Influence of renal dysfunction on clinical outcomes in elderly patients with atrial fibrillation: a subanalysis of the phase 3, randomized, placebo-controlled ELDERCARE-AF trial

Background

Renal dysfunction is common in elderly patients with atrial fibrillation (AF) and is thought to be associated with increased risk of thromboembolic and bleeding events. Once-daily low-dose (15 mg) edoxaban was superior to placebo in preventing stroke or systemic embolic events (S/SEE) without significantly increasing major bleeding events in very elderly (≥80 years) non-valvular AF (NVAF) patients in whom standard oral anticoagulant therapy at approved doses was inappropriate (ELDERCARE-AF trial). Little is known about how renal dysfunction affects the effects of low-dose edoxaban in these patients.

Purpose

We used prespecified subgroup analysis to investigate the relation between renal function (assessed by creatinine clearance, CrCl) and the efficacy and safety of edoxaban in elderly NVAF patients.

Methods

ELDERCARE-AF patients were divided into 3 subgroups according to baseline CrCl: normal renal function/mild dysfunction (CrCl >50 mL/min), moderate renal dysfunction (CrCl ≥30 to ≤50 [“30–50”] mL/min) and severe renal dysfunction (CrCl ≥15 to <30 [“15–30”] mL/min). Primary efficacy and safety endpoints were annualized incidence of S/SEE and ISTH-defined major bleeding, respectively.

Results

Of 984 patients randomized to edoxaban 15 mg or placebo (each group N=492), 681 completed the trial. The 303 discontinuations were due to withdrawal of consent (n=158), death (n=135), or other causes (n=10). Discontinuation rate was the same in the edoxaban and placebo groups. S/SEE incidence in patients with CrCl >50, 30–50 and 15–30 mL/min was 2.0%, 1.3% and 3.5%, respectively, in edoxaban, and 4.4%, 4.6% and 9.7%, respectively, in placebo. In those with CrCl 30–50 and 15–30 mL/min, it was significantly lower in edoxaban than in placebo (adjusted hazard ratio [HR], 0.30 [95% CI, 0.10–0.91], p=0.03; and 0.33 [95% CI, 0.16–0.71], p<0.01, respectively). Incidence of major bleeding in patients with CrCl >50, 30–50 and 15–30 mL/min was 1.0%, 1.8% and 6.2%, respectively, in edoxaban, and 0.9%, 1.5% and 2.4%, respectively, in placebo. Incidence of major bleeding in those with CrCl 15–30 mL/min was higher in edoxaban but not significantly (adjusted HR, 2.53 [95% CI, 0.96–6.72], p=0.062). Incidence of gastrointestinal bleeding in patients with CrCl 15–30 mL/min was 4.3% in edoxaban and 1.6% in placebo (adjusted HR, 2.61 [95% CI, 0.79–8.68], p=0.12). Incidence of all-cause death in patients with CrCl >50, 30–50 and 15–30 mL/min was 5.8%, 6.8% and 15.2%, respectively, in edoxaban, and 7.0%, 6.3% and 15.5%, respectively, in placebo (no significant intergroup differences).

Conclusions

Incidence of S/SEE, major bleeding and all-cause death increased with declining renal function in elderly NVAF patients. Edoxaban 15 mg remained superior to placebo in preventing S/SEE, even in those with moderate to severe renal dysfunction. Incidence of major bleeding in patients with severe renal dysfunction was higher (non-significantly) with edoxaban than with placebo.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Daiichi-Sankyo Co., Ltd.

Comparison of multicolor scanning laser ophthalmoscopy and optical coherence tomography angiography for detection of microaneurysms in diabetic retinopathy

This study aimed to evaluate the usefulness of multicolor (MC) scanning laser ophthalmoscopy (MC-SLO) in detecting microaneurysm (MA) in eyes with diabetic retinopathy (DR). This was a retrospective cross-sectional study. Eyes with DR underwent fluorescein angiography (FA), MC-SLO, optical coherence tomography angiography (OCTA), and color fundus photography (CFP) were analyzed. The foveal region was cut in an 6 × 6 mm image and the number of MA in each image was counted by retina specialists to determine the sensitivity and positive predictive value. FA results were used as the ground standard. MAs were classified as those with early, late, or no dye leakage based on FA images. Fifty-four eyes of 35 patients with an average age of 64.5 ± 1.24 years were included. The sensitivity of MA detection was 37.3%, 15.3%, and 4.12% in MC-SLO, OCTA, and CFP, respectively (P < 0.01 in each pair).The positive predictive value was 66.4%, 46.4%, and 27.6% in MC, OCTA, and CFP, respectively (P < 0.01 in each pair). Sensitivity for MAs with early leakage was 36.4% in MC-SLO, which was significantly higher than 4.02% in OCTA. MC-SLO was more useful in detecting MA in eyes with DR than OCTA.

Silicone oil versus gas tamponade for primary rhegmatogenous retinal detachment treated successfully with a propensity score analysis: Japan Retinal Detachment Registry

Background/aims

To compare the effects of silicone oil tamponade (SOT) to that of gas tamponade (GT) on the best-corrected visual acuity (BCVA) after successful vitrectomy for retinal detachment (RD).

Methods

A retrospective, multicentre, nationwide study with RD who were registered in the Japan-RD Registry. All cases with RD treated with successful vitrectomy between February 2016 and March 2017 were studied. A propensity score matching was performed using the preoperative findings as covariates to adjust the relevant confounders. The primary outcome was the estimated mean difference of the postoperative BCVA in 6 months between eyes treated with SOT to those treated with GT.

