely to be treated within 120 minutes of diagnosis, primary percutaneous coronary intervention (PPCI) should be the preferred treatment. Those for whom this is unlikely should be treated with a pharmaco-invasive strategy. We aimed to compare survival in patients treated with timely PPCI (within 120 mins), delayed PPCI (>120mins), or a pharmaco-invasive strategy (t-PA) amongst an Irish population.MethodsPatients were identified from the Irish national acute coronary syndrome (ACS) registry. Ethical approval and a consent declaration were obtained to access data. All-cause mortality was determined using multiple source surveillance using central death notification and publicly accessible online death notifications. Proximity from home address to the nearest PPCI centre was determined using Google Maps. Statistical analyses were performed using Stata.Results7,486 STEMI patients were identified from January 2013 – March 2018. 6,612 were included in the analysis. Minimum follow up was 3 years, median follow up was 5.5 years. 4,040 received timely PPCI, 2,162 delayed PPCI, 335 t-PA. Baseline characteristics are shown in table 1. There was no difference in survival between the timely PPCI (84.7%) and t-PA groups (84.2%) (HR 0.93, 95%CI 0.71–1.25; Log-Rank p=0.62). There was increased mortality in the delayed PPCI (80.6%) in comparison with both timely PPCI (HR 1.5, 95%CI 1.16–1.49; Log-Rank p<0.000) and t-PA groups (HR 1.23, 95%CI 0.93–1.66; Log-Rank p=0.16), figure 1, 2.Abstract 11 Table 1P values in comparison to Pharmaco-invasive group Timely PPCI(n = 4,040) Delayed PPCI(n = 2,162) Pharmaco-Invasive(n = 335) % Male 78.8 (p=0.07) 77.3 (p=0.47) 75.5 Mean Age 61.8 (p=0.07) 63.1 (p=0.36) 62.8 % Aged ≥75 17.1 (p=0.08) 21% (p=0.88) 20.9% Proximity to PPCI Centre 37.3km (p<0.00) 68.1km (p<0.00) 140.7km Live >100km from PPCI 9% (p<0.00) 27.8% (p<0.00) 73.7% % Out-of-hours 64.7% (p<0.00) 63.8% (p<0.00) 74.9% Mean ECG to Reperfusion 78.2 min (p<0.00) 221.8min (p<0.00) 55.3 min Smoker 42.4% (p=0.96) 46.4% (p=0.82) 42.6% DM 11.3% (p=0.03) 13.8% (p=0.41) 13.7% Abstract 11 Figure 1Survival post STEMI by treatment modalityAbstract 11 Figure 2Survival of Pharmaco-invasive vs delayed PPCI (Enlarged, Scale begins at 0.8)ConclusionPatients who were treated with a pharmaco-invasive strategy had lower all-cause mortality on long term follow up versus those who received PPCI outside of the target treatment window. Given the high proportion of patients who received delayed PPCI (33%), consideration should be given to expanding a pharmaco-invasive approach to patients who are unlikely to receive timely PPCI.

