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Purpose: The presence of non-obstructive coronary artery disease (CAD) on coronary computed tomography angiography (CTA) has been associated with the occurrence of major adverse cardiac events (MACE). However, factors associated with the development of MACE in women with non-obstructive CAD have not been fully elucidated. We sought to examine the influence of risk factors and coronary artery calcification on MACE in women with non-obstructive CAD on coronary CTA.Methods and Results: Women from PROMISE and SCOT-HEART trials with none or non-obstructive CAD on coronary CTA comprised the study cohort. Baseline characteristics and clinical presentation were assessed. Survival analysis using Kaplan-Meier curves was done to compare outcomes stratified by the atherosclerotic cardiovascular disease (ASCVD) risk score and the Agatston score. The primary endpoint was a composite of all-cause mortality, myocardial infarction, and revascularization. 2,597 women had non-obstructive CAD or normal coronary CTA, with a median follow-up of 32 months. Compared to women without MACE, women with MACE had lower high-density lipoprotein cholesterol (HDL-C) levels and higher mean ASCVD risk scores. Further, women with non-obstructive CAD and ASCVD ≥7.5% had higher risk of MACE than those with ASCVD < 7.5% [3.2 % vs. 1.1%, adjusted HR (aHR) of 3.1 (95% CI 1.32, 7.23), P-value 0.009]. The Agatston calcium score, on the other hand, was not independently associated with MACE among this population of symptomatic women. Conclusions: Symptomatic women with non-obstructive CAD on coronary CTA are at higher risk for MACE, with the ASCVD risk score being independently associated with the occurrence of adverse events.

Abnormal and indeterminate electrocardiographic (ECG) changes during cardiac stress imaging are not uncommon. While the prognostic importance of abnormal ECG despite normal imaging has been previously studied, prognosis of indeterminate stress ECG changes is uncertain.We studied the prognostic value of stress ECG changes in symptomatic patients without known CAD and normal stress imaging from the PROMISE trial. Patients with normal ECG (concordant), indeterminate ECG and abnormal ECG (discordant) were identified among those with negative exercise imaging stress test (EIST) and negative vasodilator nuclear stress test (PIST). Outcomes of interest were major adverse cardiovascular endpoint (MACE, including all-cause mortality, myocardial infarction, and unstable angina hospitalization) and likelihood of coronary revascularization.In EIST, indeterminate stress ECG [1.1% vs. 0.2% adjusted hazard ratio (aHR) 4.2, (95% CI 1.11-15.6), p = 0.034] and discordant ECG [7.2% vs. 0.2% adjusted hazard ratio (aHR) 27.6, (95% CI 9.6-79.8), p 0.0001] were associated with increased likelihood of revascularization compared to normal stress ECG. Similar findings were observed with PIST [indeterminate vs concordant [1.7% vs. 0.5% adjusted hazard ratio (aHR) 5.9, (95% CI 1.1-31.7), p = 0.041; discordant vs concordant 15.4% vs. 0.5% adjusted hazard ratio (aHR) 24.2, (95% CI 4.6-127.7), p = 0.0002]. MACE rates were similar between ECG subgroups, in both EIST and PIST.In symptomatic patients without known CAD undergoing stress imaging, indeterminate and discordant ECG changes results may indicate presence of obstructive CAD despite normal imaging results and predict increased likelihood of coronary revascularization despite no significant difference in MACE.

Aims Right ventricular systolic dysfunction (RVSD) is an important determinant of outcomes in heart failure (HF) cohorts. While the quantitative assessment of RV function is challenging using 2D-echocardiography, cardiac magnetic resonance (CMR) is the gold standard with its high spatial resolution and precise anatomical definition. We sought to investigate the prognostic value of CMR-derived RV systolic function in a large cohort of HF with reduced ejection fraction (HFrEF). Methods and results Study cohort comprised of patients enrolled in the CarDiac MagnEtic Resonance for Primary Prevention Implantable CardioVerter DefibrillAtor ThErapy registry who had HFrEF and had simultaneous baseline CMR and echocardiography (n = 2449). RVSD was defined as RV ejection fraction (RVEF) Conclusion RV systolic dysfunction is an independent predictor of ACM in HFrEF, with a more pronounced prognostic value in select subgroups, likely reflecting the importance of RVSD in the early stages of HF progression.

A 63-year-old female with a history of hypertension presented with progressively worsening shortness of breath. She underwent a cardiac catheterization and was found to have prominent Thebesian veins as well as anomalous connections between the proximal right coronary artery and the right ventricle. Cardiac computed tomography was ordered for further evaluation and showed a coronary fistula to the right ventricular outflow tract confirming the diagnosis of a coronary-cameral fistula (CCF). CCF are rare congenital anomalous communications that occur between coronary arteries and a cardiac chamber. They are usually an incidental finding and patients are rarely symptomatic. As the use of coronary computed tomography angiography is rapidly expanding, the detection of CCF will likely increase in the general population.

