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Background Cardiac sarcoidosis (CS) is clinically diagnosed in 5% of patients with sarcoidosis but imaging studies suggest higher prevalence. We evaluated the prevalence, clinical manifestations, and cardiovascular outcomes of CS, diagnosed through 18F-Fluorodeoxyglucose positron emission tomography ([18F]FDG-PET), in a southern European population. Methods Retrospective single-centre study of patients screened for sarcoidosis with [18F]FDG-PET. Subjects with histological confirmation were divided in two groups, CS or extracardiac sarcoidosis, according to Heart Rhythm Society's criteria. Primary endpoint was defined as the composite of heart failure hospitalizations, uncontrolled arrythmias, pacemaker implantation, and cardiovascular (CV) mortality. Secondary outcomes included each component and all-cause mortality. Results From 128 patients with biopsy-proven extracardiac sarcoidosis, 10.2% had probable CS, 54% without symptoms of cardiac involvement. Ten patients had suggestive [18F]FDG uptake patterns, three subjects had an indicative cardiac magnetic resonance (CMR). Patients with probable CS had significantly higher prevalence of coronary and valvular disease, heart failure, and atrial fibrillation compared with those without cardiac involvement. During a mean follow-up of 4.0 SD2.7 years, the primary outcome occurred more frequently in patients with probable CS (53.8% vs. 3.5%; HR 25.45; 95% CI 5.27–122.9; p Conclusions Among patients with biopsy-proven sarcoidosis, cardiac involvement detected by [18F]FDG-PET or CMR is associated with a higher risk of CV events, irrespective of symptoms.

Collateral development in chronic total occlusions (CTO) is crucial to perfuse the distal myocardium and its angiographic evaluation is frequently used to assess the need for revascularization. We aimed to analyse the association between the presence of ischemia and hibernating myocardium, evaluated by cardiac [13N]NH3/2-[18F]FDG PET-CT, and the angiographic characterization of the collateral circulation. Prospective study including patients with a CTO who underwent a [13N]NH3 and, when deemed necessary, 2-[18F]FDG PET-CT. Well developed (WD) collaterals were defined as a concomitant angiographic Rentrop grade 3 and Werner collateral connection score 2 or 3, whereas the remaining as poorly developed (PD). Two percentage thresholds used to identify prognostic benefit of revascularization were applied: ischemia >10% and hibernating myocardium >7%. Fifty-nine patients (age 62.9±9.1 years, 58 male) were recruited, WD collaterals were present in 28 (47.5%). No significant differences were found in ischemia (WD 6.4±4.3 vs. PD 7.0±4.1, p=0.64) and hibernation (WD 1.8±1.9 vs. PD 3.1±3.3, p=0.18) scores. Most CTO territories demonstrated ischemia, but only 19 (46.3%) were associated with an area >10% (WD 47.6% vs. PD 45.0%, p=0.58). Scared non-viable myocardium was limited to 9 (15.3%) patients and was not associated with PD collaterals. Hibernating myocardium was frequent (54.2%), but just 6 (10.2%) CTO patients had an area of >7% (WD 3.6% vs. PD 16.1%, p=0.20). Collateral assessment by angiography has a poor association with the ischemic burden and hibernation state of CTO territories. Myocardial viability was present even in most CTO with angiographic PD collaterals.

Fluorine-18 sodium fluoride (Na[18F]F) atherosclerotic plaque uptake in positron emission tomography with computed tomography (PET-CT) identifies active microcalcification. We aim to evaluate global cardiac microcalcification activity with Na[18F]F, as a measure of unstable microcalcification burden, in high cardiovascular (CV) risk patients. Thirty-four high CV risk individuals without previous CV events were scanned with Na[18F]F PET-CT. Cardiac Na[18F]F uptake was assessed through the global molecular calcium score (GMCS), which was calculated by summing the product of the mean standardized uptake value times the area of the cardiac regions of interest times the slice thickness for all cardiac transaxial slices, divided by the total number of slices. Mean age is 63.5 ± 7.8 years and 62% male. Median GMCS is 320.9 (240.8-402.8). Individuals with more than five CV risk factors (50%) have increased GMCS [356.7 (321.0-409.6) vs. 261.1 (225.6-342.1), P = 0.01], which is positively correlated with predicted fatal CV risk by SCORE (rs = 0.32, P = 0.04). There is a positive correlation between GMCS and weight (rs = 0.61), body mass index (rs = 0.66), abdominal perimeter (rs = 0.74), thoracic fat volume (rs = 0.47), and epicardial adipose tissue (rs = 0.41), all with P ≤ 0.01. There is no correlation between GMCS and coronary calcium score nor coronary artery wall Na[18F]F uptake. In a high CV risk group, the global cardiac microcalcification burden is related to CV risk factors, metabolic syndrome variables and cardiac fat. Cardiac GMCS is a promising risk stratification tool, combining a straightforward and objective methodology with a comprehensive analysis of both coronary and valvular microcalcification.