Results

Of the 3446 cases registered, 2097 cases met the entry criteria. There were 2042 eyes that had GT and 55 eyes that had SOT. Primary success was defined as a reattached retina with no tamponade at 6 months. After propensity score matching, each group contained 40 cases. The preoperative BCVA was 0.966±0.738 logMAR units in the GT group and 1.270±0.945 logMAR units in the SOT group (p=0.177). Six months postoperatively, the BCVA in the GT group was significantly better at 0.309 logMAR units in the GT group than the 0.671 logMAR units in the SOT group (p=0.002).

Conclusions

Even after successful surgery for RD, eyes that experienced SOT had poorer BCVA than eyes treated with GOT. SOT should be considered cautiously.

Precis

Propensity score analysis of eyes with rhegmatogenous RD showed that postoperative vision was worse in eyes treated once with silicone oil than with gas even after completely successful surgery.

Low bleeding and stroke rates with minor age-dependent increase confirm the safety and effectiveness of edoxaban in patients with atrial fibrillation across age groups: Two-year results from ETNA-AF

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo

Background

Age is a risk factor for ischemic stroke and bleeding in patients with atrial fibrillation (AF). The large dataset from the global prospective, noninterventional ETNA-AF program allows for analysis of the impact of age on clinical events in AF patients treated with edoxaban.

Purpose

Evaluate the safety and effectiveness of edoxaban by age subgroups and the impact of age on clinical events.

Methods

Baseline patient characteristics, thromboembolic and bleeding events, and mortality data were collected from patients with 2-year follow-up in ETNA-AF program and analyzed in defined age subgroups. Cox regression analysis was conducted using age as a continuous variable and clinical events as outcome variables.

Results

A total of 27,617 patients were categorized into four age subgroups: &lt;65, 65-74, 75-84 and ≥85 years. Patient demographics and baseline characteristics are shown in the Table. Percentage of male, mean body weight, and mean creatinine clearance decreased with age, whereas percentages of patients with heart failure, patients on reduced dose edoxaban 30 mg, mean stroke and bleeding risk scores increased with age. The annualized rates of ischemic stroke and major bleeding increased with age, yet remained low. Importantly, the rate of intracranial hemorrhage was low across age groups, including the ≥85 years group.  The hazard ratio (HR) for ischemic stroke was 1.041 (95%CI 1.028-1.053), ie. with a 1-year increase in age, the risk of ischemic stroke increased by 4.1%. The HRs for other clinical events were: major bleeding 1.044 (95%CI 1.033-1.055), intracranial hemorrhage 1.027 (95%CI 1.007-1.046), major gastrointestinal bleeding 1.065 (95%CI 1.048-1.081), all-cause mortality 1.086 (95%CI 1.079-1.093).

Conclusion

Two-year follow-up data from the global ETNA-AF program support the use of edoxaban as a safe and effective treatment for AF patients across all age groups, including the very elderly, in routine clinical care. The impact of age on the risk of ICH was smaller than that of ischemic stroke and major bleeding. &lt;65 yr(N = 4,278) ≥65-74 yr(N = 9,396) ≥75-84 yr(N = 10,728) ≥85 yr(N = 3,214) Age [years], mean (SD)Male, %Weight [kg], mean (SD) 57.3 (6.6)72.580.6 (20.3) 69.9 (2.9)61.973.0 (17.7) 79.1 (2.8)53.968.0 (16.0) 87.9 (2.8)42.260.1 (14.9) CrCL [mL/min], mean (SD)CHA2DS2-VASc, mean (SD)Mod. HAS-BLED≠, mean (SD) 101.8 (33.7)1.6 (1.1)1.4 (1.0) 75.3 (22.3)2.8 (1.2)2.5 (1.1) 57.9 (18.1)4.1 (1.2)2.7 (1.0) 42.5 (14.3)4.4 (1.3)2.7 (1.0) 2-year clinical events Major Bleeding (ISTH)%/yr [95% CI] Intracranial Hemorrhage%/yr [95% CI] Major GI Bleeding%/yr [95% CI] 0.49 [0.35; 0.68] 0.18 [0.09; 0.30] 0.22 [0.13; 0.36] 0.84 [0.70; 0.99] 0.26 [0.18; 0.34] 0.34 [0.26; 0.44] 1.16 [1.00; 1.32] 0.31 [0.23; 0.40]0.60 [0.49; 0.72] 1.88 [1.51; 2.30] 0.46 [0.29; 0.69]1.19 [0.90; 1.53] Any Stroke%/yr [95% CI]Ischemic Stroke%/yr [95% CI]Hemorrhagic Stroke%/yr [95% CI] 0.54 [0.38; 0.73]0.38[0.26; 0.56]0.12[0.06; 0.23] 0.79 [0.66; 0.94]0.59[0.47; 0.71]0.19[0.13; 0.27] 1.15 [1.00; 1.32]0.89[0.76; 1.04]0.23[0.16; 0.31] 1.53 [1.21; 1.92]1.21[0.92; 1.56]0.320.18; 0.52] All-cause Death%/yr [95% CI]CV Death (sensitivity)%/yr [95% CI] 1.05 [0.83; 1.32]0.51[0.36; 0.70] 1.82 [1.62; 2.04]0.83[0.69; 0.98 3.51 [3.25; 3.80]1.65[1.47; 1.84] 9.08 [8.27; 9.96]4.16[3.62; 4.77] ≠Excluding labile INR.

Annualized clinical event rates during two-year follow-up are low in 27,617 atrial fibrillation patients on edoxaban: results from the global noninterventional ETNA-AF program

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo

Background and Purpose

The large global Edoxaban Treatment in routiNe clinical prActice (ETNA)-AF program was designed to assess the safety and effectiveness of edoxaban, complementing randomized clinical trials.

