Primary resistance to integrase strand transfer inhibitors in Spain using ultrasensitive HIV-1 genotyping

BACKGROUND

Transmission of resistance mutations to integrase strand transfer inhibitors (INSTIs) in HIV-infected patients may compromise the efficacy of first-line antiretroviral regimens currently recommended worldwide. Continued surveillance of transmitted drug resistance (TDR) is thus warranted.

OBJECTIVES

We evaluated the rates and effects on virological outcomes of TDR in a 96 week prospective multicentre cohort study of ART-naive HIV-1-infected subjects initiating INSTI-based ART in Spain between April 2015 and December 2016.

METHODS

Pre-ART plasma samples were genotyped for integrase, protease and reverse transcriptase resistance using Sanger population sequencing or MiSeq™ using a ≥ 20% mutant sensitivity cut-off. Those present at 1%-19% of the virus population were considered to be low-frequency variants.

RESULTS

From a total of 214 available samples, 173 (80.8%), 210 (98.1%) and 214 (100.0%) were successfully amplified for integrase, reverse transcriptase and protease genes, respectively. Using a Sanger-like cut-off, the overall prevalence of any TDR, INSTI-, NRTI-, NNRTI- and protease inhibitor (PI)-associated mutations was 13.1%, 1.7%, 3.8%, 7.1% and 0.9%, respectively. Only three (1.7%) subjects had INSTI TDR (R263K, E138K and G163R), while minority variants with integrase TDR were detected in 9.6% of subjects. There were no virological failures during 96 weeks of follow-up in subjects harbouring TDR as majority variants.

CONCLUSIONS

Transmitted INSTI resistance remains rare in Spain and, to date, is not associated with virological failure to first-line INSTI-based regimens.

Effects of radiation on toxicity, complications, revision surgery and aesthetic outcomes in breast reconstruction: An argument about timing and techniques

BACKGROUND

Radiotherapy (RT) combined with breast reconstruction can reduce the risk of cancer recurrence and increase the survival rate. However, this approach seems to worsen aesthetic outcomes and increase complication rates. The impact of breast reconstruction timing and techniques on clinical outcomes, however, remains unclear. For this reason, we aimed to perform a more comprehensive analysis of a series of patients undergoing RT and breast reconstruction.

METHODS

Patients were divided into 4 groups according to the timing of reconstruction (before RT and after RT) and surgical technique (heterologous reconstruction and autologous reconstruction (AR)). The median time between RT and reconstruction, number of revision surgeries, incidence of complications, toxicity, aesthetics and associated clinical risk factors were used to assess the clinical outcomes. An objective system of skin toxicity evaluation was performed.

RESULTS

Ninety-five patients were included in this study. No significant differences in the median time between RT and reconstruction, incidence of complications, toxicity or aesthetics were noted between different timings or techniques of reconstruction. Patients undergoing AR needed more revision surgeries to complete reconstruction. However, the total number of surgical procedures was similar between the groups. In a comparison between the treated and untreated breasts by an objective system, RT produced an increase in erythema and pigmentation and a decrease in elasticity in the treated breast (p<0.05 for all parameters). On multivariate analysis, smoking was a significant predictor associated with complications.

CONCLUSIONS

Combined breast reconstruction and RT seem to be successful regardless of the order of treatment or the type of reconstruction.

Case Report: Lipoprotein Glomerulopathy Complicated by Atypical Hemolytic Uremic Syndrome

Lipoprotein glomerulopathy (LPG) is a rare inherited disease caused by mutations in the APOE gene, encoding apolipoprotein E (apoE). Atypical hemolytic uremic syndrome (aHUS) is a thrombotic microangiopathy (TMA) characterized by overactivation of the alternative complement pathway. Here we report the case of a 21-year-old man with LPG who developed aHUS. A functional complement assay demonstrated an overactivation of the complement system. Complementary genetic analysis revealed a homozygous aHUS risk allele for complement factor-H related 1 (CFHR1), CFHR1^*B. To the best of our knowledge, this is the first report of an aHUS in a patient with LPG.

POS0996 SIX-YEAR RESULTS FROM THE ESPERANZA COHORT: EVALUATION OF CLINICAL FEATURES, DISEASE ACTIVITY MEASURES AND TREATMENT ASPECTS IN AXIAL AND PERIPHERAL EARLY SPONDYLOARTHRITIS

Background:

Esperanza was a multicenter national health program developed to facilitate an early diagnosis of patients with Spondyloarthritis (SpA) in Spain.

Objectives:

To compare the clinical evolution of patients with axial SpA (axSpA) and peripheral SpA (pSpA) included in this program.

Methods:

Patients from the Esperanza cohort fulfilling ASAS criteria for axSpA or pSpA and completed the 6-year follow-up were included. Patients were classified according to the predominant symptom. In case of having axSpA and pSpA, they were classified as axSpA. Clinical features, disease activity and treatment aspects at baseline and 6-year visit were evaluated.

Results:

From 775 patients recruited at baseline, 6-year follow-up data from 178 (83.5%) fulfilling ASAS criteria at the final visit were available: 133 (74.7%) for axSpA and 45 for pSpA (25.3%). 118 (66.3%) were males (50.6% with axSpA and 62.2%, pSpA, p=0.4). Patients with axSpA had more frequently positive HLA-B27 (90.5%) vs. (9.5%), p<0.001. Follow-up clinical features are shown in Table 1. At the final visit, both axSpA and pSpA presented an improvement in clinical symptoms, disease activity (CRP, BASDAI, ASDAS and VAS-pt) and quality of life (ASQoL). A worsening of mobility (BASMI) was observed in both groups. The prevalence of uveitis, psoriasis and inflammatory bowel disease (IBD) at baseline was 10.7%, 18% and 5.6%, respectively. At the 6-year visit, the cumulative prevalence (CP) was 14% for uveitis (16.5% in axSpA and 6.7% in pSpA), 22.5% for psoriasis (12.8% in axSpA and 51.1% in pSpA) and 7.9% for IBD (5.3% in axSpA and 15.6% in pSpA). Most of the patients were prescribed NSAIDS at baseline and more patients maintained this treatment at the 6-year visit in axSpA compared with pSpA (96.9% vs 87.5%, p=0.02). At the final visit, a higher percentage with pSpA received csDMARDs in comparison with axSpA (81% vs. 35.7%, p<0.001). Sixty (44.4%) patients received biologic therapy at the final visit and no differences were observed in their prescription: 43% in axSpA and 48.6% in pSpA(p=0.6).