18F-sodium fluoride (18F-NaF) has been used to access aortic stenosis in clinical research setting. It is known that its uptake is related with microcalcification. The purpose of this study was to assess the relationship between 18F-NaF uptake by the aortic valve and cardiovascular risk. Twenty-five patients with risk factors for cardiovascular disease, without known cardiovascular disease or aortic stenosis underwent PET-CT with 18F-NaF. Cardiovascular risk was assessed through the ASCVD (Atherosclerotic Cardiovascular Disease) risk calculator. Aortic valve 18F-NaF (AoVCUL) uptake was evaluated through the corrected uptake per lesion (CUL = max SUV - mean blood-pool SUV). Calcium score was obtained through cardiac CT. The patients present a mean age of 63.90 ± 8.60 years and 56% males. The mean ASCVD was of 28.76 ± 18.96 (M 25, IQR 38.50). The mean aortic valve calcium score (AoVCaSc) was of 53.24 ± 164.38 (M 6; IQR 29.75) and the AoVCUL was of 0.50 ± 0.10 (M 0.52, IQR 0.15). The patients were classified according to the ASCVD: patients with a risk greater or equal than the 50th percentile of the ASCVD risk and patients with a risk lower than the 50th percentile. The AoVCUL was evaluated in both groups: AoVCUL = 0.56 ± 0.10 vs 0.42 ± 0.15, p = 0.02; AoVCaSc was of 0 in 11 patients (44%) and those with an ASCVD greater or equal than the 50th percentile had a mean AoVCaSc of 8.00 ± 13.80, and those with an ASCVD risk lower than the 50th percentile had a mean AoVCaSc of 95.00 ± 223.45; p = 0.09. In this study microcalcification, evaluated through 18F-NaF on PET-CT, was related with cardiovascular risk. Although the score of calcium seems to be higher in higher cardiovascular risk patients, no significant difference was found between groups.

Introduction and Aims: Cardiac allograft vasculopathy (CAV) is one of the most significant complications after orthotopic heart transplantation. We aimed to investigate the incidence and predictors of CAV in a large cohort of orthotopic heart transplantation patients. Methods: We conducted a retrospective analysis on a prospective cohort of 233 patients who underwent transplantation between November 2003 and May 2014. Baseline clinical data and invasive coronary angiograms (n=712) performed as part of the follow-up program were analyzed by two independent investigators. Results: We included 157 male and 45 female patients with a median age of 66 years. A third of patients had previous ischemic heart disease, 30% peripheral arterial disease, 37% hypertension and 47% dyslipidemia, and 17% were smokers. Acute moderate or severe rejection occurred in 42 patients during the first year. Over a median follow-up of 2920 days, 18% were diagnosed with CAV, with an incidence of 2.91 cases per 100 person-years. Predictors of CAV were previous ischemic heart disease (HR 2.32, 95% CI 1.21-4.45, p=0.01), carotid artery disease (HR 2.44, 95% CI 1.27-4.71, p

OBJECTIVES Atherosclerotic plaque molecular imaging with F-sodium fluoride (NaF) PET with computed tomography (PET-CT) may identify active unstable microcalcification. We sought to explore renal arteries calcification activity in a group of high cardiovascular (CV) risk subjects without manifest CV disease. METHODS High CV risk hypertensive individuals from a single centre were prospectively scanned with F-NaF-PET-CT in major vascular territories. Renal arterial wall activity was retrospectively analysed and expressed as the ratio between maximum standard uptake value in the lesion and mean blood pool activity in the superior vena cava [tissue-to-background ratio (TBR)]. We explored renal artery wall F-NaF activity's association to CV risk factors and renal function. RESULTS Mean age was 64 ± 8.6 years, 56% male, 96% Caucasian and 24% had chronic kidney disease (CKD) (n = 25). Six individuals (24%) showed renal artery wall radiotracer uptake (TBR 1.4 ± 0.4); these subjects were heavier, had higher triglycerides, high-sensitivity C-reactive protein and predicted CV risk (SCORE) compared to the remaining cohort (P < 0.05 for all comparisons). There was a trend toward higher F-NaF uptake in other major vessels and increased thoracic fat volume in subjects with renal artery wall uptake. Glomerular filtration rate (GFR) was lower in subjects with positive renal plaques (93.0 ± 29.7 vs. 65.0 ± 19.7 ml/min, P = 0.04). Renal artery radiotracer uptake and eGFR were inversely correlated (r = -0.42, P = 0.04). CONCLUSION In a high CV risk group without manifest CV disease, higher renal artery wall F-NaF activity is associated with superior predicted CV risk and lower GFR.