Methods

ETNA collects data on patient characteristics and clinical events in unselected AF patients treated with edoxaban for stroke prevention, integrating data from prospective, noninterventional studies conducted in Europe, Japan, South Korea, and Taiwan.

Results

The 2-year follow-up analysis included 27,617 patients, the majority of whom (82.6%) received the recommended dose according to the local label. At baseline, the mean age was 73.6 ± 9.8 years and 58.1% were male. Half of the patients (50.5%) were 75 years or older. The CHA2DS2-VASc score was 3.3 ± 1.5, and the modified HAS-BLED score was 2.4 ± 1.1. The rate of ischemic stroke was 0.74%/yr, major bleeding 1.02%/yr, intracranial hemorrhage 0.29%/yr, and major gastrointestinal (GI) bleeding 0.51%/yr. All-cause mortality was 3.13%/yr, and cardiovascular (CV) mortality 1.45%/yr (see Table).

Conclusion

The rates of ischemic stroke and major bleeding events remained low globally and across regions during the two-year follow-up period in AF patients treated with edoxaban. Global(N = 27,617) Japan(N = 11,330) Korea/Taiwan(N = 2,870) Europe(N = 13,417) Age, mean (SD) 73.6 (9.8) 74.2 (10.1) 71.6 (9.5) 73.6 (9.5) Gender, male, % 58.1 59.4 60.2 56.6 Weight [kg], median (IQR) 69 (58, 81) 59 (51, 68) 65 (57, 73) 80 (70, 90) CrCL [mL/min], mean (SD) 68.7 (28.4) 63.9 (25.8) 63.4 (23.7) 74.4 (30.5) CHA2DS2-VASc, mean (SD) 3.3 (1.5) 3.5 (1.7) 3.1 (1.4) 3.2 (1.4) Mod. HAS-BLED≠, mean (SD) 2.4 (1.1) 2.4 (1.1) 2.3 (1.1) 2.5 (1.1) Edoxaban 60mg/30mg, % 53.5 / 46.5 27.6 / 72.4 48.8 / 51.2 76.4 / 23.6 2-year clinical events, N (%/year), [95% CI] Major Bleeding (ISTH) 477 (1.02) [0.93; 1.11] 188 (1.09) [0.94; 1.25] 51 (1.00) [0.74; 1.31] 238 (0.97) [0.85; 1.11] Intracranial Hemorrhage 135 (0.29) [0.24; 0.34] 68 (0.39) [0.30; 0.50] 17 (0.33) [0.19; 0.53] 50 (0.20) [0.15; 0.27] Major GI Bleeding 241 (0.51) [0.45; 0.58] 122 (0.70) [0.58; 0.84] 18 (0.35) [0.21; 0.55] 101 (0.41) [0.33; 0.50] Any Stroke 455 (0.97) [0.88; 1.06] 244 (1.41) [1.24; 1.60] 54 (1.06) [0.80; 1.38] 157 (0.64) [0.54; 0.75] Ischemic Stroke 347 (0.74) [0.66; 0.82] 179 (1.03) [0.89; 1.20] 43 (0.84) [0.61; 1.13] 125 (0.51) [0.42; 0.61] Hemorrhagic Stroke 99 (0.21) [0.17; 0.26] 67 (0.39) [0.30; 0.49] 9 (0.17) [0.08; 0.33] 23 (0.09) [0.06; 0.14] All-cause Death 1479 (3.13) [2.98; 3.30] 470 (2.70) [2.46; 2.96] 72 (1.40) [1.09; 1.76] 937 (3.80) [3.56; 4.05] CV Death 684 (1.45) [1.34; 1.56] 140 (0.80) [0.68; 0.95] 26 (0.50) [0.33; 0.74] 518 (2.10) [1.92; 2.29] ≠Excluding labile INR.

Circular dichroism and resonance Raman spectroscopies of bacteriochlorophyll b-containing LH1-RC complexes

The core light-harvesting complexes (LH1) in bacteriochlorophyll (BChl) b-containing purple phototrophic bacteria are characterized by a near-infrared absorption maximum around 1010 nm. The determinative cause for this ultra-redshift remains unclear. Here, we present results of circular dichroism (CD) and resonance Raman measurements on the purified LH1 complexes in a reaction center-associated form from a mesophilic and a thermophilic Blastochloris species. Both the LH1 complexes displayed purely positive CD signals for their Q_y transitions, in contrast to those of BChl a-containing LH1 complexes. This may reflect differences in the conjugation system of the bacteriochlorin between BChl b and BChl a and/or the differences in the pigment organization between the BChl b- and BChl a-containing LH1 complexes. Resonance Raman spectroscopy revealed remarkably large redshifts of the Raman bands for the BChl b C3-acetyl group, indicating unusually strong hydrogen bonds formed with LH1 polypeptides, results that were verified by a published structure. A linear correlation was found between the redshift of the Raman band for the BChl C3-acetyl group and the change in LH1-Q_y transition for all native BChl a- and BChl b-containing LH1 complexes examined. The strong hydrogen bonding and π-π interactions between BChl b and nearby aromatic residues in the LH1 polypeptides, along with the CD results, provide crucial insights into the spectral and structural origins for the ultra-redshift of the long-wavelength absorption maximum of BChl b-containing phototrophs.