Conclusion:

The early diagnosis of recent-onset SpA achieves a significant improvement in clinical features, disease activity and quality of life in patients with axSpA and pSpA after 6 years of follow-up. Although previous publications revealed a low radiographic progression in this cohort1, the worsening of BASMI must aware clinicians of possible evolutive structural damage.

Reference:

[1]Fernández-Carballido et al. RMD Open. 2020 Sep;6(2):e001345

Acknowledgements:

The Spanish Foundation of Rheumatology received funding from Pfizer (formerly Wyeth) to develop the Esperanza Program. Later, the Program has been supported by restricted grants from the Instituto de Salud Carlos III and Fondos FEDER (FIS PI13/02034 and PI17/01840) and AbbVie.

Disclosure of Interests:

Carolina Tornero: None declared, Victoria Navarro-Compán: None declared, Beatriz Joven-Ibáñez: None declared, RAQUEL ALMODOVAR: None declared, Xavier Juanola-Roura: None declared, Cristina Fernández-Carballido: None declared, Juan Carlos Quevedo-Abeledo: None declared, Jose Rosas: None declared, Azucena Hernández: None declared, Carlos A. Montilla-Morales: None declared, Jose Ramón Maneiro: None declared, A. Juan-Mas: None declared, Jose Antonio Pinto Tasende: None declared, Mireia Moreno: None declared, Jesus Sanz: None declared, Teresa Ruiz Jimeno: None declared, Manuel Moreno: None declared, María Lourdes Ladehesa Pineda: None declared, Eugenio de Miguel Speakers bureau: AbbVie, Novartis, Pfizer, MSD, BMS, UCB, Roche, Grunental, Janssen, Sanofi., Paid instructor for: Janssen, Novartis, Roche, Consultant of: AbbVie, Novartis, Pfizer, Galapagos, Grant/research support from: Abbvie, Novartis, Pfizer.

POS1218 SAFETY AND EFFICACY OF ANAKINRA IN SEVERE SARS-COV2 INFECTION (COVID19) AT A TERTIARY HOSPITAL

Background:

SARS-CoV-2 virus is a novel coronavirus that causes COVID-19 disease, which in its most severe form produces life-threatening atypical pneumonia and ARDS. Coronaviruses induce dysregulation of the immune system resulting in a cytokine storm syndrome with activation of the macrophage mediated mainly by IL-1 and IL-6. Although there is no specific treatment to date, researchers have explored novel approaches through targeting both IL-6 and IL-1. Anakinra is a recombinant human IL-1 receptor antagonist that prevents IL-1β and IL-1α binding and therefore blocks signal transduction. Its high bioavailability, rapid action, relatively short half-life and good safety profile make it a promising drug.

Objectives:

Analyse the experience of administering Anakinra for severe forms of COVID19 in patients hospitalised at a tertiary hospital.

Methods:

Retrospective single-center study in which all patients admitted for COVID-19 and treated with Anakinra from April 1st to the end of the 1st wave (July 2020) were included. Medical records were reviewed to collect demographic, clinical and lab test data, using Brescia-COVID respiratory severity scale, SaFi, CRP, Ferritin, LDH and lymphocytes. Variables were assessed at baseline, 72h and 7 days after treatment initiation. Descriptive statistical analysis was performed, including a sub-analysis of patients who received anakinra as the only biological treatment.

Results:

54 patients were included, of which 37 male (68.5%) with a median age of 69.5 years (36-94). Comorbidities were lung disease 14 pts (25.9%), cardiovascular disease 39 pts (72.2%), Diabetes Mellitus 11 pts (20.4%), kidney disease and rheumatic disease each in 6 pts (11.1%), and immunosuppression 13 pts (24.1%). Each patient received a mean of 4.85 doses of anakinra (± 3.96). Other therapies included low-dose steroids (70.3%); high-dose steroids: 1mg/kg (87%), bolus (24%), Tocilizumab (57.4%), Infliximab (24.1%), Lopinavir/Ritonavir (48%), Hydroxychloroquine (94.4%), and Azithromycin (79.6%). Mortality was 22% overall, 75% due to COVID19, 8.3% due to infectious complications and 16.7% due to non-infectious complications. In the group receiving Anakinra as only biological drug, mortality accounted for 17.9% of patients, 75% due to COVID19 and 25% to non-infectious complications. No adverse effects related to anakinra were observed.

General group (n=54)Group receiving anakinra as only biological drug (n=23)PBaselineAfter 72hAfter 7dBaselineAfter 72hAfter 7dBrescia-COVID1.65 (0.95)1.63 (1.13)1.73 (1.19)1.09 (0.8)0.91 (0.88)1.09 (0.8)Mean(SD)Values:Values:Values:Values:Values:Values:NS0: 11.1%0: 16.7%0: 7.9 %0: 26.1%0: 39.1%0: 8.7 %1: 31.5%1: 27.8%1: 52.6%1: 47.8%1: 34.8%1: 82.6%2: 42.6%2: 38.9%2: 18.4%2: 21.7%2: 21.7%2: 8.7%3: 53.7%3: 7.4%3: 7.9%3:4.34%3: 4.34%3: 0%4: 3.7%4: 9.3%4: 13.2%4: 0%4: 0%4: 0%SaFi222.60 (115.2)240.51 (117.6)250.95 (102.6)306.35 (124.7)316.04 (129.8)300.36 (135.4)NSMean (SD)Values:Values:Values:Values:Values:Values:>300:>300:>300:>300:>300:>300:25.9%24.5 %34.2 %56,52%52.2 %45.46 %201-299201-299:201-299:201-299:201-299:201-299:: 14.8%26.4%34.2%17.39%21.7%27.27%<201:<201:<201:<201:<201:<201:59.3%49%31.6%26.1%26.1%27.27%Lymphocytes, 10^3/microLMean (SD)1.07 (1.5)5.16 (3.05)1.15 (2.49)0.88 (0.56)1.25 (0.79)1.15. (2.4)NSFerritine,ng/mlMean (SD)1098.4 (944.8)1080.23 (873.9)1069.19 (989.42)1112.76 (621.80)903.25 (385.49)704.14 (261.86)NSC-reactive protein, mg/LMean (SD)38.78 (37.58)21.46 (20.17)7 (6)50 (6.38)34.67 (23.3)19.96 (28.92)NSLDH, U/LMean (SD)387.64 (163.1)394.98 (209.32)374.26 (157.63)326.38 (111.66)308 (116.59)355 (151.96)NSRespiratory improvement*N/A20.37%51.85%N/A30.43%69.5%.007Lab test improvement**N/A51.85%77.78%N/A60.87%78.2%NS