Three-dimensional printing (3D) has emerged as an alternative to imaging to guide left atrial appendage closure (LAAC) device sizing.We assessed the usefulness of 3D printing compared to a standard imaging-only approach for LAAC.We identified studies comparing an imaging-only with a 3D printing approach in LAAC. A fixed-effects meta-analysis was performed targeting a co-primary endpoint of disagreement in device sizing and leaks.Eight studies that assigned 283 participants to an imaging-only approach and 3D printing approach (145 patients) were included. 3D printing significantly reduced the risk of the co-primary endpoint (risk raio (RR) = 0.19; 95% confidence interval (CI) 0.09-0.37), with consistency across the studies (I2 = 0%). Individually, both device size disagreements [RR 0.13 (95% CI 0.06-0.29), P 0.001] and leaks [RR 0.24 (95% CI 0.09-0.64) P = 0.004] were reduced under a 3D printing modeling strategy.Compared with an imaging-only strategy, 3D printing is associated with reduction in device size disagreements and leaks.

Objectives In ST-segment elevation myocardial infarction (STEMI), time delay between symptom onset and treatment is critical to improve outcome. The expected transport delay between patient location and percutaneous coronary intervention (PCI) centre is paramount for choosing the adequate reperfusion therapy. The “Centro” region of Portugal has heterogeneity in PCI assess due to geographical reasons. We aimed to explore time delays between regions using process mining tools. Methods Retrospective observational analysis of patients with STEMI from the Portuguese Registry of Acute Coronary Syndromes. We collected information on geographical area of symptom onset, reperfusion option, and in-hospital mortality. We built a national and a regional patient's flow models by using a process mining methodology based on parallel activity-based log inference algorithm. Results Totally, 8956 patients (75% male, 48% from 51 to 70 years) were included in the national model. Most patients (73%) had primary PCI, with the median time between admission and treatment Conclusion Process mining tools help to understand referencing networks visually, easily highlighting its inefficiencies and potential needs for improvement. A new PCI centre in the “Centro” region is critical to offer timely first-line treatment to their population.

Background Cardiopulmonary exercise testing (CPET) has an important role in mortality prediction in heart failure (HF) and patient selection for heart transplant. New indices as circulatory power (CP) and ventilatory power (VP) have been proposed as predictors of cardiac events. In addition, VP predicts mean pulmonary artery pressure (mPAP) in patients with pulmonary arterial hypertension. Purpose We aimed to analyse the prognostic value of classic and new CPET variables in patients with HF. Methods We retrospectively assessed consecutive patients with HF who underwent CPET in a single-centre between 2013 and 2017. New CPET variables were collected: CP was defined as the product of peak O2 uptake and peak systolic blood pressure (SBP), while VP was defined as peak SBP divided by the minute ventilation–CO2 production (VE/VCO2) slope. The primary endpoint was a composite of all-cause mortality, heart transplant, or HF hospitalization. Survival analysis was performed using Kaplan-Meier curves and multivariable Cox regression. Results Overall, 216 patients (mean age 55.4±10.9, 77.3% male) were included, 38.4% with ischemic HF, and mean left ventricle ejection fraction (LVEF) 30±14%. Most patients were evaluated through the modified Naughton (76.3%), the original Naughton (19.0%), and Bruce protocols (4.7%). Regarding classic CPET variables: mean pVO2 16.8±6.0 mL O2 kg–1 min–1, mean percent-predicted pVO2 62.6±23.9%, median VE/VCO2 slope 37.3 [32.6–44.5], exercise oscillatory ventilation (EOV) present in 13.9%, resting partial pressure of end-tidal carbon dioxide (PETCO2) ≥33 mmHg with an increase of 3–8 mmhg during exercise in 17.1%, and mean peak SBP 128.8±27.2 mmHg. Median circulatory power was 1927 [1404–2694] mmHg·min/mL/kg and mean ventilatory power 3.47±1.32 mmHg. After a median follow-up of 5 [4–6] years, the primary endpoint occurred in 66.2% of patients (rehospitalization, heart transplant, and all-cause death occurred in 57.0%, 25.9%, and 32.4%, respectively). In Cox regression multivariate analysis, the primary endpoint was predicted by pVO2 (HR 0.90, 95% CI: 0.87–0.93), percent-predicted pVO2 (HR 0.97, 95% CI: 0.96–0.98), VE/VCO2 slope (HR 1.04, 95% CI: 1.03–1.06), VP (HR 0.62, 95% CI: 0.52–0.73) but not CP (HR 0.99, 95% CI: 0.98–1.01). Kaplan-Meier curves according to the LVEF are depicted in Fig. 1A. ROC analysis (Fig. 1B) revealed that VP (AUC 0.768) has higher discriminative power for the primary endpoint, compared to pVO2 (AUC 0.741). One hundred and twenty-seven patients also underwent right heart catheterization: mean mPAP was 30.6±12.9 and it was not correlated with VP (r=−0.06, p=0.47). Conclusion CPET variables are good predictors of all-cause mortality, heart transplant, or HF hospitalization. Ventilatory power (but not circulatory power) is an additional useful variable in event prediction. On the other hand, VP is not correlated with mPAP in patients with HF. Funding Acknowledgement Type of funding sources: None.