Alpelisib plus fulvestrant for PIK3CA-mutated, hormone receptor-positive, human epidermal growth factor receptor-2-negative advanced breast cancer: final overall survival results from SOLAR-1

BACKGROUND

Activation of the phosphatidylinositol-3-kinase (PI3K) pathway via PIK3CA mutations occurs in 28%-46% of hormone receptor-positive (HR+), human epidermal growth factor receptor-2-negative (HER2-) advanced breast cancers (ABCs) and is associated with poor prognosis. The SOLAR-1 trial showed that the addition of alpelisib to fulvestrant treatment provided statistically significant and clinically meaningful progression-free survival (PFS) benefit in PIK3CA-mutated, HR+, HER2- ABC.

PATIENTS AND METHODS

Men and postmenopausal women with HR+, HER2- ABC whose disease progressed on or after aromatase inhibitor (AI) were randomized 1 : 1 to receive alpelisib (300 mg/day) plus fulvestrant (500 mg every 28 days and once on day 15) or placebo plus fulvestrant. Overall survival (OS) in the PIK3CA-mutant cohort was evaluated by Kaplan-Meier methodology and a one-sided stratified log-rank test was carried out with an O'Brien-Fleming efficacy boundary of P ≤ 0.0161.

RESULTS

In the PIK3CA-mutated cohort (n = 341), median OS [95% confidence interval (CI)] was 39.3 months (34.1-44.9) for alpelisib-fulvestrant and 31.4 months (26.8-41.3) for placebo-fulvestrant [hazard ratio (HR) = 0.86 (95% CI, 0.64-1.15; P = 0.15)]. OS results did not cross the prespecified efficacy boundary. Median OS (95% CI) in patients with lung and/or liver metastases was 37.2 months (28.7-43.6) and 22.8 months (19.0-26.8) in the alpelisib-fulvestrant and placebo-fulvestrant arms, respectively [HR = 0.68 (0.46-1.00)]. Median times to chemotherapy (95% CI) for the alpelisib-fulvestrant and placebo-fulvestrant arms were 23.3 months (15.2-28.4) and 14.8 months (10.5-22.6), respectively [HR = 0.72 (0.54-0.95)]. No new safety signals were observed with longer follow-up.

CONCLUSIONS

Although the analysis did not cross the prespecified boundary for statistical significance, there was a 7.9-month numeric improvement in median OS when alpelisib was added to fulvestrant treatment of patients with PIK3CA-mutated, HR+, HER2- ABC. Overall, these results further support the statistically significant prolongation of PFS observed with alpelisib plus fulvestrant in this population, which has a poor prognosis due to a PIK3CA mutation. CLINICALTRIALS.

GOV ID

NCT02437318.

Prediction of atrial fibrillation by 12-lead electrocardiogram parameters in patients without structural heart disease

Background

Recently, the analysis of electrocardiogram (ECG) waveform by artificial intelligence has been reported to pick out those who have atrial fibrillation (AF) or have a high potential of developing AF, which, however, cannot explain the mechanisms or algorisms for the prediction from its nature.

Purpose

The purpose of this study is to conduct a comprehensive analysis to investigate the difference of weighting in predicting capability for AF among hundreds of automatically-measured ECG parameters using a single ECG at sinus rhythm.

Methods and results

Out of Shinken Database 2010–2017 (n=19170), 12825 patients were extracted, where those with ECG showing AF rhythm at the initial visit (including all persistent/permanent AF and a part of paroxysmal AF) and those with structural heart diseases were excluded. Out of 639 automatically-measured ECG parameters in MUSE data management system (GE Healthcare, USA), 438 were used. [Analysis 1] A predicting model for paroxysmal AF were determined by logistic regression analysis (Total, n=12825; paroxysmal AF, n=1138), showing a high predictive capability (AUC = 0.780, p&lt;0.001). In this model, the relative contribution of ECG parameters (by coefficient of determination) according to the time phase were P:72.4%, QRS:32.7%, and ST-T:13.7%, respectively (Figure A). [Analysis 2] Excluding AF at baseline, a predicting model for new-developed AF were determined by Cox regression analysis (Total, n=11687; new-developed AF, n=87), showing a high predictive capability (AUC = 0.887, p&lt;0.001). In this model, the relative contribution of parameters (by log likelihood) according to the time phase were P:40.8%, QRS:42.5%, and ST-T:24.9%, respectively (Figure B).

Conclusions

We determined ECG parameters that potentially contribute to picking up existing AF or predicting future development of AF, where the measurement of P wave strongly contributed in the former whereas all time phases were similarly important in the latter.

Weighting of parameters to predict AF

Funding Acknowledgement

Type of funding source: Private hospital(s). Main funding source(s): Self funding of the institute

Real-world effectiveness and the safety of anticoagulant treatment in elderly non-valvular atrial fibrillation in the ANAFIE registry, the largest real-world elderly AF registry

Background

The optimal anticoagulant regimen for elderly AF has not been well elucidated, because this population, especially the very elderly (≥85 years), have not been sufficiently represented in most randomized controlled clinical trials for stroke prevention in non-valvular AF (NVAF).

Purpose

The ANAFIE registry was designed to evaluate the real-world anticoagulant treatment status of elderly (≥75 years) NVAF patients including &gt;8,000 very elderly patients. In this main analysis of the ANAFIE, the incidence of stroke or systemic embolic events (stroke/SEE), and major bleeding were compared between warfarin (WF) and direct oral anticoagulants (DOACs).

Methods

A total of 33,018 NVAF patients aged ≥75 years was enrolled in the ANAFIE, and followed for 2 years. The incidence of stroke/SEE and major bleeding by type of anticoagulants (WF and all DOACs) was estimated using Kaplan-Meier method. Hazard ratio (HR) and 95% confidence interval (95% CI) were calculated by Cox proportional hazard model.

