[Contemporary epidemiology and treatment of hospitalized heart failure patients in real clinical practice in China]

Objective: To observe the etiology, comorbidities, clinical features and treatment patterns of hospitalized patients with heart failure (HF) in China. Methods: Data were collected prospectively on hospitalized patients with HF who were enrolled in China Heart Failure Center Registry Study from 169 participating hospitals from January 2017 to August 2018. In this cross-sectional study, patients were stratified by left ventricular ejection fraction (LVEF) category: heart failure with reduced ejection fraction (HFrEF, LVEF<40%); heart failure with mid-ranged ejection fraction (HFmrEF, 40%≤LVEF<50%) and heart failure with preserved ejection fraction (HFpEF, LVEF≥50%). The clinical data were collected, including demographic information, diagnosis, signs, electrocardiogram, echocardiography, laboratory tests, and treatment. Results: A total of 31 356 hospitalized patients with HF were included, 19 072 (60.8%) were males and the average age was (67.9±13.6) years old. The common causes of HF were hypertension (57.2%), coronary heart disease (54.6%), dilated cardiomyopathy (14.7%), valvular heart disease (9.2%). The common complications were atrial fibrillation/atrial flutter (34.1%), diabetes (29.2%), and anemia (26.7%). 32.8% of patients had a history of hospitalization for HF within the previous 12 months. There were 11 034 (35.2%) patients with HFrEF, 6 825 (21.8%) patients with HFmrEF and 13 497 (43.0%) patients with HFpEF. Compared with patients with HFpEF, patients with HFrEF had a lower systolic blood pressure ((124.7±21.1)mmHg(1 mmHg=0.133 kPa) vs. (134.9±22.9)mmHg), faster heart rate ((85±19) beats/minutes vs. (81±19)beats/minutes), and higher percentage of New York Heart Association (NYHA) class Ⅳ, smoking, alcohol, left bundle branch block, and QRS time≥130 ms, and higher levels of blood uric acid, BNP, and NT-proBNP (all P<0.05). Compared with patients with HFmrEF and HFrEF, patients with HFpEF were older, more women, and higher comorbidity burden including hypertension, atrial fibrillation/atrial flutter, anemia and chronic obstructive pulmonary disease (all P<0.05). HFmrEF took a mid-position between HFrEF and HFpEF in age, gender, heart rate, systolic blood pressure, hypertension, atrial fibrillation/atrial flutter, anemia, and chronic obstructive pulmonary disease (all P<0.05). Patients with HFmrEF had the highest proportion of coronary heart disease, myocardial infarction and percutaneous coronary intervention (all P<0.05). During hospitalization, loop diuretics were used in 90.2% of patients, and intravenous inotropics were used in 20.4% of patients. The use of ACEI/ARB/ARNI, β blockers and aldosterone receptor antagonists at discharge were 71.8%, 79.1% and 83.6% in HFrEF and 69.9%, 75.5% and 72.4% in HFmrEF, respectively. The use of digoxin at discharge was 25.3% (HFrEF 36.7%, HFmrEF 23.1%, HFpEF 17.0%). The rates of cardiac resynchronization therapy and implantable cardioverter defibrillator in HFrEF were 2.7% and 2.1%. Conclusions: Among the hospitalized patients with HF in China, coronary heart disease and hypertension are the mostly prevalent causes. HFpEF accounts for a large proportion of hospitalized patients with HF. HFrEF, HFmrEF and HFpEF have different etiology and clinical features. In real-world, there are still large gaps in the effective application of the guideline recommended therapies to HF patients, especially the non-pharmacological therapy option, which needs to be improved further in China.

5106A pattern-discovery-based outcome predictive tool integrated with clinical data repository: design and a case study on contrast related acute kidney injury

Introduction

Clinical data repositories (CDR) including electronic health record (EHR) data have great potential for outcome prediction and risk modeling. However, most CDRs were only used for data displaying, and using data from CDR for outcome prediction often requires careful study design and sophisticated modeling techniques before a hypothesis can be tested.