HIV-uninfected children exposed prenatally to the virus and to prophylactic antiretroviral therapy are at an uncertain risk of long-term myocardial dysfunction. This study aimed to analyse the structure and function of their ventricles and to identify potential screening tools for this at-risk population. One hundred and fifteen children (77 exposed vs 38 controls) aged between 2.7 and 16.2 years were included. An echocardiographic study was performed where both ventricles' dimensions and systolic functions were evaluated. In the left ventricle, parameters related to diastolic function were also analysed. Tissue Doppler values were determined in the basal state and after passive leg raising. Serologic analysis of amino-terminal pro-B-type natriuretic peptide (NT-proBNP) was carried out. The two groups had identical ventricular sizes and left ventricular diastolic functions. However, contractility assessed by myocardial peak systolic velocity was significantly inferior in the exposed group. These systolic echocardiographic differences were present despite similar values of NT-proBNP in both groups.Conclusion: HIV-exposed uninfected children may be vulnerable to ventricular systolic dysfunction at long term. Cardiovascular surveillance and periodic monitoring of biventricular function are therefore recommended. Myocardial peak systolic velocity may be a useful screening tool for this purpose.What is Known:• Previous studies on HIV-exposed uninfected children subjected prenatally to antiretroviral therapy have alerted to potential long-term cardiovascular toxicity effects on the left ventricle.What is New:• The study gives new insights on ventricular function and morphology in HIV-exposed uninfected children.• Myocardial peak systolic velocities are significantly inferior in this paediatric sub-group, therefore long-term cardiac surveillance is recommended.

Funding Acknowledgements Type of funding sources: None. Background Overt cardiac involvement is reported in 5% of patients with sarcoidosis, although autopsy and imaging studies suggest higher prevalence, worldwide variation. The role of 18F-fluorodeoxyglucose positron emission tomography ([18F]FDG-PET) in non-invasive diagnosis and follow-up has increased in the last decade. Purpose Our goal is to describe the prevalence, clinical manifestations and outcomes of cardiac sarcoidosis (CS), diagnosed through [18F]FDG-PET, in a southern European population. Methods We included all patients with histological diagnosis of extracardiac sarcoidosis screened with [18F]FDG-PET between 2009 and 2020. We collected data on clinical manifestations, cardiac magnetic resonance (CMR) results, and mortality outcomes and compared those with and without cardiac involvement. We applied the criteria for the diagnosis of CS from Heart Rhythm Society. Results Of the 400 patients screened with [18F]FDG-PET, 128 had a histological diagnosis of extracardiac sarcoidosis (54.7% females, mean age 51.0 ± 14.2 years). None underwent endomyocardial biopsy. Ten patients had a pattern of [18F]FDG uptake consistent with CS defined as diffuse (n = 5), focal (n = 3), and focal on diffuse (n = 2). Of the 128 patients, 14 also underwent CMR, which identified 2 subjects with positive findings in both modalities and 3 additional patients: focal (n = 1), multifocal mid-wall (n = 2), focal mid-wall (n = 2), and multifocal subepicardial (n = 1) delayed gadolinium enhancement. Overall, 13 patients (10.2%) fulfilled the criteria for probable CS (53.8% female, mean age 56.2 ± 12.6 years), all with multiorgan involvement, mostly lung and lymph nodes (each 92%), followed by skin and central nervous system (each 15%). Median left ventricle ejection fraction was 62% [55-65] and there were cardiac manifestations of CS in 6 patients (46%): sick sinus syndrome (n = 2), complete heart block (n = 1), frequent premature ventricular complexes (n = 1), ventricular tachycardia plus heart failure (n = 1), and bifascicular block plus heart failure (n = 1). Eleven patients (85%) with probable CS were medicated with immunosuppressant drugs: corticosteroids (n = 9), methotrexate (n = 4), and azathioprine (n = 2). Four patients with previous [18F]FDG screening were revaluated after treatment, each showing no cardiac uptake. After a mean follow-up of 4.0 ± 1.0 years, mortality was three-fold higher in patients with cardiac involvement, despite the absence of statistical significance (15% vs. 5%, P = 0.151). Conclusions In a southern European population with histological extracardiac sarcoidosis, the prevalence of cardiac involvement was 10.2%, most asymptomatic. [18F]FDG-PET improves the diagnostic yield and plays an important role in monitoring response to therapy. The higher mortality trend in those with CS needs to be ascertained in longer follow-up.