IntroductionRegadenoson is a highly selective adenosine A2 receptor blocker. It induces profound coronary vasodilation, without significant atrioventricular block or bronchoconstriction, enabling sustained uptake of radioisotopes for up to 30 minutes to enable myocardial perfusion imaging (MPI). However, its effect on the QTc interval remains uncertain with previous literature reporting mixed results.MethodsDuring the covid-19 pandemic, as the use of aerosol-generating procedures including exercise stress tests was restricted, an increase in MPI use was seen in our centre, and we thus undertook a prospective evaluation of the effect of Regadenoson on QTc. Consecutive patients were enrolled (n=34) between October 2021 and February 2022. Patients with QTc >460ms at baseline or a paced rhythm were excluded from the study. QTc was measured from a 12-lead ECG at baseline, immediately after Regadenoson and radioisotope were administered intravenously via a brachial vein (t=40secs), and then at 2-minute intervals from the start of Regadenoson administration until any QTc prolongation (if present) had resolved.ResultsMedian baseline QTc was 425 ms (range: 389 ms – 460 ms, figure 1). Median QTc at peak prolongation (observed at 40 secs in 32 patients and 4 mins in 2 patients) was 477 ms (range 434 ms - 545 ms) including, of note, 4 (11%) patients with QTc prolongation >500ms. The median time for QTc to return to ≤460ms was 4 mins (2 mins - 32 mins). No significant side effects or dysrhythmias were reported.Abstract 8 Figure 1Peak QTc prolongation at baseline vs post-regadenoson administrationConclusionRegadenoson administration was well tolerated by patients. As a result of the QTc prolongation of >500ms seen in some patients, albeit with the absence of dysrhythmia, regadenoson administration should be undertaken by experienced staff in an appropriate clinical setting. However, more research is needed to ascertain with greater accuracy the average QTc prolongation of Regadenoson, as it shows promise as a potential agent where exercise is either not possible or not permitted due to restrictions.

IntroductionCalcified coronary artery disease continues to present significant challenges when performing percutaneous coronary intervention. Recently, intravascular lithotripsy (IVL) has been introduced into the interventionalist’s armamentarium. The safety and efficacy of IVL has been shown in non-randomized studies. IVL was introduced to Galway University Hospital in 2018. Analysis of patient outcomes in our real-world population has never been performed. We aimed to describe the patient characteristics, procedural aspects and short-term outcomes of patients undergoing calcium modification with IVL in our tertiary referral centre.MethodsThis is a single centre retrospective cohort study including all patients who underwent calcium modification using IVL in a single tertiary referral centre. Patients >18 years undergoing IVL treatment from December 2018 to April 2023 were eligible for inclusion. Patient demographics, procedural data, in-hospital outcomes and follow-up were obtained from the patient’s electronic health record and recorded in a dedicated database.ResultsA total of 141 patients underwent IVL in UHG during the study period. Most were male (80.14%) with a mean age 72.4 +/- 9.04 years. High rates of cardiovascular risk factors were noted including hypertension 81.6%, hyperlipidaemia 73%, diabetes 34.8% and smoking history 57.8%. The left anterior descending artery was most commonly treated (60, 42.5%), followed by the right coronary (34, 24%), left circumflex (20, 14%). Eighteen procedures involved IVL to the left main stem (12.7%). IVL was used to treat instent restenosis in 28 cases (19.86%). 47.5% of patients were treated with IVL in the context of an acute coronary syndrome. Procedures were guided by intravascular imaging in 55 patients (39%). Predilation was performed in 92.2%. One IVL balloon was used in 96.5% of cases with only 5 requiring 2 IVL balloons. The median number of pulses delivered was 60 [IQR 40–80]. Twenty patients (14.2%) undergoing IVL for ISR were treated with drug coated balloons. Of the remainder, the median number of stents implanted was 1 [IQR 1–2] and the median stented length was 30mm [IQR 20–41]. Postdilation was performed following stenting in 94%. Procedural complications occurred in 7 patients (5%) including contained perforation 0.7%, slow flow 1.4%, side branch loss 2.1% and conduction abnormalities requiring temporary pacing wire 0.7%. One in-hospital death occurred (0.7%) due to sepsis and multi-organ failure. At 6-months follow up, freedom from all-cause mortality was 92.5% (figure 1A). Subgroup analysis demonstrated no difference in all-cause mortality in diabetics versus non-diabetics or in those with chronic kidney disease (figures 1B and 1C).Abstract 10 Figure 1Freedom from all-cause mortality at 6 months in patients undergoing calcium modification using IVL (figure 1A), Freedom from all-cause mortality at 6 months in diabetics versus non-diabetics undergoing IVL therapy (figure 1B), Freedom from all-cause mortality at 6 months in patients with chronic kidney disease versus those with normal kidney function (figure 1C)ConclusionIVL is a recently introduced calcium modification technique. Our data represents a large real-world cohort of consecutive patients treated with IVL at a tertiary referral centre. Our results support current data suggesting the safety and efficacy of IVL. A low procedural complication rate was noted with encouraging short-term outcomes. Further work is required to compare outcomes to other calcium modification techniques and understand appropriate complementary techniques to IVL therapy.