Purpose

We built a prediction tool integrated with CDR based on pattern discovery aiming to bridge the above gap and demonstrated a case study on contrast related acute kidney injury (AKI) with the system.

Methods

A cardiovascular CDR integrated with multiple hospital informatics systems was established. For the case study on AKI, we included patients undergoing cardiac catheterization from January 13, 2015 to April 27, 2017, excluding those with dialysis, end-stage renal disease, renal transplant, and missing pre- or post-procedural creatinine. To handle missing data, a prior-history-note composer was designed to fill in structured data of 14 diseases related to cardiovascular problem. Crucial data such as ejective fraction was extracted from the structured reports. AKI was defined according to Acute Kidney Injury Network by increase of serum creatinine from most recent baseline to the post-procedure 7-day peak. To build predictive modeling, we selected 17 variables covered in existing AKI models. Pattern discovery was recently developed as an interpretable predictive model which works on incomplete noisy data. In this study, we developed a pattern discovery based visual analytics tool, and trained it on 70% data up to August 2016 with three interactive knowledge incorporation modes to develop 3 models: 1) pure data-driven, 2) domain knowledge, and 3) clinician-interactive. In last two modes, a physician using the visual analytics could change the variables and further refine the model, respectively. We tested and compared it with other models on the 30% consecutive patients dated afterwards, which is shown in Figure 1.

Results

Among 2,560 patients in the final dataset with 17 pre-procedure variables derived from CDR data, 169 (7.3%) had AKI. We measured 4 existing models, whose areas under curves (AUCs) of receiver operating characteristics curve for the test set were 0.70 (Mehran's), 0.72 (Chen's), 0.67 (Gao's) and 0.62 (AGEF), respectively. A pure data-driven machine learning method achieves AUC of 0.72 (Easy Ensemble). The AUCs of our 3 models are 0.77, 0.80, 0.82, respectively, with the last being top where physician knowledge is incorporated.

Demo and demonstration

Conclusions

We developed a novel pattern-discovery-based outcome prediction tool integrated with CDR and purely using EHR data. On the case of predicting contrast related AKI, the tool showed user-friendliness by physicians, and demonstrated a competitive performance in comparison with the state-of-the-art models.

P1226Very low achieved low-density lipoprotein cholesterol level with alirocumab treatment after acute coronary syndrome: ODYSSEY OUTCOMES

Background

Recent guidelines for cholesterol management recognize uncertainty regarding long-term efficacy and safety of prolonged very low levels of LDL-C on treatment with a PCSK9 inhibitor, including risk of new-onset diabetes. ODYSSEY OUTCOMES used a treat-to-target approach to demonstrate reduction of coronary heart disease death, non-fatal myocardial infarction, ischaemic stroke, or unstable angina (MACE) with the PCSK9 inhibitor alirocumab (ALI) vs placebo (PBO) in 18,924 patients with recent acute coronary syndrome and elevated LDL-C despite intensive statin therapy. ALI was blindly adjusted (75 or 150 mg dose) to target LDL-C 0.6–1.3 mmol/L (25–50 mg/dL). To avoid sustained very low LDL-C, blind substitution of PBO for ALI was intended if 2 consecutive LDL-C levels were <0.39 mmol/L (15 mg/dL). Patients were followed for median of 2.8 years (maximum of 5 years).

Purpose

We report the efficacy and safety of ALI in patients who reached very low LDL-C (consecutively <0.39 mmol/L), compared with matched patients from the PBO group.

Methods

Of 9462 patients randomized to receive ALI, 730 (7.7%) reached very low LDL-C and had substitution of PBO a median 8.3 months after randomization. Using propensity score matching, they were compared (3:1) with 2152 patients initially assigned to PBO. Propensity score matching was also used to compare the incidence of new-onset diabetes in 525 patients without diabetes at baseline who had very low LDL-C levels on ALI with 1675 matched patients in the PBO group. Neurocognitive events and haemorrhagic stroke were also evaluated in relation to very low LDL-C.