Funding Acknowledgements Type of funding sources: None. Introduction Calcification plays a major role in coronary atherogenesis. Positron emission tomography (PET) imaging with fluorine-18 sodium fluoride (Na[18F]F) is able to detect microcalcification and is associated with cardiovascular (CV) risk factors. Thoracic fat volume (TFV) and epicardial adipose tissue (EAT) are associated with atherosclerosis, pro-inflammatory state, and CV events. Purpose We aimed to evaluate the association between Na[18F]F uptake and cardiac fat variables. Methods Cardiac Na[18F]F uptake was assessed as global molecular calcification score (GMCS): the sum of the product of the mean standardized uptake value times the area of the cardiac regions of interest times the slice thickness for all cardiac transaxial slices, divided by the total number of slices. TFV was assessed in computed tomography (CT) using automated software to sum the voxels consisting of fat (threshold of -190 to -30 Hounsfield units) between the bifurcation of pulmonary artery and the end of pericardial sac. EAT was segmented manually tracing the counter of the pericardium with 3DSlicer and the final volume calculated using the dedicated software. Coronary artery calcium score (CAC) was measured with dedicated software for calcium scoring (GE Healthcare Advantage Workstation 4.2). Results Thirty-four high CV risk individuals without previous CV events (50% with ≥5 CV risk factors) were retrospectively scanned with Na[18F]F PET-CT. Mean age is 63.5 ± 7.8 years and 62% male. Median values are: GMCS 320.9 (240.8-402.8), TFV 167.8 (131.4-211.3) mL, EAT 81.3 (60.7-107.2) cm3, and CAC 0.0 (2.5-20.0). There is a positive correlation between GMCS and abdominal perimeter (rs = 0.74), weight (rs = 0.61), TFV (rs = 0.47), and EAT (rs = 0.41), all with p ≤ 0.01. Thoracic and epicardial fat volumes are strongly correlated (rs = 0.80, p Conclusions In this exploratory analysis with high CV risk patients, the global cardiac microcalcification burden assessed by GMCS is associated with TFV and EAT, but there was no correlation between these variables and CAC. We hypothesize that both GMCS and cardiac fat variables might help to identify higher-risk patients in earlier phases than traditional CT.

Funding Acknowledgements Type of funding sources: None. Introduction The blood urea nitrogen-to-creatinine ratio (BUN/SCr) has been proposed as a prognostic marker in heart failure (HF). We aimed to evaluate whether BUN/SCr predicts mortality outcomes in a real-world Southern European population with decompensated chronic HF. Methods We retrospectively studied 1057 patients with chronic HF admitted to our emergency department between November 2016 and December 2017 with acute decompensation. We excluded patients with a GFR Results 1025 patients were included, median age 80 years (IQR 73-85), 52.4% male, mean LVEF 42.8 ± 12.7%, and mean GFR 57.2 ± 23.9 mL/min/m2. Mean BUN/SCr was 24.9 ± 8.2 and mean SBP was 139 ± 29mmHg (r=-0.17, p 27.15). In the T3 group, the multivariable-adjusted OR for CV and all-cause death was 5.43 (95% CI 2.20-13.37) and 2.72 (95% CI 1.66-4.46), respectively, compared to the T1 group. No significant differences between T1 and T2 groups. Conclusions BUN/SCr at admission predicts CV and all-cause death in patients with chronic HF after an episode of decompensation. BUN/SCr, as an easy-to-use tool, helps to identify those patients who benefit from tight monitoring both during hospitalization and after discharge. Abstract Figure_1

Funding Acknowledgements Type of funding sources: None. Background Elevated plasma lipoprotein(a) [Lp(a)] concentrations are associated with an increased risk of atherosclerotic cardiovascular disease and its role in risk categorizing was recognized in the new ESC guidelines for the management of dyslipidaemias. We investigated 1) the association between baseline Lp(a) levels and incident long-term cardiovascular (CV) events and 2) its relationship with type 2 diabetes mellitus (T2DM) in a Southern European population. Methods We retrospectively assessed baseline Lp(a) concentrations in a total of 499 patients of a primary prevention cohort followed at the Lipidology Clinic of our hospital, with a median follow-up time of 15 (IQR 12-17) years. Lp(a) was analysed as a continuous variable, as a categorical variable with a 180mg/dL cut-off and by quartiles. We collected data on major CV events (CV death, myocardial infarction, stroke) as a composite outcome. Cox proportional hazard regression analyses were used to estimate hazard ratios (HR) and 95% confidence interval (CI). Results Mean age was 48.30 ± 14.41 years and 61.70% were male (n = 499). Median Lp(a) was 36.60 (IQR 0-396) mg/dL and 12.4% of patients had very high Lp(a) (≥180mg/dL); T2DM prevalence was 13.60%. The composite outcome incidence was 10%. At the baseline, individuals with T2DM had lower Lp(a) levels (11.85 IQR 3-330 mg/dL vs. 46.40 IQR 0-396, p Conclusion In a single centre cohort of a primary prevention southern European population, we did not find an association between Lp(a) levels and incident CV events in a 15-year median follow-up time.

