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Background The common method of assessing left ventricle (LV) volumes and ejection fraction (EF) is hand-tracing Biplane Simpson method. Alternatively, ultrasound vendors offer different semi-automated LV endocardial border detection software with anatomical intelligence to assess LV volumes and EF. By using speckle-tracking technique, this software tracks the LV endocardium throughout the cardiac cycle and computes the LV volumes in every image frame using the disk summation method from which a volume-curve is generated, and the EF is calculated using the maximum and minimum volumes obtained. Data on the performance of this method in comparison with the hand-tracing Biplane Simpson method in daily clinical practice is scarce. Purpose To determine the accuracy of LV volumes and EF using semi-automated LV endocardial detection tracing, and to compare the reproducibility of this method with the hand-tracing Biplane Simpson method, among operators with varying level of experience in echocardiography. Methods This was a single center retrospective observational study, conducted in year 2020. 127 patients, aged >18 years, who underwent clinically indicated transthoracic echocardiography were recruited. The echocardiographic images were analyzed independently in a blinded fashion by 3 operators – a sonographer, a fellow-in-training and a cardiologist specialized in echocardiography. The LV volumes and EF were first measured using hand-tracing Biplane Simpson method, then repeated using semi-automated tracing at a different time and the operator were blinded to the initial hand-tracing measurements. Results The mean age of patients was 50±16 years, 35.4% were male, mean body surface area was 1.62±0.18m2, 92.1% were in sinus rhythm, and 61.4% had good acoustic window. Table 1 shows the LV end-diastolic volume (EDV), end-systolic volume (ESV) and EF, measured using different method, by the 3 operators. There were excellent correlation and agreement between semi-automated tracing measurements and hand-tracing measurements of LV EDV (r=0.985, LOA [mean ± 1.96 SD] 16.9 ml, ICC 0.991), ESV (r=0.990, LOA 12.7 ml, ICC 0.994) and EF (r=0.962, LOA 7.43%, ICC 0.967) by experienced cardiologist. The limit of agreement (LOA) between cardiologist and sonographer for semi-automated tracing measurement of LV EDV, ESV and EF were 29.13 ml, 19.74 ml and 9.25% respectively, which was comparable with that of hand-tracing measurement. The agreement between cardiologist and fellow-in-training for semi-automated tracing measurement of LV volumes and EF was slightly better than hand-tracing method, with a LOA of 25.60 ml, 17.48 ml and 7.08%, for EDV, ESV and EF respectively (Table 2). Conclusion In daily clinical practice, measurement of LV volumes and EF using semi-automated LV endocardial tracing method is accurate and demonstrates comparable reproducibility with hand-tracing Biplane Simpson method among operators with different level of experience in echocardiography. Funding Acknowledgement Type of funding sources: None.

Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Ministry of Health Malaysia Background Left ventricular diastolic dysfunction (LVDD) has been shown to be more prevalent in patients with diabetes, and once progress to overt heart failure, carry worse clinical outcomes. Substantial number of patients were classified as indeterminate diastolic function based on the current ASE/EACVI guidelines. The implication of current diastolic function classification in predicting MACE among diabetic patients is not well established. Purpose To assess prognostic impact of current guidelines-based diastolic function classification, and determine predictors of 2-year MACE based on individual LVDD parameters. Methods A total of 111 patients with diabetes and hypertension who attended diabetic clinic follow-up at the primary healthcare settings were enrolled. All patients had no prior cardiovascular events, had preserved left ventricular (LV) ejection fraction on echocardiography and sinus rhythm on ECG at screening. Echocardiography was performed to obtain parameters of LV dimensions, LV volumes and LV diastolic function. The 2016 ASE/EACVI guidelines were applied to classify diastolic function. All patients were followed up until 2 years to assess MACE. Results There were 65 (58.6%) female patients. Mean age was 59.86 ± 7.45 years; mean duration of type 2 diabetes was 10.5 ± 5.41 years. 80 (72.1%) patients were classified as having normal diastolic function (nDF); 24 (21.6%) patients were classified as indeterminate diastolic function (iDF); 7 patients (6.3%) were classified as LVDD. Patients with LVDD had significantly higher LV mass index (LVMI) (mean 121.72 ± 23.28g/m2 vs 116.62 ± 24.66g/m2 in iDF vs 102.50 ± 22.89g/m2 in nDF, p = 0.003); higher left atrial volume index (LAVI) (mean 41.24 ± 10.28ml/m2 vs 30.55 ± 10.07ml/m2 in iDF vs 25.75 ± 6.30ml/m2 in nDF, p Among these 111 patients, 10 patients (9%) reported MACE at 2 years. The risk of 2-year MACE is elevated in both indeterminate diastolic function[hazards ratio (HR) 3.80, p = 0.023] and LVDD (HR 37.78, p = 0.002). BMI (HR 1.25, p = 0.004), and systolic blood pressure (HR 1.07, p Conclusions LVDD and indeterminate diastolic function were correlated with increased MACE at 2 years. BMI and systolic blood pressure were predictors of increased risk of MACE at 2 years. Further investigation with larger sample size is warranted.