* SaFi normalised or increased 100 mmHg or more

** Improvement of 2 or more analytic variables

Conclusion:

Anakinra in severe SARS-CoV-2 infection offers respiratory improvement and partial lab tests improvement. No adverse effects were observed.

Acknowledgements:

We wish to acknowledge Puerta de Hierro Majadahonda COVID19 task force and all the patients and staff affected by the pandemic.

Disclosure of Interests:

None declared

A, Sanz J, Urruticoechea-Arana A, Moya P, Belzunegui Otano JM, Sanabra C, Sastré C. AB0503 DISEASE CONTROL IN ANKYLOSING SPONDYLITIS PATIENTS WITH PERIPHERAL ARTHRITIS IN REAL CLINICAL PRACTICE IN SPAIN: MiDAS STUDY RESULTS

Background:

MIDAS study assessed disease activity in patients (pts) with ankylosing spondylitis (AS) treated in clinical practice in Spain.

Objectives:

This subanalysis compared disease activity status between AS pts with and without peripheral arthritis (PA).

Methods:

Observational, non-interventional, cross-sectional, multicenter study. Pts ≥18 years with ≥6 months diagnosis, fulfilling ASAS and modified New York criteria; undergoing treatment ≥3 months. Disease activity was measured by BASDAI and ASDAS-CRP. The number of painful and swollen joints was recorded in AS pts according to the OMERACT recommendations.1

Results:

313 AS pts included: 251 (80.2%) without PA and 62 (19.8%) with PA (Table 1). The most frequently involved painful joints in pts with PA were knees (29.0%) and hips (25.8%), while the swollen ones were proximal interphalangeal joints of the hands (17.7%), knees (9.7%) and wrists (8.1%). According to BASDAI (Figure 1A), pts with PA showed a higher score 4.2 (2.4) and a lower percentage 58.1% had disease activity controlled (BASDAI<4) than total AS pts (3.1 [2.2] and 64.5%, respectively) and pts without PA (2.8 [2.1] and 70.1%, respectively). According to ASDAS-CRP (Figure 1B), mean (SD) score was 1.9 (1.1) for AS pts, 2.4 (1.1) for pts with PA and 1.8 (1.1) for pts without PA, while 29.4% AS pts, 14.5% pts with PA and 33.1% pts without PA had inactive disease (ASDAS-PCR<1.3). By combining both indices (ASDAS-CRP and BASDAI), 51.8% AS pts showed adequate control (inactive disease/remission) of disease activity, 29.0% of pts with PA and 57.4% of pts without PA.

Table 1.

Baseline demographic and clinical characteristics of the AS pts

AS(n=313)AS without PA(n=251)AS with PA(n=62)Age (years), mean (SD)50.4 (12.0)50.1 (11.9)51.5 (12.5)Sex (male), n (%)237 (75.7%)193 (76.9%)44 (71.0%)Time since diagnosis (years), mean (SD)15.5 (11.6)15.4 (11.4)16.0 (12.6)Time from onset of symptoms to diagnosis (years), mean (SD)5.0 (7.2)4.9 (7.1)5.6 (7.6)Presence of HLA-B*27+, n (%)245 (78.5%)197 (78.8%)48 (77.4%)Family history of AS, n (%)66 (21.1%)55 (21.9%)11 (17.7%)Family history of psoriasis, n (%)43 (13.7%)34 (13.5%)9 (14.5%)Pts previously treated with bDMARD, n (%)99 (31.6%)79 (31.5%)20 (32.3%)Swollen joint count (0-66), mean (SD)0.1 (0.9)0.0 (0.0)0.7 (1.9)Painful joint count (0-68), mean (SD)0.6 (2.4)0.0 (0.0)3.0 (4.7)CRP levels (mg/l), mean (SD)5.1 (8.2)4.7 (7.6)6.7 (10.3)Active disease, n (%)* BASDAI ≥4111 (35.5%)26 (41.9%)75 (29.9%) ASDAS-CRP ≥2.1133 (42.4%)93 (37.1%)40 (64.5%) BASFI, mean (SD)3.4 (2.7)3.1 (2.6)4.5 (2.8) MASES index, mean (SD)0.2 (0.8)0.2 (0.7)0.4 (1.2) SPARCC index, mean (SD)0.4 (1.1)0.3 (1.0)0.6 (1.4) Pts perceived disease control (PASS), n (%)270 (86.3%)221 (88.0%)49 (79.0%) ASAS-HI, mean (SD)5.8 (4.4)5.4 (4.2)7.6 (4.6)

*Refers to the percentage of pts with active disease according to BASDAI≥4 and ASDAS-CRP ≥2.1.

Figure 1.

Disease status according to peripheral joints involvement A)Disease control according to BASDAI B)Disease activity according to ASDAS-CRP

Conclusion:

Patients of the MiDAS study with peripheral disease showed higher disease activity and worse physical function, suggesting a severe and complex phenotype more than the one of the AS pts without PA.

References:

[1]J Rheumatol 1993;20:526-91.

AS, ankylosing spondylitis; ASDAS-CRP, Ankylosing Spondylitis Disease Activity Score- C-reactive protein; BASDAI, Bath Ankylosing Spondylitis Disease Activity Index; PA, peripheral arthritis.

Acknowledgements:

We thank to MIDAS group investigators and patients included in the study.