Funding Acknowledgements Type of funding sources: None. Introduction The incidence of acute myocardial infarction (AMI) among young patients is increasing. The YOUNG-MI Registry reported that those under 40 years had similar risk profiles and outcomes compared to those aged 41 to 50. We aimed to evaluate cardiovascular risk factors and mortality outcomes in two age cohorts from southern European. Methods We retrospectively evaluated 4758 patients admitted to our coronary intensive care unit between 2004 and 2017 with AMI. We only included patients Results From the 1233 patients included (mean age 50.5 ± 6.5 years, 82.2% male), 53% had STEMI. Cohort B had higher rates of hypertension (59.8 vs. 42.9%, p Conclusion Among patients who suffer AMI, those under 50 years old have a different risk profile, compared to the 50-60 years cohort. However, there is no significant difference in all-cause mortality. Abstract Figure.

Introduction The TIMI (Thrombolysis in Myocardial Infarction) and GRACE (Global Registry of Acute Coronary Events) risk scores identify high-risk patients with Non-ST elevation acute coronary syndrome (NSTE-ACS) who can benefit from an early invasive strategy. Purpose We aimed to compare both scores predictive accuracy for mortality in a real-world cohort of patients presenting with NSTE-ACS. Methods We retrospectively evaluated 4264 patients admitted to our coronary intensive care unit between 2004 and 2017 with a diagnosis of NSTE-ACS. The TIMI and GRACE scores were calculated for each patient, and all-cause mortality was recorded during hospitalization, at one month and one year. To better characterize global troponin release, we defined Total Troponin (TT) as the sum of initial and discharge troponin. We used the area under the receiver operating characteristic curve (AUC) to compare the predictive value of both scores for mortality during hospitalization, at one month and one year. Results Mean patient age was 67.6±12.4 years and 66.4% were male (n=2833). Mean GRACE score was 124.6±35.8 and mean TIMI score was 2.7±1.6. There was a weak correlation between GRACE and TIMI score (r=0.3, p Conclusion In patients with NSTE-ACS, GRACE risk score is a better predictor of in-hospital, one month and one-year mortality, compared to TIMI risk score. TT, as a measure of ischemia burden, might improve accuracy of GRACE score in predicting short and long-term mortality. Figure 1 Funding Acknowledgement Type of funding source: None

Introduction The expected delay of transport between patient location and percutaneous coronary intervention (PCI) centre is paramount for choosing the adequate reperfusion therapy in ST-segment elevation myocardial infarction (STEMI). The central region of Portugal has heterogeneity in PCI assess due to geographical reasons. However, this data is usually presented numerically without providing a visual distribution of patients. Purpose We aimed to analyse the impact of distance to PCI centres on mortality in patients with STEMI through visual maps of patients' flow by using an experimental process mining tool, integrated in EIT Health's project PATHWAYS. Methods Using the Portuguese Registry of Acute Coronary Syndromes (ProACS), we retrospectively assessed patients with an established diagnosis of STEMI, geographical presentation specified, reperfusion option identified (PCI, fibrinolysis or no reperfusion), short-term outcomes defined as discharge or in-hospital death. With the 2 317 patients that fulfilled the criteria, we used a process mining tool to build national and regional models that represent the flow of patients in a healthcare system, enhancing differences between groups. Results Colour gradient in nodes and arrows changes from green to red, with green representing a lower number of patients as opposed to red. In the national model, most patients from all regions had PCI. Mortality was similar between PCI and fibrinolysis groups (4%) but higher in those without reperfusion (9%). In the central region model, one third of the patients were more than 120 minutes away from a PCI centre. Despite that, almost one third of these patients had PCI instead of fibrinolysis. In this model, fibrinolytic therapy had higher in-hospital survival rate than PCI (98% vs. 94%). Overall mortality was higher in the central model compared with the national model (6.92% vs. 5%). Central region had less PCI (53% vs. 73%), more fibrinolysis (15% vs. 7%) and more patients with no reperfusion (32% vs. 20%). Conclusion In the ProACS registry, mortality was higher in the central region compared with national data. Even though global interpretation of these findings is limited by underrepresentation from certain central areas, process mining offers an easily understandable view of patients flow. With its statistical upgrade and continuous development, this tool will facilitate the analysis of big data and comparison between groups. Funding Acknowledgement Type of funding source: Public grant(s) – EU funding. Main funding source(s): EIT Health

Fluorine-18 sodium fluoride (Na[Thirty-four high CV risk individuals without previous CV events were scanned with Na[In a high CV risk group, the global cardiac microcalcification burden is related to CV risk factors, metabolic syndrome variables and cardiac fat. Cardiac GMCS is a promising risk stratification tool, combining a straightforward and objective methodology with a comprehensive analysis of both coronary and valvular microcalcification.