Background Left ventricular diastolic dysfunction (LVDD) has been shown to be more prevalent in patients with diabetes, and once progress to overt heart failure, carry worse clinical outcomes, compared to those without diabetes. The complexity of previous 2009 ASE/EACVI algorithms makes diastolic function (DF) assessment challenging. Hence, prognostic value of LVDD estimates in clinical setting is not well-established. Objective To evaluate the impact of 2016 recommendations in estimates of LVDD and predicting cardiovascular outcomes in patients with diabetes and hypertension. Materials and methods A total of 111 patients with diabetes and hypertension who attended diabetic clinic follow-up at the primary healthcare settings were enrolled. All patients were clinically NYHA Class I, had no prior adverse cardiac events, and had preserved left ventricular (LV) ejection fraction on echocardiography at screening. Echocardiography was performed to obtain parameters of LV dimensions, LV volumes and LVDD. Both 2009 and 2016 algorithms were applied in DF assessment. All patients follow-up at 1 year to assess clinical outcomes. Results There were 65 (58.6%) female patients. Mean age was 59.86 (7.45); mean duration of diabetes was 10.5 (5.41). 55 (50.5%) patients had LV hypertrophy on echocardiography. Prevalence of LVDD (14.4% vs 55.0%) and elevated LV filling pressure (9.0% vs 26.1%) were lower with 2016 compared with 2009 recommendations. Prevalence of indeterminate DF was 18.0% and 12.6% according to 2016 and 2009 recommendations respectively. Concordance between 2016 and 2009 recommendations was fair (k=0.29, p None out of 45 patients who were diagnosed with indeterminate and normal DF according to 2016 and LVDD with 2009 algorithms developed MACE at 1 year. Out of 12 patients diagnosed with LVDD based on both 2016 and 2009 recommendations, 4 patients developed MACE at 1 year. 2016 recommendations showed better accuracy (sensitivity=80.0%; specificity=88.68%) than 2009 recommendations (sensitivity=80.0%; specificity= 45.28%) in predicting MACE at 1 year. Conclusions The application of 2016 recommendations results in lower prevalence of LVDD. The 2016 criteria detect more advanced cases and predict 1 year cardiovascular outcomes better. Further studies are warranted to investigate the prognostic impact of this criteria. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Institute of Health (NIH), Ministry of Health Malaysia

Background The PIONEER-HF trial has demonstrated the safety of Sacubitril-Valsartan initiation during acute decompensated heart failure (ADHF) compared to Enalapril. The efficacy outcome was also addressed by the surrogate end point of reduction in NT-proBNP. However, the safety and efficacy of Sacubitril-Valsartan initiation during ADHF compared to initiation after ADHF was unknown. Objectives (1) To compare the safety and efficacy of Sacubitril-Valsartan initiation during ADHF(inpatient) to initiation after ADHF(outpatient). (2) To explore the echocardiogram parameters associated with Sacubitril-Valsartan initiation during ADHF(inpatient) versus after ADHF(outpatient). Methods We enrolled patients diagnosed with heart failure with reduced ejection fraction (HFrEF) initiated on Sacubitril-Valsartan from February 2017 to December 2018. The baseline characteristics, echocardiogram parameters (changes in LVEF and positive remodeling), composite safety outcomes (hypotension, interruption of Sacubitril-Valsartan and worsening of renal function), and efficacy outcomes (cardiac death, readmission for heart failure) were compared. Results Thirty-seven patients were identified out of which 21 patients started Entresto after ADHF (outpatient group) and 16 patients during ADHF (inpatient group). The median follow-up duration was 196 days (IQR: 105 to 328days). The baseline characteristics were similar between the 2 groups. Outpatient groups achieved a significantly higher maximally tolerable dose of Sacubitril-Valsartan compared to inpatient group (median 400mg/day versus 200mg/day, p = 0.008) despite a similar starting dose (median 100mg/day versus 100mg/day, p = 0.127). The composite efficacy outcomes were similar between the 2 groups (4.8% versus 18.8%, p = 0.296). The composite safety outcome was similar between the groups (18.8% versus 4.8%, HR5.70 p = 0.054, 95%CI 0.967 to 33.60). Both groups achieved a significant improvement in LVEF after initiation of Sacubitril-Valsartan therapy: mean LVEF 23.44 ± 7.88% to 34.30 ± 13.88% (p = 0.001) in outpatient group; mean LVEF 22.99 ± 11.31% to 38.81 ± 13.91% (p = 0.002) in inpatient group. Reverse remodeling (reduction of LVESV≥15%) was similar between the 2 groups (61.9% versus 50.0%, p = 0.506). Conclusions Among patients with HFrEF in ADHF, initiation of Sacubitril-Valsartan therapy during or after ADHF led to similar safety and efficacy. Overall, there was a significant improvement in LVEF and positive remodeling of the LV regardless of the timing of initiation of therapy.

Aim Despite aspirin therapy, acute coronary syndrome (ACS) patients are at risk of developing re-events owing to the aspirin resistance. This study sought to explore the possibility of utilizing miR-19b-1-5p as a suitable biomarker for aspirin resistance and future major adverse cardio-cerebrovascular (MACCE) events in the ACS patients. Methods Buffy coat from ACS (n=945) patients was used to measure the miR-19b-1-5p expression by RT-qPCR and Platelets function was determined by Multiplate® aggregometry testing. Furthermore, MACCE was collected over a mean follow-up time of 1.01±0.43 years. Linear regression concerning the relationship between miR-19b-1-5p expression and Multiplate® data and cox regression concerning MACCE were used for the analysis, to be able to adjust for confounding. Results Low miR-19b-1-5p expression was found to be related to aspirin resistance as could be observed from sustained platelet aggregation in the presence of aspirin (-Log-miR-19b-1-5p, (B (95% CI); 41.51 (5.09–77.93); p Conclusions Lower miR-19b-1-5p expression was found to be associated with sustained platelet aggregation on aspirin, an increased leucocyte count and the risk of MACCE in ACS patients. Therefore, miR-19b-1-5p could be a suitable marker for aspirin resistance and might predict future MACCE in ACS patients.