Disclosure of Interests:

Xavier Juanola Speakers bureau: Novartis, Abbvie, Pfizer, Lilly, Consultant of: Novartis, Lilly, Abbvie, Cristina Fernández-Carballido Speakers bureau: I have received lectures fees from Abbvie, Celgene, Janssen, Lilly, MSD, Novartis, Pfizer, Roche and UCB., Consultant of: I have worked as a paid consultant for Abbvie, Celgene, Janssen, Lilly, Novartis, Pfizer and UCB., Alejandro Muñoz Jimenez.: None declared., Jesus Sanz Speakers bureau: Abbvie, Janssen-Cilag, Novartis, Lilly, Consultant of: Abbvie, Janssen-Cilag, Novartis, Lilly, Amgen, Grant/research support from: Abbvie, ANA URRUTICOECHEA-ARANA Speakers bureau: Abbvie, Bristol, Celgene, Janssen, Lilly, MSD, Novartis, Pfizer and UCB, Consultant of: Abbvie, Bristol, Celgene, Janssen, Lilly, MSD, Novartis, Pfizer and UCB, Patricia Moya Speakers bureau: Abbvie, Novartis and UCB, Consultant of: Roche, Joaquin Maria Belzunegui Otano Speakers bureau: Lilly, Amgen, Novartis, Abbvie, Janssen., Cristina Sanabra Employee of: Novartis employee, Carlos Sastré Employee of: Novartis employee.

Triglycerides and Residual Atherosclerotic Risk

BACKGROUND

Even when low-density lipoprotein-cholesterol (LDL-C) levels are lower than guideline thresholds, a residual risk of atherosclerosis remains. It is unknown whether triglyceride (TG) levels are associated with subclinical atherosclerosis and vascular inflammation regardless of LDL-C.

OBJECTIVES

This study sought to assess the association between serum TG levels and early atherosclerosis and vascular inflammation in apparently healthy individuals.

METHODS

An observational, longitudinal, and prospective cohort study, including 3,754 middle-aged individuals with low to moderate cardiovascular risk from the PESA (Progression of Early Subclinical Atherosclerosis) study who were consecutively recruited between June 2010 and February 2014, was conducted. Peripheral atherosclerotic plaques were assessed by 2-dimensional vascular ultrasound, and coronary artery calcification (CAC) was assessed by noncontrast computed tomography, whereas vascular inflammation was assessed by fluorine-18 fluorodeoxyglucose uptake on positron emission tomography.

RESULTS

Atherosclerotic plaques and CAC were observed in 58.0% and 16.8% of participants, respectively, whereas vascular inflammation was evident in 46.7% of evaluated participants. After multivariate adjustment, TG levels ≥150 mg/dl showed an association with subclinical noncoronary atherosclerosis (odds ratio [OR]: 1.35; 95% confidence interval [CI]: 1.08 to 1.68; p = 0.008). This association was significant for groups with high LDL-C (OR: 1.42; 95% CI: 1.11 to 1.80; p = 0.005) and normal LDL-C (OR: 1.85; 95% CI: 1.08 to 3.18; p = 0.008). No association was found between TG level and CAC score. TG levels ≥150 mg/dl were significantly associated with the presence of arterial inflammation (OR: 2.09; 95% CI: 1.29 to 3.40; p = 0.003).

CONCLUSIONS

In individuals with low to moderate cardiovascular risk, hypertriglyceridemia was associated with subclinical atherosclerosis and vascular inflammation, even in participants with normal LDL-C levels. (Progression of Early Subclinical Atherosclerosis [PESA]; NCT01410318).

Glycated Hemoglobin and Subclinical Atherosclerosis in People Without Diabetes

BACKGROUND

The metabolic injury caused by protein glycation, monitored as the level of glycated hemoglobin (HbA1c), is not represented in most risk scores (i.e., Systematic Coronary Risk Estimation or atherosclerotic cardiovascular disease risk scale).

OBJECTIVES

The purpose of this study was to assess the association between HbA1c and the extent of subclinical atherosclerosis (SA) and to better identify individuals at higher risk of extensive SA using HbA1c on top of key cardiovascular risk factors (CVRFs).

METHODS

A cohort of 3,973 middle-aged individuals from the PESA (Progression of Early Subclinical Atherosclerosis) study, with no history of cardiovascular disease and with HbA1c in the nondiabetic range, were assessed for the presence and extent of SA by 2-dimensional vascular ultrasound and noncontrast cardiac computed tomography.

RESULTS

After adjusting for established CVRFs, HbA1c showed an association with the multiterritorial extent of SA (odds ratio: 1.05, 1.27, 1.27, 1.36, 1.80, 1.87, and 2.47 for HbA1c 4.9% to 5.0%, 5.1% to 5.2%, 5.3% to 5.4%, 5.5% to 5.6%, 5.7% to 5.8%, 5.9% to 6.0%, and 6.1% to 6.4%, respectively; reference HbA1c ≤4.8%; p < 0.001). The association was significant in all pre-diabetes groups and even below the pre-diabetes cut-off (HbA1c 5.5% to 5.6% odds ratio: 1.36 [95% confidence interval: 1.03 to 1.80]; p = 0.033). High HbA1c was associated with an increased risk of SA in low-risk individuals (p < 0.001), but not in moderate-risk individuals (p = 0.335). Relative risk estimations using Systematic Coronary Risk Estimation or atherosclerotic cardiovascular disease predictors confirmed that inclusion of HbA1c modified the risk of multiterritorial SA in most risk categories.

CONCLUSIONS

Routine use of HbA1c can identify asymptomatic individuals at higher risk of SA on top of traditional CVRFs. Lifestyle interventions and novel antidiabetic medications might be considered to reduce both HbA1c levels and SA in individuals without diabetes.

Long-term results of a randomized partial irradiation trial compared to whole breast irradiation in the early stage and low-risk breast cancer patients after conservative surgery

PURPOSE

To report long-term results of a randomized trial comparing accelerated partial breast irradiation (APBI) to whole-breast irradiation (WBI) in terms of efficacy, toxicity, and cosmesis.