Background and aims Atherosclerotic plaque molecular imaging with 18 F-sodium fluoride (NaF) in positron emission tomography with computed tomography (PET-CT) provides potential discrimination between active unstable microcalcification and established dormant calcification. We aimed to study 18 F-NaF atherosclerotic plaque uptake in high cardiovascular (CV) risk participants and its associations with CV risk factors, coronary calcium score and thoracic fat volume. Methods High CV risk hypertensive individuals from a single centre were prospectively scanned with 18 F-NaF-PET-CT in the coronary, aortic and carotideal arteries. Atherosclerotic plaque 18 F-NaF uptake was expressed as Corrected Uptake per Lesion (CUL): maximum standard uptake value in each vascular territory subtracted by mean blood pool activity. Results Mean age was 64 years, 56% male and 96% Caucasian (n = 25). Ninety six per cent of the subjects showed 18 F-NaF uptake in the aorta (CUL 0.9 ± 0.3), 40% in the carotid arteries (median CUL 0.0, IQR 0.0–0.7) and 64% in the coronary arteries (0.4, IQR 0.0–0.6). Individuals with ≥ five risk factors (60%) had increased overall 18 F-NaF uptake (1.1 ± 0.3 vs . 0.7 ± 0.3, p p = 0.01). There was no correlation between 18 F-NaF uptake in the coronary arteries and calcium score ( p = 0.87). Thoracic fat was moderately correlated with overall CUL (r = 0.41, p = 0.04). Conclusions In a high CV risk group, 18 F-NaF atherosclerotic plaque uptake was related to the burden of CV risk factors and thoracic fat volume, but there was no association between coronary uptake and calcium score.

The aim of the present study was to evaluate the uptake of F18-NaF by the arterial wall in patients with high cardiovascular (CV) risk profile. The tracer uptake was assessed in relation to gender and the number of CV risk factors. 25 patients without known CV disease were included and evaluated by PET-CT with F18-NaF: 14 (56%) men and 11 (44%) women. The mean target-to-background ratio (TBR: max SUV/mean blood-pool SUV) but not the corrected uptake per lesion (CUL: max SUV – mean blood-pool SUV) was higher in men than women (TBR: 1.8 ± 0.6 vs 1.7 ± 0.2; P = 0.04; CUL: 0.7 ± 0.3 vs W 0.6 ± 0.1; P = 0.4). Patients with >3 CV risk factors had higher CUL (0.8 ± 0.1 vs 0.6 ± 0.2; P = 0.01) but not TBR (1.8 ± 0.2 vs 1.7 ± 0.6; P = 0.7) than patients with

18F-sodium fluoride (18F-NaF) has been used to evaluate aortic stenosis. It is know that its uptake is related with microcalcification. The purpose of this study is to assess the relationship between 18F-NaF uptake by the aortic valve and by the main arterial vessels and cardiovascular risk. Twenty-five hypertensive patients without known cardiovascular disease or aortic stenosis underwent PET-CT with 18F-NaF. Cardiovascular risk was assessed through the ASCVD risk calculator. The patients had a mean age of 64.0±8.6 years and 56% were males. The mean ASCVD risk was of 28.8±19.0 (IQR: 10–48.5). The uptake of 18F-NaF assessed through the corrected uptake per lesion (CUL = max SUV – mean blood-pool SUV) was of 0.49±0.14 (IQR: 0.44–0.57) and the mean uptake in the aortic, coronary and carotid territories was of 0.66±0.21 (IQR: 0.53 - 0.76).The patients were classified according to the ASCVD: Group A: patients with a risk above the 50thpercentile of the ASCVD risk distribution (50thpercentile=25), 12 patients) and Group B: patients with a risk under or equal to the 50thpercentile of the ASCVD risk distribution, 13 patients. The uptake of 18F-NaF in the aortic valve (AoV)and in the main vascular territories (VT) were evaluated in both groups: A vs B: AoV CUL = 0.57±0.09 vs 0. 42±0.14, p=0.005; VT= 0.78±0.16 vs 0.54±0.20, p=0.003. We also evaluate the relation between AoV uptake and VT uptake and they were significantly related (r=0.69, p=0.0001). In conclusion on this study microcalcification of the aortic valve and in the main vessels, evaluated through 18F-NaF uptake, were related between them and with cardiovascular risk reinforcing the importance of cardiovascular risk prevention in aortic valve degeneration and vascular atherosclerosis.

