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Background Important disparities in the treatment and outcomes of women and men with atrial fibrillation are well recognized. Whether introduction of direct oral anticoagulants has reduced disparities in treatment is uncertain. Methods All patients who had an incident hospitalization from 2010 to 2019 with non-valvular atrial fibrillation in Scotland were included in this cohort study. Community drug dispensing data were used to determine prescribed oral anticoagulation therapy and comorbidity status. Logistic regression modelling was used to evaluate patient factors associated with treatment with vitamin K antagonists and direct oral anticoagulants. Results A total of 172,989 patients (48% women [82,833/172,989]) had an incident hospitalization with non-valvular atrial fibrillation in Scotland between 2010 and 2019. The proportion of patients with thromboembolic risk factors (CHA2DS2VASc score >0 in men and >1 in women) treated with oral anticoagulation therapy increased from 36.8% to 66.3% over this 10-year period. By 2019, factor Xa inhibitors accounted for 83.6% of all oral anticoagulants prescribed, while treatment with vitamin K antagonists and direct thrombin inhibitors declined to 15.9% and 0.6%, respectively. Women were less likely to be prescribed any oral anticoagulation therapy compared to men (adjusted odds ratio, aOR 0.68 [95% CI, CI 0.67–0.70]). This disparity was mainly attributed to vitamin K antagonists (aOR 0.68 [95% CI 0.66–0.70]), whilst there was less disparity in use of factor Xa inhibitors between women and men (aOR 0.92 [95% CI 0.90–0.95]). At 1 year following hospitalization with atrial fibrillation, patients not prescribed oral anticoagulation therapy were more likely to have subsequent major adverse cardiovascular events compared to those prescribed with oral anticoagulation therapy (38.8% [15,380/39,608] versus 17.0% [6,761/39,671] in women and 35.2% [12,977/36,868] versus 16.4% [7,395/45,093] in men). Conclusions Women with non-valvular atrial fibrillation were significantly less likely to be prescribed vitamin K antagonists compared to men. Most patients admitted to hospital in Scotland with incident non-valvular atrial fibrillation are now treated with factor Xa inhibitors and this is associated with less treatment disparities between women and men. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): This study was supported by the British Heart Foundation through a Clinical Research Training Fellowship (FS/18/25/33454), Intermediate Clinical Research Fellowship (FS/19/17/34172), Senior Clinical Research Fellowship (FS/16/14/32023) and a Research Excellence Award (RE/18/5/34216), and a research grant to NHS Lothian from Bristol Myers Squibb Pharmaceuticals Ltd and Pfizer UK Ltd.

Background B-type natriuretic peptide (BNP) and mid-regional pro-atrial natriuretic peptide (MRproANP) testing are recommended to aid in the diagnosis of acute heart failure. However, the application of these biomarkers for optimal diagnostic performance is uncertain. Methods We performed a systematic review and harmonised individual patient-level data to evaluate the diagnostic performance of BNP and MRproANP for the diagnosis of acute heart failure using random-effects meta-analysis. We subsequently developed and externally validated a decision-support tool called CoDE-HF for both BNP and MRproANP that combines the natriuretic peptide concentrations with clinical variables using machine learning to report the probability of acute heart failure for an individual patient. Results Fourteen studies from 12 countries provided individual patient-level data in 8,493 patients for BNP and 3,847 patients for MRproANP, in whom, 48.3% (4,105/8,493) and 41.3% (1,611/3899) had an adjudicated diagnosis of acute heart failure, respectively. The negative and positive predictive values of guideline-recommended thresholds for BNP (100 pg/mL) and MR-proANP (120 pg/mL) were 93.6% (95% confidence interval 88.4–96.6%) and 68.8% (62.9–74.2%), and 95.6% (92.2–97.6%) and 64.8% (56.3–72.5%), respectively. However, we observed significant heterogeneity in the diagnostic performance across important patient subgroups (Figure 1). In the external validation cohort, CoDE-HF was well calibrated with excellent discrimination in those without prior acute heart failure for both BNP and MRproANP (area under the curve of 0.946 [0.933–0.958] and 0.943 [0.921–0.964], and Brier scores of 0.105 and 0.073, respectively). CoDE-HF performed consistently across all subgroups for both BNP and MRproANP, and identified 30% and 65.7% at low-probability (negative predictive value of 99.1% [98.8–99.3%] and 99.1% [98.8–99.4%]), and 30% and 17.3% at high-probability (positive predictive value of 91.3% [90.7–91.9%] and 70.0% [68.5–71.4%]) in those without prior heart failure, respectively (Figure 2). Conclusion In an international collaborative analysis, we observed that guideline-recommended thresholds for BNP and MRproANP to diagnose acute heart failure varied significantly across patient subgroups. A decision-support tool using machine learning to combine natriuretic peptides as a continuous measure and other clinical variables provides a more accurate and individualised approach. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): Medical Research Council and British Heart Foundation Figure 1. NPV of BNP threshold (100 pg/mL)Figure 2. NPV of the CoDE-HF rule-out score