METHODS AND MATERIALS

WBI group was treated with 3D conformal external irradiation, 2 Gy daily/fraction, 5 fractions/week, to a total dose of 50 Gy. APBI group was treated with 3D conformal external irradiation 3.75 Gy/fraction, twice a day, 5 fractions/week, to a total dose of 37.5 Gy in the APBI group. Patients were followed up every 6 months up to 5 years and yearly thereafter. During follow-up visits, the clinician evaluated chronic toxicity and scored cosmetic results with a four-scale system.

RESULTS

After a median follow-up of 10.3 years, 43 patients in each group (84%) are alive without disease. One patient died after disease progression in the APBI arm, and there was no death in the WBI arm. The rest of the patients died from another disease different than breast cancer, similarly between groups. There was greater fibrosis in the APBI group (9 patients grade 1 and one grade 2) compared to WBI (3 patients grade 1 and one grade 2); p = 0.18. Regarding cosmesis, in APBI group, 19 and 21 (43.2 and 47%) patients had excellent or good results, similar to the WBI group with 18 patients (40.9%) in each cosmesis outcome. The WBI group did not have any patient with poor cosmesis but the APBI had 3 (6.8%; p = 0.24).

CONCLUSION

After a follow-up of 10 years, there were no differences in efficacy between the 2 treatment arms. Despite slight greater toxicity in the APBI group, the cosmesis was similar and satisfactory in both groups.

Multimodality cardiac imaging for management of a cardiac mass in the era of COVID-19: a case report

BACKGROUND

Atrial myxomas are the most common benign cardiac tumours. This case highlights an unusual presentation and complex management of a patient who was incidentally found to have a left atrial tumour concerning for a myxoma.

CASE SUMMARY

A 54-year-old-woman presented with symptoms of nausea and vomiting and was found to have a left atrial mass incidentally in addition to a renal infarct. She was also found to have COVID-19 and the mass was initially thought to be a thrombus. With the help of multimodality imaging, it was determined that the mass was an atrial myxoma and she was started on short-term anticoagulation to prevent recurrent embolization. After 6 weeks of anticoagulation, she successfully underwent elective resection of the mass which was confirmed to be myxoma with superimposed thrombus.

DISCUSSION

It is difficult to differentiate cardiac tumours from intracardiac thrombus and multimodality cardiac imaging is crucial to make an accurate diagnosis. While the treatment of atrial myxomas involves early surgical resection, it becomes more complicated with concurrent COVID-19 infection.

Association Between Left Ventricular Noncompaction and Vigorous Physical Activity

BACKGROUND

Left ventricular (LV) hypertrabeculation fulfilling noncompaction cardiomyopathy criteria has been detected in athletes. However, the association between LV noncompaction (LVNC) phenotype and vigorous physical activity (VPA) in the general population is disputed.

OBJECTIVES

The aim of this study was to assess the relationship between LVNC phenotype on cardiac magnetic resonance (CMR) imaging and accelerometer-measured physical activity (PA) in a cohort of middle-aged nonathlete participants in the PESA (Progression of Early Subclinical Atherosclerosis) study.

METHODS

In PESA participants (n = 4,184 subjects free of cardiovascular disease), PA was measured by waist-secured accelerometers. CMR was performed in 705 subjects (mean age 48 ± 4 years, 16% women). VPA was recorded as total minutes per week. The study population was divided into 6 groups: no VPA and 5 sex-specific quintiles of VPA rate (Q1 to Q5). The Petersen criterion for LVNC was evaluated in all subjects undergoing CMR. For participants meeting this criterion (noncompacted-to-compacted ratio ≥2.3), 3 more restrictive LVNC criteria were also evaluated (Jacquier, Grothoff, and Stacey).

RESULTS

LVNC phenotype prevalence according to the Petersen criterion was significantly higher among participants in the highest VPA quintile (Q5 = 30.5%) than in participants with no VPA (14.2%). The Jacquier and Grothoff criteria were also more frequently fulfilled in participants in the highest VPA quintile (Jacquier Q5 = 27.4% vs. no VPA = 12.8% and Grothoff Q5 = 15.8% vs. no VPA = 7.1%). The prevalence of the systolic Stacey LVNC criterion was low (3.6%) and did not differ significantly between no VPA and Q5.

CONCLUSIONS

In a community-based study, VPA was associated with a higher prevalence of CMR-detected LVNC phenotype according to diverse established criteria. The association between VPA and LVNC phenotype was independent of LV volumes. According to these data, vigorous recreational PA should be considered as a possible but not uncommon determinant of LV hypertrabeculation in asymptomatic subjects.

Subclinical Atherosclerosis and Brain Metabolism in Middle-Aged Individuals: The PESA Study

BACKGROUND

Atherosclerosis has been linked to cognitive decline in late life; however, the impact of cardiovascular risk factors (CVRFs) and subclinical atherosclerosis on brain metabolism at earlier stages remains unexplored.

OBJECTIVES

This study sought to determine the association between brain metabolism, subclinical atherosclerosis, and CVRFs in middle-aged asymptomatic individuals.

METHODS

This study included 547 asymptomatic middle-aged participants (50 ± 4 years, 82% men) from the PESA (Progression of Early Subclinical Atherosclerosis) study with evidence of subclinical atherosclerosis. Participants underwent ¹⁸F-fluorodeoxyglucose (FDG)-positron emission tomography. Global brain FDG uptake and voxel-wise analyses were used to evaluate the associations of cerebral metabolism with CVRFs and atherosclerotic plaque burden in carotids and femorals assessed by 3-dimensional vascular ultrasound.

RESULTS

Global FDG uptake showed an inverse correlation with 30-year Framingham Risk Score (FRS) (β = -0.15, p < 0.001). This association was mainly driven by the presence of hypertension (d = 0.36, p < 0.001). Carotid plaque burden was inversely associated with global brain FDG uptake (β = -0.16, p < 0.001), even after adjusting for 30-year FRS. Voxel-wise approaches revealed that the brain areas most strongly affected by hypometabolism in association with 30-year FRS, hypertension, and carotid plaque burden were parietotemporal regions (angular, supramarginal, and inferior/middle temporal gyri) and the cingulate gyrus.