IntroductionCatheter ablation (CA) for symptomatic atrial fibrillation (AF) offers the best outcomes for patients in terms of freedom from AF and carries a IA recommendation from the ESC for drug refractory symptomatic AF. Despite current best techniques a significant proportion of patients suffer a recurrence of atrial arrhythmias post CA, hence there is scope to potentially improve outcomes both in terms of technical aspects of the procedure as well as patient selection. Ablation Index TM (AI, Biosense Webster, Inc., Diamond Bar, CA, USA) is one such technical innovation, it combines contact force, power and time to give a numerical value intended to guide operators in creating safe, durable and transmural ablation lesions. Although AI is widely used, little data has been published on the long-term results of AI guided pulmonary vein isolation (PVI). Here for the first time, we present real world 5-year follow-up data of AI guided PVI.MethodsWe performed a retrospective study of 123 consecutive patients who underwent AI guided PVI shortly after its introduction to routine practice starting in late 2016 at our centre (table 1). The study inclusion criteria were wide and allowed for both paroxysmal and persistent patients as well as PVI ‘plus’ procedures. Patients were excluded if not due to be followed at out centre, as were patients with prior cardiac surgery or left atrial ablation. Data was collected via the MPH AF Ablation Registry and ethical approval was given by the MMUH/MPH IRB. All statistical analyses were performed in R version 4.1.2.ResultsThe patients studied in this cohort tended to be older, with higher BMI, have greater CHA2DS2-VASc scores and larger left atrial sizes when compared to similar previously published cohorts, while gender balance and other characteristics were similar [1 – 3]. The probability of freedom from atrial arrhythmia at 1–5 years is as follows (number at risk in brackets): Year 1: 0.95(110), Year 2: 0.90(86), Year 3: 0.81(57) and Year 4: 0.70(31) (note the number at risk falls below 10% of the original cohort at 5 years). 54 (43%) of patients were on a class Ic/III anti-arrhythmic drugs (AAD) prior to ablation, only 10(8%) of patients continued their AAD after the blanking period (3 months). Table 2 describes the number of procedures; the lesions sets and other procedural details. 100% of patients achieved acute procedural success. 1.6% was the major complication rate (phrenic nerve injury, pericarditis requiring pericardiocentesis). Univariate and multivariate regression analysis were performed on the following covariates – age, gender, paroxysmal versus persistent AF, components of the CHA2DS2-VASc score, LA size as measured on CT and BMI. Age > 75 (p=0.013HR 2.8 CI 1.6–6.4) and BMI > 35 (p=0.02 HR 2.9 CI 1.2–7) were statistically significant independent predictors of recurrent AF. Notably there was no difference between paroxysmal and persistent AF types (figures 1 and 2).Abstract 9 Table 1Patient characteristics n 123 Male n (%) 92 (74.8) Age, mean (SD) 65.35 (9.87) Age Over 75, n (%) 18 (14.6) BMI, mean (SD) 28.78 (4.50) BMI over 35, n (%) 13 (10.6) Persistent AF, n (%) 60 (48.8) CHADSVASC Score, mean (SD) 2.11 (1.55) Heart Failure, n (%) 11 (8.9) Hypertension, n (%) 72 (58.5) Diabetes, n (%) 13 (10.6) Vascular Disease, n (%) 26 (21.1) Stroke or TIA, n (%) 7 (5.7) LA-AP in mm, mean (SD) 46.60 (7.45) LA-AP=Left atrial antero-posterior diameter measured by computed tomography. BMI=Body Mass Index. TIA=Transient Ischaemic Attack.SD = Standard deviation.Abstract 9 Table 2Procedural characteristics Procedure Count Patients (%) 1 96 (78.0) 2 24 (19.5) 3 2 (1.6) 4 1 (0.8) Mean # Procedures 1.25 Index Procedure: PVI Only 93 (75.6) PVI ‘Plus’ 30 (24.4) CTI 14 (37.8) Roof Line 10 (27.0) Posterior