Results

Overall, ALI reduced the incidence of MACE (9.5% vs 11.1%; HR 0.85, 95% CI 0.78–0.93; P<0.001). Characteristics used in propensity score matching (and associated with very low LDL-C on ALI) included sex (male), diabetes (present), baseline LDL-C and lipoprotein(a) (lower), region (Asia), statin treatment, smoking, hypertension, and body mass index. Despite being switched to PBO, patients with very low LDL-C on ALI had fewer MACE than matched patients from the PBO group (6.4% vs 8.5%; HR 0.71, 95% CI 0.52–0.98; P=0.039; Figure). Very low LDL-C on ALI was not associated with risk of new-onset diabetes, compared with matched patients from the PBO group (15.1% vs 13.0%; HR 1.10, 95% CI 0.85–1.43; P=0.46). There was no association of very low LDL-C on ALI with neurocognitive events or haemorrhagic stroke.

Conclusions

The overall efficacy of ALI on cardiovascular outcomes was not diminished by the patients who had blinded substitution of PBO for sustained very low LDL-C. Despite a short duration of active treatment, these patients had fewer MACE than matched controls from the PBO group. No adverse consequence of very low LDL-C was identified. However, because patients with sustained very low LDL-C were switched to PBO, the long-term safety of more prolonged very low LDL-C, including risk of new-onset diabetes, deserves further study.

Acknowledgement/Funding

Funded by Sanofi and Regeneron Pharmaceuticals

P613Cardiac magnetic resonance imaging derived left ventricular mechanical function in patients with atrial fibrillation and left atrial low voltage zones

Background

The relation of left atrial low voltage zones (LVZ) to left ventricular function in patients undergoing pulmonary vein isolation (PVI) is not known.

Objective

To explore the relationship of left atrial low voltage zones (LVZ) on left ventricular function in patients with atrial fibrillation.

Methods

From June to Nov. 2018, 107 (mean age 67y, 70 men, 73 persistent AF) consecutive patients with symptomatic AF underwent a PVI with LVZ mapping. Before PVI the left ventricular ejection fraction (EF) and stroke volume (SV) were measured by cardiac magnetic resonance imaging (CMR). From feature-tracking of CMR-cine images left ventricular global, systolic and diastolic longitudinal strains (GLS), circumferential strains (GCS) and radial strains (GRS) were calculated.

Results

Of 59 patients CMR scanning in sinus rhythm was performed, LVZ were present in 24 patients.

LVEF was significantly lower in patients with left atrial LVZ (62±9% vs. 55±15%) (p=0,03). Left ventricular stroke volume was significantly decreased by the extent of LVZ (94±23 vs. 72±21ml), (p=0,03).

The left ventricular diastolic strains during ventricular filling (caused by atrial contraction) of GLS (r=−0,52), GCS (r=−0,65) and GRS (r=−0,65) were highly signifcantly correlated to the occurence and extent of LVZ (each p<0,001 respectively).

The only systolic ventricular strain was GLS, which decreased (r=−0,3, p=0,03) by the occurance of atrial low voltage.

Conclusion

The active, atrial part of diastolic left ventricular filling properties is impaired by the occurrence and extent of left atrial LVZ. In patients with left atrial LVZ the left ventricular stroke volume and ejection fraction is decreased already in sinus rhythm. It seems possible that atrial mechanical dysfunction and presence of atrial low voltage maybe predicted by LV diastolic strain analysis.

P605Correlation of left atrial phasic transport function and arrhythmogenic substrate in patients with atrial fibrillation: cardiac magnetic resonance feature tracking and bipolar voltage mapping

Background

Bipolar voltage mapping is a widely accepted approach to identify areas of arrhythmogenic substrate in patients presenting for atrial fibrillation (AF) ablation.

However, until now little is known about the correlation of left atrial (LA) bipolar voltage distribution and LA transport function.

Purpose

To study the impact of LA low voltage zones (LVZ) on LA transport function.