Results

In the analysis set of 32,099 patients, the mean age was 81.5 years. 23,738 (74%) were &lt;85 years and 8,361 (26.0%) were ≥85 years. 92.5% of the whole population used anticoagulants including WF (27.6%) or DOACs (72.3%). The ratio of each DOAC was dabigatran 7.8%, rivaroxaban 21.5%, apixaban 26.9% and edoxaban 16.1%. Stroke/SEE and major bleeding was observed in 396 patients (1.24/100 patient-years [py]) and 279 patients (0.87/100py). The time in therapeutic range for patients &lt;85 years and ≥85 years in the WF group was 76.7% and 72.2%, respectively. The incidence of stroke/SEE was numerically lower in patients taking any DOAC vs. WF regardless of age group (&lt;85 years [HR 0.83] and ≥85 years [HR 0.71]). Major bleeding was also lower vs. WF in both age groups (&lt;85 years [HR 0.60] and ≥85 years [HR 0.65]).

Conclusion

In elderly NVAF patients enrolled in the ANAFIE registry, the incidence of stroke/SEE and major bleeding was lower in patients taking a DOAC compared with WF for all patients ≥75 years, even for very elderly patients.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Daiichi Sankyo Co., Ltd.

Risk factors of major bleeding in elderly atrial fibrillation patients from the ANAFIE registry

Background

Bleeding is associated with shorter life expectancy during anticoagulant treatment in atrial fibrillation (AF) patients. Prior studies showed bleeding during anticoagulant treatment occurred more frequently in elderly AF patients than in younger AF patients. HAS-BLED score is a risk assessment tool for bleeding. However, since it was developed from the database of patients with warfarin, it has not been clarified whether this score is applicable in the era of direct oral anticoagulant (DOACs), especially for elderly AF patients.

Purpose

All Nippon AF In the Elderly (ANAFIE) registry was designed to obtain real-world information regarding patients with non-valvular AF (NVAF) aged ≥75 years, including current status of anticoagulant therapy and prognosis. The present study aimed to determine factors that associate with major bleeding for elderly NVAF patients using the dataset of ANAFIE registry conducted in Japan.

Methods

Total of 32,099 patients aged ≥75 years with NVAF were enrolled in ANAFIE registry, and followed for 2 years. Incidence rates of major bleeding for total population, &lt;85 years old group and ≥85 years old group were estimated using Kaplan-Meier method. Cox proportional hazards model was used to determine independent predictors of major bleeding. The factors included in the model were selected by backward elimination procedure.

Results

Mean age was 81.5 years. 23,738 (74.0%) was &lt;85 years old and 8,361 (26.0%) was ≥85 years old. 92.5% of whole population used anticoagulants including warfarin (27.6%) or DOACs (72.3%). Major bleeding occurred in 279 patients at 12 months with 189 in &lt;85 years and 90 in ≥85 years old group. The cumulative incidence rate of major bleeding at 12 months by Kaplan-Meier method was 0.9% in whole patients, and was slightly higher in ≥85 years than in &lt;85 years old group (1.1% vs 0.8%). In multivariate analysis of the whole patients, history of major bleeding (hazard ratio [HR]: 2.17), severe hepatic dysfunction (HR: 3.62), malignancy (HR: 1.52), falling within a year (HR: 2.07), antiplatelet use (HR: 1.37) and warfarin use (HR: 1.81) emerged as independent predictors of major bleeding. Severe hepatic dysfunction (HR: 9.17), HbA1c &lt;6.0% (HR: 2.19) and dementia (HR: 2.00) were associated with major bleeding in patients only in aged ≥85 years. On the other hand, proton pump inhibitor use (HR: 1.36), creatinine clearance &lt;30 mL/min (HR: 1.53) and polypharmacy (HR: 1.61) were associated with major bleeding only in those aged &lt;85 years.

Conclusion

Among elderly (≥75 years old) Japanese NVAF patients in the era of DOACs, prior major bleeding, severe hepatic dysfunction, malignancy, falling within a year, antiplatelet use and warfarin use were identified as independent predictors of major bleeding. Impact of some predictors differed between the 2 age groups (&lt;85 years vs ≥85 years).

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Daiichi Sankyo Co., Ltd.

Risk factors associated with stroke/systemic embolic events in elderly non-valvular atrial fibrillation patients in the ANAFIE registry, the largest real-world elderly AF registry

Background

Since prevalence of atrial fibrillation (AF) is increasing by aging, AF in elderly has been recognized as a big burden to keep long lasting healthy life worldwide. CHADS2 and CHA2DS2-VASc scores are commonly used for stroke risk assessment for AF, but predictors for elderly was not well elucidated, especially for very elderly (≥85 years old) patients.

Purpose

All Nippon AF In the Elderly (ANAFIE) registry was designed to evaluate a real-world treatment status of elderly (≥75 years old) non-valvular AF (NVAF) patients, including anticoagulant therapy and outcomes. The present analysis aimed to identify factors for stroke/systemic embolic events (SEE) of elderly NVAF patients using the dataset of ANAFIE registry, which was conducted in Japan.

Methods

Total of 32,099 patients aged ≥75 years with NVAF were enrolled in ANAFIE registry, and followed for 2 years. Incidence of stroke/SEE for total population, &lt;85 years old group and ≥85 years old group was estimated using Kaplan-Meier method. Cox proportional hazards model was used to determine independent predictors of stroke/SEE. The factors included in the model were selected by backward elimination procedure.

