Development and validation of an ECG-based cardiac syncope risk calculator

Background

The early diagnosis of cardiac syncope is often challenging. We therefore developed an ECG-based risk calculator as an aid for rapid rule-out or rule-in of cardiac syncope and aimed to validate this decision tool.

Methods

In a prospective diagnostic international multicenter study (derivation cohort), 2007 patients, 40 years or older, presenting with syncope to the emergency department were recruited. The primary diagnostic outcome, cardiac syncope, was centrally adjudicated by two independent cardiologists using all clinical information obtained during syncope work-up including 12-month follow up. 12-lead ECG was recorded at presentation and read by residents blinded to clinical information. Significant ECG predictors of cardiac syncope were identified using penalized backward selection. Findings were validated in an independent US multicenter cohort with 2'269 syncope patients.

Results

In the derivation cohort (median age 71 years, 40% women), centrally adjudicated cardiac syncope was present in 267 patients (16%). Seven ECG criteria (rhythm, heart rate, corrected QT-interval, ST-segment depression, atrioventricular-block, bundle-branch-block and ventricular extrasystole/non-sustained ventricular tachycardia) were identified as significant predictors for cardiac syncope and combined into the bAseL Ecg Risk calculaTor for Cardiac Syncope (ALERT-CS). Diagnostic accuracy of ALERT-CS for cardiac syncope, as quantified by the area under the receiver-operating characteristics curve (AUC), was high (0.80, 95%-confidence interval (CI) 0.77–0.83) and significantly higher compared to the EGSYS score (0.73, 95% CI 0.70–0.76, p<0.001). In combination, ALERT-CS significantly increased the AUC of BNP (0.82, 95% CI 0.79–0.85 vs 0.77, 95% CI 0.74–0.81, p=0.003), hs-cTnT (0.84, 95% CI 0.0.81–0.87 vs 0.77, 95% CI 0.74–0.80, p<0.001) and integrated clinical judgment in the ED (0.90, 95% CI 0.89–0.92 vs 0.87, 95% CI 0.84–0.90, p<0.001).

A predicted probability for cardiac syncope below 5.5% by ALERT-CS identified 138 patients (8%) eligible for triage towards rapid rule-out of cardiac syncope with a sensitivity of 99%. A predicted probability above 37.5% identified 181 patients (11%) eligible for triage towards rapid rule-in of cardiac syncope with a specificity of 95%. Prognostic verification for 30-day major adverse cardiac events (MACE) showed a high rate of MACE in the rule-in group and a very low rate of MACE in the rule-out group (Figure).

External validation (median age 72 years, 48% women) showed similar diagnostic accuracy (AUC 0.76, 95% CI 0.73–0.79) and prognostic results.

Conclusion

Combining seven ECG criteria within the simple ALERT-CS may aid ED physicians in the early rule-out or rule-in of cardiac syncope.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Swiss National Science Foundation, Swiss Heart Foundation

Early diagnosis of acute myocardial infarction in patients with a history of percutaneous coronary intervention

Background

Recurrence of acute chest pain after percutaneous coronary intervention (PCI) is common. The early detection of acute myocardial infarction (AMI) as a possible cause of acute chest pain can be challenging in patients with a history of PCI due to e.g. pre-existing electrocardiographic abnormalities. It is unknown, whether high-sensitivity cardiac troponin T (hs-cTnT) concentrations and hs-cTnT-based rapid algorithms perform equally well in patients with a history of PCI.

Purpose

To investigate the impact of prior PCI on the diagnostic performance of hs-cTnT concentrations for early rule-out and rule-in of AMI.

Methods

In an ongoing multicentre international study, we prospectively enrolled unselected patients presenting to the emergency department (ED) with symptoms suggestive of AMI. Final diagnoses were centrally adjudicated by two independent cardiologists using all available medical records obtained during clinical care including 90 day follow-up information and cardiac imaging. High-sensitivity cTnT concentrations at presentation and after 1h were compared against the adjudicated final diagnosis. Patients were stratified according to the presence or absence of previous PCI.