Methods

107 consecutive patients presenting for ablation of symptomatic AF (34 paroxysmal AF, 73 persistent AF) were prospectively enrolled. Each patient underwent cardiac magnetic resonance imaging (CMR) within 24 hours prior to the ablation procedure. 59 patients were in sinus rhythm (SR) and 48 in AF. LA phasic indexed volumes (LAVi) and ejection fractions were calculated using biplane area length formula. In addition LA phasic strains and strain rates were analyzed using dedicated software (Figure 1A & B).

LA bipolar voltage mapping was performed prior to beginning of ablation in sinus rhythm using a 3-dimensional mapping system and LVZ were defined as areas of bipolar voltage <0.5mV.

Results

LVZ were present in 47 patients (23 in SR). The area of LVZ was 14.6cm2 (5.3–34.0). For patients in AF at the time of CMR only elevated minimal and maximal LAVi (p=0.001 and p=0.002 respectively) but no LA functional parameter was predictive for the occurrence of LVZ. In contrast for patients in SR all LA phasic volumes (endsystolic, pre atrial contraction and enddiastolic LAVi) and LA function parameters (passive, active and total ejection fraction (EF), reservoir, conduit and booster pump strains and strain rates) were predictive for the occurrence of LVZ. After clustered and pooled multivariate logistic regression only impaired booster pump strain rate was still predictive for occurrence of LVZ (OR 0.974, 95% CI 0.950–0.998, p=0.036).

In addition Pearson correlation analysis revealed a strong link between LA booster pump functional parameters and cm2 expansion of LVZ areas: LA active EF, LA booster pump strain and SR (r=−0.42, p=0.044; r=−0.47, p=0.024; r=−0.65, p=0.001 [Figure 1C] respectively).

Conclusion

For patients in SR LA transport function is closely linked to the occurrence of LA LVZ and outperforms LA volumetric measurements for the prediction of LA LVZ.

Furthermore LA booster pump function parameters show robust correlation to the extension of LA LVZ.

Developmental role of adenosine kinase for the expression of sex-dependent neuropsychiatric behavior

Deficits in social memory, cognition, and aberrant responses to stimulants are common among persons affected by schizophrenia and other conditions with a presumed developmental etiology. We previously found that expression changes in the adenosine metabolizing enzyme adenosine kinase (ADK) in the adult brain are associated with deficits in various cognitive domains. To distinguish between developmental and adult functions of ADK, we used two transgenic mouse lines with widespread disruption of ADK expression in the adult brain, but differences in the onset of ADK deletion. Specifically, we compared Nestin-Cre^+/-:ADK-flox^fl/fl (ADK^ΔBrain) mice with global loss of ADK in the whole brain, beginning in mid-gestation and persisting for life, with Gfa2-Cre^+/-:ADK-flox^fl/fl (ADK^ΔAstro) mice that have normal ADK expression throughout development, but lose astrocyte-specific ADK-expression in young adulthood. Because ADK-expression in adulthood is generally confined to astrocytes, adult ADK^ΔAstro mice show a similar expression profile of ADK in key areas of the brain related to neuropsychiatric behavior, compared to adult ADK^ΔBrain mice. We sought to determine a neurodevelopmental role of ADK on the expression of psychiatric behaviors in adult male and female mice. Adult ADK^ΔBrain mice showed significant deficits in social memory in males, significant contextual learning impairments in both sexes, and a hyper-responsiveness to amphetamine in males. In contrast, ADK^ΔAstro mice showed normal social memory and contextual learning but hypo-responsiveness to amphetamine in males. Our results demonstrate a key developmental role of ADK in mediating behaviors in adulthood related to neuropsychiatric disease and support the greater prevalence of these disorders among males.