Mycobacterium neoaurum (M. neoaurum)is an infrequently encountered cause of infection in humans. It is a member of the rapidly growing mycobacteria family. It predominately afflicts those with a compromised immune status and a chronically indwelling vascular access. Isolation of this organism is challenging yet the advent of 16s ribosomal sequencing paved the way for more sensitive detection. No treatment guidelines are available and treatment largely depends on the experience of the treating physician and nature of the isolate. We report a case ofM. neoaurumbacteremia in an immune competent host, with a chronically placed peripherally inserted central catheter (PICC line).

Complete esophageal obstruction is a rare complication of endoscopic variceal banding, with only 6 cases in the English literature since the introduction of endoscopic variceal banding in 1986. We report a case of complete esophageal obstruction following esophageal banding due to entrapment of part of a sliding hiatal hernia. To our knowledge, our case is one of few with esophageal obstruction post-banding, and the first associated with a hiatal hernia. We recommend caution when performing esophageal banding on patients with a hiatal hernia.

213 Background: Anthracyclines and anti-Her-2 targeted therapy are commonly used effective breast cancer treatments. They are known to decrease Left Ventricular Ejection Fraction (LVEF), which may increase patients’ morbidity and mortality. There is currently no consensus on post treatment cardiac follow-up. Recent observations suggested that ACEI and B blocker drugs could have cardioprotective effects. We conducted a retrospective study to assess patients’ cardiac outcome using post-treatment LVEF follow-up and effect of ACEI and B blocker on cardiac outcome for breast cancer patients who received cardiotoxic agents in our institution. Methods: We reviewed 155 charts of non-metastatic breast cancer patients between 2000-2008, who received anthracyclines and/or anti-Her-2 targeted therapy. Patients were stratified into groups A (anthracycline), B (trastuzumab) and C (anthracycline+trastuzumab). Results: Patients’ median age was 52.5 years. Six patients had coronary artery disease and 45 received radiation to the left breast. After a median follow-up of 93 months, only 3 of 155 (2%) patients developed symptoms of congestive heart failure. One hundred twenty patients had pre-treatment LVEF evaluation, while only 31 patients had pre and post LVEF evaluation. Mean LVEF difference was -7.89, - 9.01, -9 and -6.08 for all patients, group A, group B and group C, respectively. Thirty patients were on ACEI, 7 of them had LVEF follow-up with mean difference of -6.86. Thirty patients were on B blocker, 7 of them had LVEF follow-up with mean difference of -15. Because of the small size of the groups who had LVEF follow-up, no statistical difference can be detected. Conclusions: Our patient population showed very low incidence of clinically significant cardiac events in relation to anthracycline and anti-her-2 directed therapy after a median follow-up of 93 months. However, further follow is required to assess cardiac outcome that may affect quality of life and survival later in life. In this regard, our institution is establishing a dedicated cardio-oncology service to closely monitor patients who have been treated with cardiotoxic agents and provide early cardiac management if needed.

216 Background: Considerable medical research done in the last decade, have brought new diagnostic and therapeutic options to the medical oncology field. This has, fortunately, greatly improved treatment options and outcomes of our cancer patients. Newer therapies such as immunotherapies have changed the toxicity profile of our interventions. In addition to “classic chemotherapy toxicity” these therapies can induce autoimmune phenomena including pneumonitis, colitis, etc. that may not initially be considered in patients’ differential diagnosis. We have noted that, we are frequently not being notified of our patients’ hospital admission. This creates an environment in which we can’t contribute to the patients care while they are in the hospital, and makes it difficult to gauge the degree of toxicity our therapies may be causing. Direct communication with the admitting services, asking them to consult us upon patients’ hospitalization would improve rate of consultation. This, we believe, will translate into better patient care. Methods: An official letter was sent to all admitting services’ head of department and program director in our hospital requesting them and their staff to notify/consult the oncology team regarding any cancer patient being admitted to the hospital. We reviewed 406 admissions prior to letter and 145 post. We compared consultation rates before and after the letter. Results: Consultation rate went up from 42 % before the letter to 59 % after, with an absolute increase of 17%. The odds ratio was 1.96 with 95% confidence interval [1.315-2.947], and statistically significant p value of 0.00066. Conclusions: Direct communication with admitting services showed an increase rate of consultation, which we believe improves inpatient care as well as outpatient follow up. This method is simple and we believe cost effective, taking in consideration that better patient care, likelihood of shorter hospital stay and proper outpatient follow up, outweigh the cost of consultation service. Also, we believe, that the presence of consulting service will provide fruitful educational environment for our residents.