Wall Isolation 4 (10.8) Carina 3 (8.1) CFAE 1 (2.7) Slow pathway modification 1 (2.7) MIA (Ant) 2 (5.4) FAT 2 (5.4) RF Time (mean ± SD) 1759.7 ± 366.3 Fluoroscopy Time (mean ± SD) 6.7 ± 4.6 Fluoroscopy Dose (mean ± SD) 31.1 ± 34.3 Fluoroscopy DAP (mean ± SD) 281.9 ± 308.6 PVI = Pulmonary Vein Isolation. PVI Plus = refers to additional ablation lesions beyond isolation of the pulmonary veins (including roof line, PW = posterior wall box isolation, MIA = mitral isthmus ablation, CTI = cavotricuspid isthmus, CFAE = complex fractionated atrial electrograms, Slow pathway modification = in cases where patients were found to have an inducible SVT consistent with AVNRT.Abstract 9 Figure 1Kaplan Meier Survival Curves with 95% confidence intervals for Paroxysmal versus Persistent Atrial Fibrillation. An initial trend of better outcomes in paroxysmal AF does not continue beyond 2 years. Overall survival curves are not statistically different. + denotes censorAbstract 9 Figure 2Kaplan-Meier Survival curve showing 5-year atrial arrhythmia free survival of all patients versus those aged > 75 or with a BMI >35– these subgroups were found to have statistically significant different survival curves in comparison to other patients (p<0.05). (+ denotes censor)ConclusionAblation index guided pulmonary vein isolation is a safe and effective treatment for atrial fibrillation with 95% of patients remaining free from atrial arrhythmia at one year and with a low major complication rate 1.6%. Even with high success rates, challenges remain and in this series age > 75 and BMI > 35 were associated with higher recurrence rates.

Objectives: In recent years, there has been an increase in suicide rates in Brazil. From 2015 to 2019 we had a 34% increase in self-inflicted deaths. Are there some subgroups at greater risk of suicide, such as the old people with Alzheimer’s disease? Methods: The data were obtained by consulting the systems of the Brazilian Institute of Geography and Statistics (IBGE) of the Brazilian Ministry of Health (DataSUS). Population data were measured and compared in the years 2010 and 2022, using the last two censuses. Results: Between 2010 and 2022, the number of registered deaths of patients with Alzheimer’s increased by 21.93%. Similarly, there was a 100.37% increase in suicides among the elderly population in the same period, compared to a 37.78% increase in the general population. Conclusions: It is not possible to conclude that the increase in suicide among the elderly is directly linked to Alzheimer’s disease. However, further studies are needed to determine if there is a correlation.

Objectives: The increase in suicidal behavior in patients treated with promising new drugs for Alzheimer’s disease is a dilemma that deserves to be understood. The correlations between suicide and neurodegenerative disorders have been debated for decades in the context of ethics, considering that many people with cognitive decline have opted for euthanasia. The academic community is invited to pay greater attention to issues other than ethics that can improve the quality of life of people with dementia. Methods: We sought to read the review articles on Pubmed on the topic over the last two decades to identify possible factors that are correlating suicide with Alzheimer’s Disease. The data were grouped and presented to demonstrate possible studies that should be carried out to clarify the topic better. Results: Depression and the presence of the E4 allele of Apolipoprotein E were the main correlation factors between Alzheimer’s disease and suicide. Conclusions: Targeted studies are needed to understand better the occurrence of depression in Alzheimer’s disease, as well as the role of the E4 allele in mood disorders and suicidal behavior.