Results

Mean age was 81.5 years. 23,738 (74%) was &lt;85 years old and 8,361 (26%) was ≥85 years old. Women were more prevalent in ≥85 years old than in &lt;85 years old group (53.2 vs 39.0%). Mean CHADS2 and CHA2DS2-VASc scores in the ≥85 years group were 3.0 and 4.7, and 2.8 and 4.4 in the &lt;85 years group, respectively. 92.5% of whole population used anti-coagulants including warfarin (27.6%) or direct oral anticoagulants (DOACs) (72.3%). Stroke/SEE occurred in 396 patients at 12 month with 256 in &lt;85 years old and 140 in ≥85 years old group. The cumulative incidence rate of stroke/SEE by Kaplan-Meier method at 12 months was 1.2% in the whole patients, and was higher in ≥85 years than in &lt;85 years old group (1.7% vs 1.1%). In the multivariate analysis using the whole patients, age ≥85 years (hazard ratio [HR]: 1.27), history of major bleeding (HR: 1.93), persistent AF (HR: 1.64), longstanding persistent and permanent AF (HR: 1.61), high systolic blood pressure (130-&lt;140 [HR: 1.43], ≥140 [HR: 1.44]), prior stroke (HR: 2.09), dementia (HR: 1.34), creatinine clearance &lt;30 mL/min (HR: 1.82) emerged as independent predictors. Independent predictors for stroke/SEE were almost similar between &lt;85 and ≥85 years old group except hypertension and diabetes. High blood pressure was associated with stroke/SEE only in patients aged &lt;85 years, and high blood sugar was only associated in patients aged ≥85 years.

Conclusion

Among elderly NVAF patients in the era of DOACs, higher age (≥85 years), type of AF, prior major bleeding, high blood pressure, prior stroke, dementia, and low creatinine clearance were identified as independent predictors of stroke/SEE. The blood pressure and blood sugar control differently affected &lt;85 years vs ≥85 years old group.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Daiichi Sankyo Co., Ltd.

Edoxaban treatment of elderly patients with atrial fibrillation in routine clinical practice: 1-year results of the non-interventional Global ETNA-AF program

Background

The prevalence of atrial fibrillation (AF) and the need for appropriate anticoagulation increase with age. The benefit/risk profile of direct oral anticoagulants such as edoxaban in elderly population with AF in regular clinical practice is therefore of particular interest.

Purpose

Analyses of Global ETNA-AF data were performed to report patient characteristics, edoxaban treatment, and 1-year clinical events by age subgroups.

Methods

Global ETNA-AF is a multicentre, prospective, noninterventional program conducted in Europe, Japan, Korea, Taiwan, and other Asian countries. Demographics, baseline characteristics, and 1-year clinical event data were analysed in four age subgroups.

Results

Of 26,823 patients included in this analysis, 50.4% were ≥75 years old and 11.6% were ≥85 years. Increase in age was generally associated with lower body weight, lower creatinine clearance, higher CHA2DS2-VASc and HAS-BLED scores, and a higher percentage of patients receiving the reduced dose of 30 mg daily edoxaban. At 1-year, rates of ISTH major bleeding and ischaemic stroke were generally low across all age subgroups. The proportion of intracranial haemorrhage within major bleeding events was similar across age groups. All-cause mortality increased with age more than cardiovascular mortality.

Conclusion

Data from Global ETNA-AF support the safety and effectiveness of edoxaban in elderly AF patients (including ≥85 years) in routine clinical care with only a small increase in intracranial haemorrhage. The higher all-cause mortality with increasing age is not driven by cardiovascular causes.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Daiichi Sankyo

Clinical implications of assessment of apixaban levels in elderly atrial fibrillation patients: J-ELD AF Registry sub-cohort analysis

Background

Randomized clinical trials demonstrated the efficacy and safety of apixaban in preventing stroke in patients with atrial fibrillation (AF). However, data on distribution of apixaban levels and their relationships with clinical outcomes are limited.

Purpose

To evaluate the distribution of blood apixaban concentration and its relationship with clinical outcomes.

Method

The J-ELD AF Registry is a large-scale, multicenter prospective observational study of Japanese non-valvular AF patients aged ≥75 years taking on-label dose (standard dose of 5 mg bid or reduced dose of 2.5 mg bid) of apixaban. Among the entire cohort (3,015 patients from 110 institutions), plasma apixaban levels at trough was measured by anti-Xa assay (Api-AXA) in 943 patients. The 943 patients were divided into 2 groups by the apixaban dose (standard dose [n=431] and reduced dose [n=512]) and each group was further divided into 2 groups with low and high Api-AXA levels compared with the median value.

Results

In patients with standard dose, the incidence rates (/100 person-years) of stroke or systemic embolism (1.48 and 1.99), bleeding requiring hospitalization (0.98 and 1.49), and total deaths (0.49 and 0.99) were comparable between low and high Api-AXA groups, respectively. In patients with reduced dose, although the incidence rates (/100 person-years) of stroke or systemic embolism (0.84 and 1.68) were comparable, bleeding requiring hospitalization (0.42 and 4.64), and total deaths (2.52 and 6.65) were significantly higher in high Api-AXA group than in low Api-AXA group. Multivariable Cox regression analysis revealed that in patients with reduced dose, high Api-AXA level was independently associated with bleeding requiring hospitalization (HR 12.12, 95% CI: 1.56–94.22, P=0.017) and insignificantly with total deaths (HR 2.15, 95% CI: 0.83–5.55, P=0.116).