Results

Among 5536 patients (1313 with and 4223 without previous PCI), incidence of AMI was significantly higher in patients with previous PCI (26.3% versus 21.4%; p<0.001). Patients with prior PCI and a final diagnoses other than AMI had significantly higher concentrations of hs-cTnT at presentation to the ED (median 9ng/l [IQR 6 to 15.8] vs 5.5ng/l [IQR 3 to 10]; p<0.001). However, in patients with final adjudicated diagnosis of AMI, hs-TnT concentrations at presentation were lower in patients with previous PCI (median 46ng/l [IQR 23 to 94] vs 55ng/l [IQR 25 to 175]; p=0.003). The diagnostic accuracy of hs-cTnT was high in patients with history of PCI, but significantly lower compared to patients without PCI (AUC 0.91 [95% CI 0.89–0.92] versus AUC 0.94 [95% CI 0.94–0.95]; p<0.001, respectively). When applying the ESC 0/1-algorithm among patients with previous history of PCI, the rule out pathway showed also very high safety in patients with a history of PCI (sensitivity 99.2 [95% CI 97.2–99.8] and negative predictive value 99.6 [95% CI 98.5–99.9]). However, the efficacy of the ESC 0/1h-algorithm for early rule out of NSTEMI was lower in the PCI group compared to no PCI (45.2% vs 65.1%; P<0.001, respectively), triaging more patients to the observe zone (36.8% versus 18.8%; p<0.001). Time to discharge from the ED was significantly longer in patients with prior PCI (334 min vs 290 min; p<0.001). When stratified for index AMI, patients with history of PCI waited longer for a final diagnoses of AMI (285 vs 217 min; p<0.001).

Conclusions

History of PCI impacts on the diagnostic performance of hs-cTnT. Although the ESC 0/1h-algorithm still performs very safe when applied to patients with a history of PCI, its efficacy is significantly reduced.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Swiss National Science Foundation, the Swiss Heart Foundation, the KTI, the Stiftung für kardiovaskuläre Forschung Basel the University of Basel and the University Hospital Basel

Prognostic value of health-related quality of life in patients with acute dyspnea

Background

Previous studies have shown the prognostic value of health-related quality of life (HRQL) in stable and ambulatory chronic heart failure patients. However, it is unknown whether HRQL can predict all-cause mortality in patients presenting to the emergency department (ED) after acute onset of symptoms. In order to address this unmet need, the aim of this study was to assess the prognostic value of HRQL in patients with acute dyspnea caused by acute heart failure (AHF) and other dyspnea aetiologies for 360-day mortality.

Purpose

To assess prognostic value of HRQL using the generic EQ-5D and visual analogue scale (EQ VAS) in patients with acute dyspnea.

Methods

Basics in Acute Shortness of Breath EvaLuation (BASEL V) is a prospective, multicenter, diagnostic study enrolling adult patients presenting with acute dyspnea to the ED. For this analysis, only patients with a complete set of variables necessary for calculation of EQ-5D (range 0–10; with higher score indicating worse HRQL) and EQ VAS (range 0–100; with 100 being the best imaginable health state) at baseline were included. The endpoint was the prognostic value of EQ-5D and EQ VAS at 360 days of follow-up regarding all-cause death. Prognostic accuracy was calculated using c-statistics. In a cox regression analysis EQ-5D was treated as both, a continuous and categorical variable. Adjustments were made for clinically relevant covariates (age, sex, orthopnoea, edema, level of N-terminal pro-B-type natriuretic peptide (NT-proBNP) at presentation, history of coronary artery disease and chronic obstructive pulmonary disease, diuretics, β-blockers and ACE-inhibitors at discharge).

Results

Among 2605 patients enrolled, 1141 (43,8%) had a complete set of variables allowing the calculation of EQ-5D and EQ VAS. Of these patients 594 (52.1%) had an adjudicated final diagnosis of AHF. 211 (18.5%) patients died within 360 days of follow-up. Median EQ-5D was 3 (interquartile range (IQR) 1.5–5) and median EQ VAS was 50 (IQR 40–70). The prognostic accuracy for 360-day mortality was 0.65 (95% confidence interval ((CI) 0.61–0.69) and 0.58 (95% CI 0.54–0.62) for EQ-5D and EQ VAS, respectively (p=0.002). After combining EQ-5D and EQ VAS in a logistic regression model c-statistics regarding all-cause mortality within 360 days did not improve. The prognostic accuracy of EQ-5D was comparable to that of NT-proBNP (c-statistics 0.69, p=0.385). In an adjusted cox regression analysis the hazard ratio for patients with EQ-5D >4 was 2.2 (95% CI 1.7–2.9; p<0.001).