Introduction Despite recent improvements in management, infective endocarditis remains associated with high morbidity and mortality. Over the last few decades, several factors have impacted on both the incidence and outcomes following infective endocarditis. Purpose Using a national linkage approach, we describe the changing age- and sex-stratified incidence and outcomes of infective endocarditis in Scotland over the last 25 years. Methods We conducted a consecutive retrospective individual patient linkage study across multiple national databases. Using data extracted from the Scottish hospital discharge dataset held by the Information Services Division of NHS National Services Scotland, we extracted episodes for all patients aged 20 years or older who were admitted with infective endocarditis between January 1, 1990, and December 31, 2014 in Scotland, UK. Patient episodes with infective endocarditis were linked to national prescribing and microbiology databases. The primary outcome was 1-year mortality following the index presentation. Generalised additive models were constructed to estimate the crude and age- and sex-stratified incidence rates (using a poison distribution) as well as trends in mortality (using a binomial distribution) adjusted for age, sex and comorbidity. Results Across 12,446 individual patients, there were a total of 12,667 hospitalisations (mean age 68±17 years, 55% females) with infective endocarditis using a 5-year look back period. The estimated crude rate of hospitalisation increased from 7.38 per 100,000 (95% CI 6.58 to 8.28) in 1990 to 15.09 per 100,000 (95% CI 13.90 to 16.39) in 2014 (p Conclusions Despite the crude incidence of infective endocarditis doubling over the last 25 years and case fatality remaining high, the risk of death has markedly fallen over the last two decades. Staphylococcus cultures remain an independent marker of poor prognosis in this cohort. Acknowledgement/Funding British Heart Foundation

Introduction Cardiac arrest is a major healthcare burden; survival has historically been poor. Contemporary therapies have been associated with improvements in out-of-hospital cardiac arrest survival in other healthcare systems. Purpose To determine temporal trends and predictors of 30-day and overall survival in patients with cardiac arrest who survive to hospital admission in Scotland. Methods We conducted a consecutive individual patient linkage study using data from the Scottish Morbidity Records held by the Information Services Division, National Health Service Scotland. We identified all patients who had an index cardiac arrest hospitalisation from 1st January 1990 to 31st December 2014. The primary outcome was 30-day mortality. Generalised additive models were used to estimate temporal trends. Year of admission was the primary explanatory variable, adjusted for age, sex, comorbidities (stroke, myocardial infarction, heart failure), Scottish Index of Multiple Deprivation (SIMD, a national deprivation score), and angiography within 30 days of admission. Cox regression models were constructed for overall mortality, adjusting for the above variables. Results In total, 47,692 patients had an index hospitalisation with cardiac arrest in Scotland between 1990 and 2014. The mean age was 69±16 years; 45% (n=21,257) were female. Most patients (n=24,867, 52.4%) were in top two SIMD quintiles (greater deprivation). Incidence was lowest in 1990 (27 per 100,000 population), rising until 1998 (47 per 100,000) before declining (mean 30 per 100,000 for 2010–2014) (Figure 1A). Overall rates of angiography and PCI at 30 days were low (5.4% and 3.1% respectively), albeit higher in more recent years (14.1% and 9.6% respectively for 2010–2014). Thirty-day mortality was high but decreased over time (73.7% from 1990–1994 to 63.1% from 2010–2014, p Temporal trends in cardiac arrest Conclusions Hospital episodes with cardiac arrest in Scotland peaked in the late 1990s and have since fallen. Thirty-day mortality remains high, with an improvement over time that is independent of baseline patient characteristics.

Doppler echocardiographic characteristics of normally functioning Allcarbon prostheses were studied in 149 consecutive patients with 157 valves in the mitral (n = 73) and aortic (n = 84) positions whose function was considered normal by clinical and echocardiographic evaluation. In the mitral position, the mean gradient and the effective mitral orifice area were not significantly different in either the 25-mm or the 31-mm size valves (from 5 +/- 1 to 4 +/- 1 mmHg and from 2.2 +/- 0.6 to 2.8 +/- 0.9 cm2, respectively; P = ns for both). Conversely, peak gradient was significantly and inversely correlated to actual orifice area (r = -0.70; P < 0.0006), decreasing from 15 +/- 3 mmHg in the 25-mm size valve to 9 +/- 1 mmHg in the 31-mm size. In the aortic position, the mean gradient was 29 +/- 8 mmHg in the 19-mm size valve; it decreased to 8 +/- 2 mmHg in the 29-mm size. Effective prosthetic aortic valve area, calculated using the continuity equation, ranged between 0.9 +/- 0.1 cm2 for the 19-mm size valve to 4.1 +/- 0.7 cm2 for the 29-mm size. By analysis of variance, effective prosthetic aortic valve area differentiated various valve sizes (F = 25.3; P < 0.0001) better than peak (F = 5.34; P = 0.012) or mean (F = 4.34; P = 0.0052) gradients alone, and it correlated better with actual orifice area (r = 0.89, r = -0.70 and r = -0.65, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)