CONCLUSIONS

In asymptomatic middle-aged individuals, cardiovascular risk is associated with brain hypometabolism, with hypertension being the modifiable CVRF showing the strongest association. Subclinical carotid plaque burden is also linked to reduced brain metabolism independently of CVRFs. Cerebral areas showing hypometabolism include those known to be affected in dementia. These data reinforce the need to control CVRFs early in life in order to potentially reduce the brain's midlife vulnerability to future cognitive dysfunction.

Quality assurance of quantitative cardiac T1-mapping in multicenter clinical trials - A T1 phantom program from the hypertrophic cardiomyopathy registry (HCMR) study

BACKGROUND

Quantitative cardiovascular magnetic resonance T1-mapping is increasingly used for myocardial tissue characterization. However, the lack of standardization limits direct comparability between centers and wider roll-out for clinical use or trials.

PURPOSE

To develop a quality assurance (QA) program assuring standardized T1 measurements for clinical use.

METHODS

MR phantoms manufactured in 2013 were distributed, including ShMOLLI T1-mapping and reference T1 and T2 protocols. We first studied the T1 and T2 dependency on temperature and phantom aging using phantom datasets from a single site over 4 years. Based on this, we developed a multiparametric QA model, which was then applied to 78 scans from 28 other multi-national sites.

RESULTS

T1 temperature sensitivity followed a second-order polynomial to baseline T1 values (R² > 0.996). Some phantoms showed aging effects, where T1 drifted up to 49% over 40 months. The correlation model based on reference T1 and T2, developed on 1004 dedicated phantom scans, predicted ShMOLLI-T1 with high consistency (coefficient of variation 1.54%), and was robust to temperature variations and phantom aging. Using the 95% confidence interval of the correlation model residuals as the tolerance range, we analyzed 390 ShMOLLI T1-maps and confirmed accurate sequence deployment in 90%(70/78) of QA scans across 28 multiple centers, and categorized the rest with specific remedial actions.

CONCLUSIONS

The proposed phantom QA for T1-mapping can assure correct method implementation and protocol adherence, and is robust to temperature variation and phantom aging. This QA program circumvents the need of frequent phantom replacements, and can be readily deployed in multicenter trials.

Short-Term Progression of Multiterritorial Subclinical Atherosclerosis

BACKGROUND

Atherosclerosis progression predicts cardiovascular events; however, progression of multiterritorial subclinical atherosclerosis is incompletely understood.

OBJECTIVES

This study sought to study short-term progression of atherosclerosis using different noninvasive imaging techniques and their relationship with cardiovascular risk.

METHODS

The study included 3,514 PESA (Progression of Early Subclinical Atherosclerosis) study participants (45.7 ± 4.2 years of age; 63% men). Participants underwent 2-dimensional vascular ultrasound (2DVUS) of abdominal aorta, carotid, iliac, and femoral territories to determine a plaque number score; 3DVUS to quantify carotid and femoral plaque volume; and coronary artery calcium score (CACS) at baseline and 2.8 years later. The authors calculated the rate of new disease incidence and changes in disease extent. Logistic regression models were used to evaluate associations of progression rates with baseline cardiovascular risk factors and estimated 10-year risk.

RESULTS

Imaging detected short-term (3-year) atherosclerosis progression in 41.5% of participants (26.4% by 2DVUS, 21.3% by 3DVUS, and 11.5% by CACS), particularly in peripheral territories examined by vascular ultrasound. New atherosclerosis onset accounted for approximately one-third of total progression, also more frequently by 2DVUS and 3DVUS (29.1% and 16.6%, respectively), than by CACS (2.9%). Participants with baseline disease by all 3 modalities (n = 432) also showed significant atherosclerosis progression (median: 1 plaque [interquartile range (IQR): -1 to 3 plaques] by 2DVUS; 7.6 mm³ [IQR: -32.2 to 57.6 mm³] by 3DVUS; and 21.6 Agatston units [IQR: 4.8 to 62.6 Agatston units] by CACS). Age, sex, dyslipidemia, hypertension, smoking, and family history of premature cardiovascular disease contributed to progression, with dyslipidemia the strongest modifiable risk factor. Although disease progression correlated with cardiovascular risk, progression was detected in 36.5% of participants categorized as low risk.

CONCLUSIONS

With this multimodal and multiterritorial approach, the authors detected short-term progression of early subclinical atherosclerosis in a substantial proportion (41.5%) of apparently healthy middle-aged men and women, more frequently by peripheral 2D/3DVUS than by CACS. Disease progression, as defined in this study, correlated with almost all cardiovascular risk factors and estimated risk. (Progression of Early Subclinical Atherosclerosis [PESA]; NCT01410318).

Association Between Body Size Phenotypes and Subclinical Atherosclerosis

CONTEXT

The underlying relationship between body mass index (BMI), cardiometabolic disorders, and subclinical atherosclerosis is poorly understood.

OBJECTIVE

To evaluate the association between body size phenotypes and subclinical atherosclerosis.

DESIGN

Cross-sectional.

SETTING

Cardiovascular disease-free cohort.

PARTICIPANTS

Middle-aged asymptomatic subjects (n = 3909). A total of 6 cardiometabolic body size phenotypes were defined based on the presence of at least 1 cardiometabolic abnormality (blood pressure, fasting blood glucose, triglycerides, low high-density lipoprotein cholesterol, homeostasis model assessment-insulin resistance index, high-sensitivity C-reactive protein) and based on BMI: normal-weight (NW; BMI <25), overweight (OW; BMI = 25.0-29.9) or obese (OB; BMI >30.0).

MAIN OUTCOME MEASURES

Subclinical atherosclerosis was evaluated by 2D vascular ultrasonography and noncontrast cardiac computed tomography.