Conclusions

High trough apixaban level in patients with standard dose was not associated with adverse events, while that in patients with reduced dose was associated with bleeding requiring hospitalization and total deaths. Measurement of apixaban levels may be informative in elderly patients indicated for reduced dose possibly with the intent of risk stratification and decision making.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Bristol-Myers Squibb K.K.

Impact of creatinine clearance on clinical outcomes in elderly atrial fibrillation patients receiving apixaban: J-ELD AF Registry sub-analysis

Background

Randomized clinical trials demonstrated the efficacy and safety of apixaban in preventing stroke in patients with atrial fibrillation (AF). However, data on patients with low creatinine clearance (CCr), especially CCr 15–29 mL/min, are limited.

Methods

The J-ELD AF Registry is a large-scale, multicenter prospective observational study of Japanese non-valvular AF patients aged ≥75 years taking on-label dose (standard dose of 5 mg bid or reduced dose of 2.5 mg bid) of apixaban. The enrollment period was from September 2015 to August 2016, and the observation period for each patient was 1 year. The entire cohort (3,015 patients from 110 institutions) was divided into three CCr subgroups: CCr ≥50 mL/min (n=1,165, 38.6%), CCr 30–49 mL/min (n=1,395, 46.3%), and CCr 15–29 mL/min (n=455, 15.1%).

Results

Most patients (74.3%) in the CCr ≥50 group received the standard apixaban dose, and most (97.4%) in the CCr 15–29 group received the reduced apixaban dose. The average age was 79.2 years for the CCr ≥50 group, 82.5 years for the CCr 30–49 group, and 85.6 years for the CCr 15–29 group. The lower CCr value group included more female patients, had lower body weight, and less cases of paroxysmal AF, as well as more cases of heart failure, peripheral artery disease, and myocardial infarction as comorbidities. The CHA2DS2-VASc and HAS-BLED scores were 4.2±1.2 and 2.4±0.8 for the CCr ≥50 group, 4.5±1.2 and 2.4±0.8 for the CCr 30–49 group, and 4.9±1.2 and 2.4±0.7 for the CCr 15–29 group, respectively. Kaplan Meier curves for cumulative incidence of events are shown in Figure. The event incidence rates (/100 person-years) were 1.76, 1.39, and 1.67 for stroke or systemic embolism (log rank p=0.762), 1.39, 1.93, and 3.13 for bleeding requiring hospitalization (log rank p=0.159), 1.75, 2.76, and 7.87 for total deaths (log rank p&lt;0.001), and 0.46, 0.84, and 2.62 for cardiovascular deaths (log rank p&lt;0.001), in the CCr ≥50 group, CCr 30–49 group, and CCr 15–29 group, respectively. After adjusting for confounders by Cox regression analysis, CCr 15–29 was an independent risk for total death [hazard ratio (HR) 3.22, 95% confidence interval (CI) 1.68–6.17, with reference to the CCr ≥50 group] and cardiovascular death [HR 3.18, 95% CI 1.06–9.56], but not for stroke or systemic embolism [HR 0.94, 95% CI 0.40–2.24], or bleeding requiring hospitalization [HR 2.00, 95% CI 0.93–4.28].

Conclusions

The incidence of events in each CCr value group was comparable for stroke or systemic embolism and bleeding requiring hospitalization, and significantly higher for total deaths and cardiovascular deaths only in the CCr 15–29 group, in Japanese non-valvular AF patients aged ≥75 years.

Cumulative incidence rates of events

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Bristol-Myers Squibb

Change of the pulmonary vein anatomy after cryoballoon ablation reflecting left atrial reverse remodeling

Background

Cryoballoon ablation (CBA) is a widely used procedure for atrial fibrillation (AF). However, the anatomical change of pulmonary veins (PVs) and the risk factors of PV stenosis is less clear. We aimed to decipher the prevalence and the predictive factors for PV stenosis after CBA.

Methods

We analyzed the data of 320 PVs from 80 patients who underwent CBA for AF (age: 62±10 years, 59 males, 75 paroxysmal AF). All patients underwent pre- and post-procedural cardiac computed tomography (mean 6.7±3.3 months after ablation). We defined the PV stenosis when the cross sectional area of PV was less than 50% compared with that of PV before the CBA.

Results

The average cross sectional PV area decreased significantly after CBA (pre- vs. post-CBA; 2.4±1.0cm2 vs. 2.3±1.1cm2, P&lt;0.001), whereas the volume of left atrium (LA) also decreased significantly (pre- vs. post-CBA; 75.0±23.2cm3 vs. 70.7±21.9cm3, P&lt;0.001). There was a weak but significant correlation between the reduction rate of PV area and that of LA volume (Pearson's correlation coefficient 0.411, p&lt;0.001). Only 6 PV stenosis were revealed, in which area reduction of more than 75% and 50–75% were observed in 2 PVs and 4 PVs, respectively. The incidence of PV stenosis was greater in female (male vs. female; 0.8% vs. 4.8%, P=0.043) and tend to be frequent in left PVs (left PVs vs. right PVs; 3.1% vs. 0.6%: P=0.107). Moreover, patients who developed PV stenosis tended to have lower weight and shorter height (PV stenosis group vs. non-PV stenosis group; 58.2±12.4kg vs. 67.7±13.0kg: P=0.078, 161.2±9.1cm vs. 167.2±8.8cm: P=0.094). There were no significant differences in the number of freezing, minimum temperature and total freezing time between PV stenosis group and non-PV stenosis group.

Conclusions

The ostial PV area decreased significantly but little after CBA, possibly due to LA reverse remodeling. The PV stenosis was more common in women and tend to be frequent in left PVs, lower weight, and shorter height patients, though severe stenosis after CBA was not observed in this study.