[Prognostic value of myeloperoxidase concentration in patients with acute coronary syndrome]

Objective: To evaluate the difference of plasma myeloperoxidase (MPO) level in different types of acute coronary syndrome (ACS) patients, and the value of baseline MPO level in predicting short-term and long-term outcomes in patients with ACS. Methods: The study cohort was derived from "the 12th Five-Year" National Science and Technology Support Program Project "Study on Comprehensive Intervention and Prognosis of Acute Coronary Syndrome" . We enrolled all hospitalized ACS patients who were enrolled in "the 12th Five-Year" cohort from January 1, 2011 to December 31, 2013. A total of 630 patients from 20 centers were enrolled. According to the diagnosis, the patients were divided into two groups: ST-segment elevation myocardial infarction (STEMI) group and non-ST-elevation acute coronary syndrome (NSTE-ACS) group. Plasma levels of MPO were measured by ELISA method. Cardiovascular events in the hospital were recorded. All patients were followed-up by telephone, follow-up ended December 31, 2015. The occurrence of major adverse cardiovascular events (MACE, defined as cardiac death, recurrent myocardial infarction, unscheduled coronary revascularization procedure and stroke) and all-cause death were recorded. Logistic regression analysis and Cox regression analysis were used to evaluate the predictive value of baseline MPO levels obtained during hospitalization and the long-term outcomes of ACS patients. Results: A total of 597 ACS patients were enrolled in final analysis. Level of plasma MPO in STEMI patients was significantly higher than that of NSTE-ACS patients (34.02(19.31, 67.87) μg/L vs. 27.25(16.69, 52.92) μg/L, P=0.028) . MPO was not related to the in-hospital cardiovascular events (OR=0.797, 95%CI 0.366-1.737, P=0.569). Follow up was completed in 476 patients, median follow-up time was 796 (32, 1 816) days. There were 23 all-cause deaths and 51 MACE. Plasma MPO level was not an independent predictor for all-cause death (HR=1.434, 95%CI 0.502-4.100, P=0.501) and MACE (HR=1.271, 95%CI 0.662-2.442, P=0.471). Conclusion: In hospitalized ACS patients, level of plasma MPO was significantly higher in STEMI patients than in NSTE-ACS patients, but MPO could not predict the short-term or long-term outcomes in patients with ACS.

[In vivo imaging of breast tumors by a 99mTc radiolabeled probe targeting microRNA-155 in mice models]

OBJECTIVE

MicroRNA-155 (miR-155) is significantly highly expressed in breast cancer, lung cancer, liver cancer and other malignant tumors. This study was to design and construct a radiolabeled probe targeting miR-155 for in vivo imaging in breast cancer.

METHODS

Anti-miR-155 oligonucleotide (AMO-155) was chemically synthesized with 2' OMe modification. Its 5' end was linked with acetyl amine group. After chelated with a bifunctional chelator NHS-MAG3, AMO-155 was radiolabeled with ^99mTc using stannous chloride. The serum stability was evaluated at cellular level. In vivo imaging was performed in MCF-7 tumor bearing mice after the administration of ^99mTc radiolabeled AMO-155 and scramble control probes, respectively. Furthermore, the blocked imaging of tumor bearing mice was obtained after the injection of unlabeled AMO-155 2 hours ahead. MCF-7 and MDA-MB-231 tumor bearing mice with different expression level of miR-155 were imaged, respectively. Quantitative real-time PCR (qRT-PCR) was used to identify the expression level of miR-155 in the bearing tumors.

RESULTS

^99mTc-AMO-155 was prepared with high radiolabeled efficiency (97%), radiochemical purity (greater than 98%), and radioactive specific activity (3.75 GBq/μg). ^99mTc-AMO-155 was stable in fresh human serum for 12 hours. After the administration via tail vein, ^99mTc-AMO-155 displayed significant accumulation in MCF-7 bearing tumors with high expression level of miR-155, whereas ^99mTc-control showed little accumulation. After blocked with unlabeled AMO-155, the tumor could not be visualized clearly after the administration of ^99mTc-AMO-155. Furthermore, ^99mTc-AMO-155 could show the differential expression of miR-155 in vivo. MCF-7 tumor was shown with significantly higher radioactive accumulation than MDA-MB-231, based on its higher expression level of miR-155, which was verified by qRT-PCR.

CONCLUSION

^99mTc-labeled AMO-155 with chemical modification showed good serum stability and in vivo tumor targeting ability. This study provides a potential probe for in vivo imaging of breast cancer.