RESULTS

For metabolically healthy subjects, the presence of subclinical atherosclerosis increased across BMI categories (49.6%, 58.0%, and 67.7% for NW, OW, and OB, respectively), whereas fewer differences were observed for metabolically unhealthy subjects (61.1%, 69.7%, and 70.5%, respectively). When BMI and cardiometabolic abnormalities were assessed separately, the association of body size phenotypes with the extent of subclinical atherosclerosis was mostly driven by the coexistence of cardiometabolic risk factors: adjusted OR = 1.04 (95% confidence interval [CI], 0.90-1.19) for OW and OR = 1.07 (95% CI, 0.88-1.30) for OB in comparison with NW, whereas there was an increasing association between the extent of subclinical atherosclerosis and the number of cardiometabolic abnormalities: adjusted OR = 1.21 (95% CI, 1.05-1.40), 1.60 (95% CI, 1.33-1.93), 1.92 (95% CI, 1.48-2.50), and 2.27 (95% CI, 1.67-3.09) for 1, 2, 3, and >3, respectively, in comparison with noncardiometabolic abnormalities.

CONCLUSIONS

The prevalence of subclinical atherosclerosis varies across body size phenotypes. Pharmacologic and lifestyle interventions might modify their cardiovascular risk by facilitating the transition from one phenotype to another.

Randomized Trial of Empagliflozin in Nondiabetic Patients With Heart Failure and Reduced Ejection Fraction

BACKGROUND

Large clinical trials established the benefits of sodium-glucose cotransporter 2 inhibitors in patients with diabetes and with heart failure with reduced ejection fraction (HFrEF). The early and significant improvement in clinical outcomes is likely explained by effects beyond a reduction in hyperglycemia.

OBJECTIVES

The purpose of this study was to assess the effect of empagliflozin on left ventricular (LV) function and volumes, functional capacity, and quality of life (QoL) in nondiabetic HFrEF patients.

METHODS

In this double-blind, placebo-controlled trial, nondiabetic HFrEF patients (n = 84) were randomized to empagliflozin 10 mg daily or placebo for 6 months. The primary endpoint was change in LV end-diastolic and -systolic volume assessed by cardiac magnetic resonance. Secondary endpoints included changes in LV mass, LV ejection fraction, peak oxygen consumption in the cardiopulmonary exercise test, 6-min walk test, and quality of life.

RESULTS

Empagliflozin was associated with a significant reduction of LV end-diastolic volume (-25.1 ± 26.0 ml vs. -1.5 ± 25.4 ml for empagliflozin vs. placebo, respectively; p < 0.001) and LV end-systolic volume (-26.6 ± 20.5 ml vs. -0.5 ± 21.9 ml for empagliflozin vs. placebo; p < 0.001). Empagliflozin was associated with reductions in LV mass (-17.8 ± 31.9 g vs. 4.1 ± 13.4 g, for empagliflozin vs. placebo, respectively; p < 0.001) and LV sphericity, and improvements in LV ejection fraction (6.0 ± 4.2 vs. -0.1 ± 3.9; p < 0.001). Patients who received empagliflozin had significant improvements in peak O₂ consumption (1.1 ± 2.6 ml/min/kg vs. -0.5 ± 1.9 ml/min/kg for empagliflozin vs. placebo, respectively; p = 0.017), oxygen uptake efficiency slope (111 ± 267 vs. -145 ± 318; p < 0.001), as well as in 6-min walk test (81 ± 64 m vs. -35 ± 68 m; p < 0.001) and quality of life (Kansas City Cardiomyopathy Questionnaire-12: 21 ± 18 vs. 2 ± 15; p < 0.001).

CONCLUSIONS

Empagliflozin administration to nondiabetic HFrEF patients significantly improves LV volumes, LV mass, LV systolic function, functional capacity, and quality of life when compared with placebo. Our observations strongly support a role for sodium-glucose cotransporter 2 inhibitors in the treatment of HFrEF patients independently of their glycemic status. (Are the "Cardiac Benefits" of Empagliflozin Independent of Its Hypoglycemic Activity? [ATRU-4] [EMPA-TROPISM]; NCT03485222).

Accuracy of an Electronic Health Record Patient Linkage Module Evaluated between Neighboring Academic Health Care Centers

BACKGROUND

Patients often seek medical treatment among different health care organizations, which can lead to redundant tests and treatments. One electronic health record (EHR) platform, Epic Systems, uses a patient linkage tool called Care Everywhere (CE), to match patients across institutions. To the extent that such linkages accurately identify shared patients across organizations, they would hold potential for improving care.

OBJECTIVE

This study aimed to understand how accurate the CE tool with default settings is to identify identical patients between two neighboring academic health care systems in Southern California, The University of California Los Angeles (UCLA) and Cedars-Sinai Medical Center.

METHODS

We studied CE patient linkage queries received at UCLA from Cedars-Sinai between November 1, 2016, and April 30, 2017. We constructed datasets comprised of linkages ("successful" queries), as well as nonlinkages ("unsuccessful" queries) during this time period. To identify false positive linkages, we screened the "successful" linkages for potential errors and then manually reviewed all that screened positive. To identify false-negative linkages, we applied our own patient matching algorithm to the "unsuccessful" queries and then manually reviewed a sample to identify missed patient linkages.

RESULTS

During the 6-month study period, Cedars-Sinai attempted to link 181,567 unique patient identities to records at UCLA. CE made 22,923 "successful" linkages and returned 158,644 "unsuccessful" queries among these patients. Manual review of the screened "successful" linkages between the two institutions determined there were no false positives. Manual review of a sample of the "unsuccessful" queries (n = 623), demonstrated an extrapolated false-negative rate of 2.97% (95% confidence interval [CI]: 1.6-4.4%).

CONCLUSION

We found that CE provided very reliable patient matching across institutions. The system missed a few linkages, but the false-negative rate was low and there were no false-positive matches over 6 months of use between two nearby institutions.

New three-dimensional volumetric ultrasound probe for accurate quantification of atherosclerotic plaque volume

Background

Atherosclerosis burden is directly related with the development of clinical cardiovascular events. Recent ESC guidelines endorse carotid and/or femoral plaque burden assessment as a complement for conventional cardiovascular risk evaluation. Compared with previous 3D probes, new 3D-matrix transducers for vascular ultrasound imaging are designed to improve functionality and image quality for an accurate study of atherosclerosis burden.

Purpose

We aimed to validate a commercially available 3D-matrix transducer for plaque volume measurement in early disease stages (small plaques) when accurate plaque detection and quantification is challenging, and intermediate-advanced (medium-large size) plaques in carotid and femoral arteries.