Funding Acknowledgement

Type of funding source: None

Heart rate recovery after exercise as a prognostic predictor in patients with atrial fibrillation

Background

A delayed heart rate recovery (HRR) after exercise is related to mortality in sinus rhythm. This study aimed to investigate this concept can be applied to patients with atrial fibrillation (AF).

Methods

We analyzed 483 patients with AF (mean 65 years, male 74%). HRR integral was calculated by integrating the difference in HR in every 3 second between the end of exercise and the specified time after the exercise (30, 60, 120 and 180 seconds). After evaluating the prognostic power of each HRR integral, we selected HRR integral of 180 seconds (180HRR-integral).

Results

We divided the patients into two groups using median value of 180HRR-integral. All-cause mortality, the incidence of cardiovascular events and heart failure events were higher in the poor 180HRR-integral. After adjustment for covariates, the impact of the high 180HRR-integral for all-cause mortality was 3.15 (p=0.057), 1.77 for cardiovascular events (p=0.067) and 1.28 for heart failure events (p=0.519).

Conclusion

Poor HRR was associated with worse prognosis in patients with AF.

Funding Acknowledgement

Type of funding source: None

Recommended and non-recommended edoxaban dosing in patients with atrial fibrillation (AF): one-year clinical events from the Global ETNA-AF non-interventional study (NIS)

Background

In AF patients on direct oral anticoagulants (DOAC), safety and effectiveness vary with dose. This might impact treatment decisions.

Purpose

To investigate the effects of dosing of the DOAC edoxaban in AF patients on safety and effectiveness during 1-year observation in a real-world setting.

Methods

The Global ETNA-AF NIS included 26,823 patients. Baseline data by edoxaban dosing (60mg/30mg) and their influences on the safety (major bleeding [MB], clinically relevant non-major bleeding [CRNMB]), and effectiveness (stroke, systemic embolism, myocardial infarction [MI], death) were investigated (Table).

Results

Figure shows the breakdown by dose (60mg vs 30mg) and recommended (rec) vs non-recommended (non-rec) dosing. Patients on non-rec 30mg vs on rec 60mg edoxaban were older (mean ± SD: 74±9 vs 70±9 y); had lower creatinine clearance (72.2±20.6 vs 85.8±26.8 mL/min); and had more comorbidities, history of MB (2.1% vs 1.1%), and strokes (11.0% vs 8.6%). Non-rec 60mg vs rec 30mg patients were younger (75±9 vs 78±9 y), had fewer comorbidities, history of MB (1.2% vs 2.6%), and strokes (10.2% vs 16.4%). In non-rec 30mg vs rec 60mg, MB was not lower and ischaemic events were not higher. In non-rec 60mg vs rec 30mg, no increase in MB, CRNMB or ischaemic events was seen.

Conclusion

Edoxaban was prescribed at the label recommended dose in the vast majority of patients. Non-rec 30mg patients were sicker than rec 60mg patients while non-rec 60mg patients were less sick than rec 30mg patients. Overall event rates were low, and ischaemic event rates of non-rec 30mg and bleeding event rates of non-rec 60mg were not numerically higher than that of corresponding rec dosing groups.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Daiichi Sankyo

Time course and management of key adverse events during the randomized phase III SOLAR-1 study of PI3K inhibitor alpelisib plus fulvestrant in patients with HR-positive advanced breast cancer

BACKGROUND

Alpelisib (α-selective phosphatidylinositol 3-kinase inhibitor) plus fulvestrant is approved in multiple countries for men and postmenopausal women with PIK3CA-mutated, hormone receptor-positive, human epidermal growth factor receptor 2-negative advanced breast cancer following progression on or after endocrine therapy. A detailed understanding of alpelisib's safety profile should inform adverse event (AE) management and enhance patient care.

PATIENTS AND METHODS

AEs in the phase III SOLAR-1 trial were assessed in patients with and without PIK3CA mutations. The impact of protocol-specified AE-management recommendations was evaluated, including an amendment to optimize hyperglycemia and rash management.

RESULTS

Patients were randomly assigned to receive fulvestrant plus alpelisib (n = 284) or placebo (n = 287). The most common grade 3/4 AEs with alpelisib were hyperglycemia (grade 3, 32.7%; grade 4, 3.9%), rash (grade 3, 9.9%), and diarrhea (grade 3, 6.7%). Median time to onset of grade ≥3 toxicity was 15 days (hyperglycemia, based on fasting plasma glucose), 13 days (rash), and 139 days (diarrhea). Metformin alone or in combination with other antidiabetic agents was used by most patients (87.1%) with hyperglycemia. Preventive anti-rash medication resulted in lower incidence (any grade, 26.7% versus 64.1%) and severity of rash (grade 3, 11.6% versus 22.7%) versus no preventative medication. Discontinuations due to grade ≥3 AEs were lower following more-detailed AE management guidelines (7.9% versus 18.1% previously). Patients with PIK3CA mutations had a median alpelisib dose intensity of 248 mg/day. Median progression-free survival with alpelisib was 12.5 and 9.6 months for alpelisib dose intensities of ≥248 mg/day and <248 mg/day, respectively, compared with 5.8 months with placebo.

CONCLUSIONS

Hyperglycemia and rash occurred early during alpelisib treatment, while diarrhea occurred at a later time point. Early identification, prevention, and intervention, including concomitant medications and alpelisib dose modifications, resulted in less severe toxicities. Reductions in treatment discontinuations and improved progression-free survival at higher alpelisib dose intensities support the need for optimal AE management. CLINICALTRIALS.

GOV ID

NCT02437318.