Background: There are no approved treatments for Alzheimer’s disease psychosis (ADP). Xanomeline, a brain- penetrant M1/M4 preferring muscarinic receptor agonist, showed antipsychotic efficacy in placebo-controlled trials in subjects with AD [Bodick NC et al. 1997; DOI: 10.1001/archneur.1997.00550160091022]. Despite promising efficacy, further development of xanomeline was limited by cholinergic adverse events. The investigational antipsychotic xanomeline and trospium combines xanomeline with trospium, an FDA-approved muscarinic receptor antagonist that does not measurably cross the blood-brain barrier. Trospium acts to mitigate the peripheral procholinergic side effects of xanomeline, providing a strategy for using xanomeline to stimulate brain muscarinic receptors with a decreased side effect burden. Unlike available antipsychotics, xanomeline and trospium have no direct dopamine D2-blocking activity, and as such, its safety and tolerability profile is different. Methods: The phase 3 ADEPT-1 trial is a double-blind, flexible-dose, placebo-controlled randomized withdrawal study to evaluate the safety and efficacy of xanomeline and trospium in decreasing the risk of relapse in subjects with ADP. Subjects aged 55-90 years with moderate to severe psychosis associated with mild to severe AD (Mini- Mental State Exam score range 8-22) will be enrolled into the study. Subjects will receive single-blind xanomeline and trospium for 12 weeks. Each subject will be flexibly titrated to the maximum dose of xanomeline and trospium 200 mg xanomeline/20 mg trospium/day. At the end of the single-blind treatment, eligible responders will be randomized to either continue xanomeline and trospium or be switched to matched placebo for a 26-week double- blind treatment period. A responder is defined as a subject with a ≥40% decrease (improvement) on the Neuropsychiatric Inventory- Clinician: Hallucinations + Delusions (NPI-C: H+D) score compared with baseline (day 1) and a Clinician Global Impression–Change (CGI-C) score of 1 or 2 (very much improved or improved). Results: The primary endpoint of the study, time from randomization to relapse during the double-blind, randomized withdrawal treatment, will be evaluated by survival analysis using Kaplan-Meier Methods. The study started in August 2022 and will randomize approximately 200 subjects. Conclusions: The trial design of the ADEPT-1 study is an efficient way to assess the potential for xanomeline and trospium to provide clinically meaningful benefit in preventing the return of ADP in patients who have responded to xanomeline and trospium.

Introduction and Objectives: The affected functional domains in patients with degenerative dementias serve as clues to trace with varying levels of certainty the underlying neuropathology (1) and the negative impact on their autonomy reveals part of the clinical diagnosis of the disease. Healthcare professionals often rely on tools that measure this functionality, allowing them to distinguish between mild cognitive impairment and actual dementia (FAQ (2), CDR(3)). According to the science fiction author Philip K. Dick, Kipple is a useless object like advertising cards, matchboxes after the last match has been used, yesterday’s newspaper wrapper, etc. Considering that the deterioration in the autonomy of dementia patients negatively impacts their connection with the environment, it is expected that the kipple around them will be few. The aim of this work is to create a low-cost, simple, and quick tool that allows the physician to measure the negative impact of the patient’s cognitive failures on their functionality.

Lamotrigine is an antiepileptic and mood stabilizing drug. Among its adverse effects, the induction of mania has been described. We present the case of a 59-year-old man diagnosed with epilepsy since youth, with perictal psychotic symptoms effectively treated with haloperidol. The patient was treated with lamotrigine for over five years and presented symptoms of mania after two years of receiving it at moderate doses and being free of seizures. The symptoms improved with the lamotrigine switch. Previous cases of lamotrigine-induced manic symptoms have been predominantly observed in individuals with mood disorders, with only a few reported in children undergoing treatment for epilepsy. Further studies are necessary to elucidate the potential risk factors and the neurobiological mechanisms.