Methods

We performed an ex vivo study using carotid and femoral arterial specimens from a pig model of early atherosclerosis in which actual 3D vascular ultrasound (3DVUS) volume measurements obtained using the new 3D-matrix transducer (XL14–3) were correlated against gold-standard histological measurements. Moreover, we performed a clinical experiment in a subset of intermediate-high risk patients from the “Athero-Brain: Head to Heart (H2H)” study with patent carotid and femoral atherosclerosis for comparing plaque volume evaluated by the new XL14–3 3D-matrix transducer, based on “electronic” 3D-sweep technology, with that measured by previously validated VL13–5 “mechanical” 3D-sweep transducer that uses a mechanically steered linear-array.

Results

In the ex vivo setting, we evaluated 11 atherosclerotic plaques (6 carotid and 5 femoral plaques, mean plaque volume 16.5±22.5 mm3 ranging in size from 1 to 56 mm3), finding a strong correlation between 3DVUS measures and the histological gold-standard with an intraclass correlation coefficient (ICC) of 0.994 (95% CI [0.976; 0.998]). In the clinical setting, we measured 25 plaques (14 carotid and 11 femoral plaques; mean plaque volume 273.4±216.5 mm3 ranging in size from 10 to 859 mm3) from 8 patients (mean age 75±5 years old, 45% men) finding again a strong correlation between 3DVUS electronic-based and mechanical-based volume measurements (ICC=0.996 95% CI [0.991; 0.998]). Correlation and Bland-Altman plots for the measurements of both experiments are displayed in the figure and showed good agreement (Slope close to 1 in the Passing Bablock analysis) with small or lower than clinically relevant differences between measurements.

Conclusions

3DVUS using new matrix technology accurately measures plaque volumes of early (small-size) to intermediate-advanced plaques located in superficial arteries like carotid and femoral arteries.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Institute of Health Carlos III Institute through an Integrated Excellence Project Grant

Empagliflozin Ameliorates Diastolic Dysfunction and Left Ventricular Fibrosis/Stiffness in Nondiabetic Heart Failure: A Multimodality Study

OBJECTIVES

The purpose of this study was to investigate the effect of empagliflozin on diastolic function in a nondiabetic heart failure with reduced ejection fraction (HFrEF) scenario and on the pathways causing diastolic dysfunction.

BACKGROUND

This group demonstrated that empagliflozin ameliorates adverse cardiac remodeling, enhances myocardial energetics, and improves left ventricular systolic function in a nondiabetic porcine model of HF. Whether empagliflozin also improves diastolic function remains unknown. Hypothetically, empagliflozin would improve diastolic function in HF mediated both by a reduction in interstitial myocardial fibrosis and an improvement in cardiomyocyte stiffness (titin phosphorylation).

METHODS

HF was induced in nondiabetic pigs by 2-h balloon occlusion of proximal left anterior descending artery. Animals were randomized to empagliflozin or placebo for 2 months. Cardiac function was evaluated with cardiac magnetic resonance (CMR), 3-dimensional echocardiography, and invasive hemodynamics. In vitro relaxation of cardiomyocytes was studied in primary culture. Myocardial samples were obtained for histological and molecular evaluation. Myocardial metabolite consumption was analyzed by simultaneous blood sampling from coronary artery and coronary sinus.

RESULTS

Despite similar initial ischemic myocardial injury, the empagliflozin group showed significantly improved diastolic function at 2 months, assessed by conventional echocardiography (higher e' and color M-mode propagation velocity, lower E/e' ratio, myocardial performance Tei index, isovolumic relaxation time, and left atrial size), echocardiography-derived strain imaging (strain imaging diastolic index, strain rate at isovolumic relaxation time and during early diastole, and untwisting), and CMR (higher peak filling rate, larger first filling volume). Invasive hemodynamics confirmed improved diastolic function with empagliflozin (better peak LV pressure rate of decay (-dP/dt), shorter Tau, lower end-diastolic pressure-volume relationship (EDPVR), and reduced filling pressures). Empagliflozin reduced interstitial myocardial fibrosis at the imaging, histological and molecular level. Empagliflozin improved nitric oxide signaling (endothelial nitric oxide synthetase [eNOS] activity, nitric oxide [NO] availability, cyclic guanosine monophosphate (cGMP) content, protein kinase G [PKG] signaling) and enhanced titin phosphorylation (which is responsible for cardiomyocyte stiffness). Indeed, isolated cardiomyocytes exhibited better relaxation in empagliflozin-treated animals. Myocardial consumption of glucose and ketone bodies negatively and positively correlated with diastolic function, respectively.

CONCLUSIONS

Empagliflozin ameliorates diastolic function in a nondiabetic HF porcine model, mitigates histological and molecular remodeling, and reduces both left ventricle and cardiomyocyte stiffness.

Correlation between myocardial strain and adverse remodeling in a non-diabetic model of heart failure following empagliflozin therapy

OBJECTIVES

The sodium-glucose cotransporter type 2 inhibitors reduce mortality and heart failure (HF) hospitalizations. The underlying mechanisms remain unclear but seem to be irrespective of glucose-lowering properties. This study aims to evaluate the impact of empagliflozin on myocardial biomechanics and correlation with markers of adverse remodeling.

METHODS

Following myocardial infarct induction to create a model of HF, 14 pigs were randomly assigned in a 1:1 ratio to receive either empagliflozin 10 mg daily or placebo for 2 months. Speckle-tracking echocardiography (STE) and feature-tracking cardiac magnetic resonance (FTCMR) were performed at baseline and at the end of the study to analyze myocardial deformation. The results were correlated with markers of adverse cardiac remodeling.

RESULTS

Empagliflozin significantly improved STE indices. These parameters significantly correlated with adverse cardiac remodeling. In contrast, FTCMR indices showed only a trend toward improved myocardial deformation and without significant correlation with adverse cardiac remodeling. The correlation between both techniques to assess myocardial deformation was low.

CONCLUSION

Empagliflozin enhances myocardial deformation, assessed by STE techniques, in a non-diabetic porcine model of ischemic HF. This may be related to a mitigation of adverse cardiac remodeling following ischemia reperfusion injury. In contrast, FTCMR technique needs further development and validation.