Background. The apolipoprotein E (APOE) polymorphisms are associated with cardiovascular (CV) disease, but its interaction with type 2 diabetes mellitus (T2DM) long-term incidence is unknown. We investigated the association between APOE genotype and long-term (i) CV events and (ii) T2DM incidence in a Southern European primary prevention cohort. Methods. We assessed individual APOE genotypes in a total of 436 patients followed at a lipid clinic, with a 15-year median follow-up time. We collected data on major CV events (CV death, myocardial infarction, and stroke) and T2DM development. Results. No differences were found regarding major CV event incidence among the different APOE genotypes. However, after excluding 39 patients with a prior history of T2DM, APOE2 carriers displayed a higher incidence of T2DM during follow-up (42.2%) than APOE3 (27.1%) and APOE4 (28.7%) carriers. The age-, sex-, triglycerides-, and statin usage-adjusted OR for T2DM incidence in APOE2 carriers was 1.8 (95%CI 1.1-2.9, p=0.03), compared with wild-type APOE3. To address the role of statins as a confounder, we analyzed T2DM incidence in statin-treated patients. Statin-treated APOE2 carriers also had a higher T2DM incidence (57.9%), in comparison with APOE3 homozygotes (31.6%) and APOE4 carriers (32.5%). After adjustment for confounding, APOE2 carriers on statins displayed a similar twofold increase in T2DM risk compared to APOE3 homozygotes (OR 2.1, 95%CI 1.1-4.0, p=0.03). Conclusion. Our findings suggest a twofold increase in T2DM incidence in APOE2 carriers. This may prompt for a specific glucose dysmetabolism follow-up that might be tailored on the APOE genotype.

18-Fluorine sodium fluoride is a well-known radiotracer used for bone metastasis diagnosis. Its uptake correlation with cardiovascular (CV) risk was primarily suggested in oncological patients. Moreover, as a specific marker of microcalcification, it seems to correlate with CV disease progression and plaque instability. Our purpose was to systematically review clinical studies that characterized the use of this marker in CV conditions. In atherosclerosis, most studies report a positive correlation with the burden of CV risk factors and vascular calcification. A higher uptake was found in culprit plaques/rupture sites in coronary and carotid arteries and it was also linked to high-risk features in histology and intravascular imaging analysis of the plaques. In aortic stenosis, this tracer displayed an increasing uptake with disease severity. Sodium fluoride positron emission tomography is a promising non-invasive technique to identify high-risk plaques, which sets ground to a potential use of this tracer in evaluating atherosclerotic disease progression and degenerative changes in aortic valve stenosis. Nevertheless, there is a need for further prospective evidence that demonstrates this technique’s value in predicting clinical events, adjusting treatment strategies, and improving patient outcomes.

Three-dimensional (3D) printing technology is emerging as a potential new tool for the planning of medical interventions. In the last few years, increasing data have accumulated on its ability to guide interventional cardiology procedures, going beyond initial reports in congenital heart disease settings. In fact, there is compelling evidence on the advantages of a 3D-printed guided strategy for left atrial appendage closure, suggesting a high success rate with optimal device selection and lower radiation load. Furthermore, there is emerging experience in aortic root printing, which may improve the success rate and safety of transcatheter aortic valve replacement and may be of particular interest for targeting low-risk populations. Additionally, there are stimulating reports in mitral valve intervention, setting the tone for this new field in cardiovascular percutaneous intervention. In this clinically oriented paper, we will review current 3D printing use in interventional cardiology and we will address future directions, with a focus on procedural planning and medical simulation.

Introduction: The satisfaction with the medical profession has been identified as an essential factor for the quality of care, the wellbeing of patients and the healthcare systems’ stability. Recent studies have emphasized a growing discontent of physicians, mainly as a result of changes in labor relations. Objectives: To assess the perception of Portuguese medical residents about: correspondence of residency with previous expectations; degree of satisfaction with the specialty, profession and place of training; reasons for dissatisfaction; opinion regarding clinical practice in Portugal and emigration intents. Material and Methods: Cross-sectional study. Data collection was conducted through the “Satisfaction with Specialization Survey”, created in an online platform, designed for this purpose, between May and August 2014. Results: From a total population of 5788 medical residents, 804 (12.25 %) responses were obtained. From this sample, 77% of the responses were from residents in the first three years. Results showed that 90% of the residents are satisfied with their specialty, 85% with the medical profession and 86% with their place of training. Nevertheless, results showed a decrease in satisfaction over the final years of residency. The overall assessment of the clinical practice scenario in Portugal was negative and 65% of residents have plans to emigrate after completing their residency. Conclusion: Portuguese residents revealed high satisfaction levels regarding their profession. However, their views on Portuguese clinical practice and the results concerning the intent to emigrate highlight the need to take steps to reverse this scenario.