Conclusions

In patients presenting with acute dyspnea HRQL is a strong prognostic instrument. Independently of the aetiology of the dyspnea the prognostic value of the generic EQ-5D for 360-day mortality is comparable to NT-proBNP. Patients with an EQ-5D >4 are at significantly higher risk for mortality within 360 days.

Figure 1. Prognostic value of HRQL

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Swiss National Science Foundation, Swiss Heart Foundation

Validation of the FAINT risk score in a large prospective international multicenter study

Background

Risk stratification of older patients presenting to the Emergency Department (ED) with syncope remains an unmet clinical need. The FAINT Score was derived in a large American cohort in an attempt to predict 30-day serious cardiac outcomes in patients >60y.o. While a FAINT score of 0 showed high sensitivity to exclude death and serious outcomes at 30 days in the derivation cohort, it remains unvalidated.

Methods

We validated the FAINT score (History of heart failure, history of arrhythmia, initial ECG result abnormal, elevate NT-proBNP, elevated hs-troponin T) in a large prospective international multicenter study recruiting patients 40 years presenting to the ED with syncope within the last 12 hours in eight countries on three continents. Main outcome measure was 30-day serious cardiac events or mortality. We assessed the performance and calibration of the FAINT score for validation and compared it to the OESIL score (Age >64y, cardiovascular disease history, syncope without prodromes, abnormal ECG).

Results

1885 patients were eligible for this validation analysis. 169 (8.9%) patients experienced 30-day serious adverse events.

A FAINT score of 0 was present for 378 patients (20% of the cohort) and allowed for a sensitivity of 0.97 to rule out adverse events and death at 30-days. A FAINT score of 0 or 1 was present for 626 patients (33% of the cohort) and allowed for a sensitivity of 0.92.

The area under the receiver operating characteristic curve (AUC) for the FAINT score was 0.75 (95%, Confidence Interval (CI) 0.72–0.79), which was comparable to the performance of N-terminal pro-B-type natriuretic peptide (NT-proBNP) or high-sensitivity Troponin T (hs-cTnT) alone, which are two biomarkers used in the FAINT score. The score did not outperform the OESIL score.

A calibration curve showed that the score was extremely well calibrated for low-risk patients.

Conclusion

This is the first validation of the FAINT score in a large international syncope cohort. The safety of a FAINT score of 0 or 1 was good and comparable to the results obtained in the derivation cohort. While the score is suitable to highlight low-risk patients and calibrates well in an external cohort, its discrimination for higher risk patients is not better than biomarkers alone or an older, less complex risk score.

Figure 1. Area under the Receiver Operating Curve (ROC) for the FAINT score and for NT-proBNP and hs-cTnT as continuous markers as well as for the OESIL score. CI = Confidence Interval.

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): University Hospital Basel, Switzerland

External validation of a suggested extension of the ESC 0/1h-algorithm for early rule out of myocardial infarction

Background

The European Society of Cardiology (ESC) high sensitivity cardiac troponin T 0/1h-algorithm has substantially improved the management of patients with suspected acute myocardial infarction (AMI) by triaging about 75% of patients to rapid rule-out and/or rapid rule-in. However, about 25% of patients remain in the “observe-zone”, and the optimal management of these patients is unknown. Recently, a pilot single center study with a low prevalence of AMI suggested that an absolute change of less than 7ng/L between the 0h and 3h hs-cTnT concentration would allow to help in the evaluation of patients in the observe-zone and allow triage towards rule-out with very high negative predictive value [NPV].

Purpose

To externally validate this suggested modification of the ESC 0/1h-algorithm for early rule out of AMI.

Methods

In an ongoing multicentre international study, we prospectively enrolled unselected patients presenting to the emergency department with symptoms suggestive of MI. Final diagnoses were centrally adjudicated by two independent cardiologists using all available medical records obtained during clinical care including 90 day follow-up information and cardiac imaging. High sensitivity-cTnT (Elecsys) concentrations were measured at presentation and after 1 and 3 hours. The primary outcome was safety, quantified by the sensitivity and NPV for early rule out of NSTEMI.

Results

Among 1633 enrolled patients with available 0, 1 and 3h hs-cTnT concentrations, NSTEMI was the adjudicated final diagnosis in 337 (20.6%) patients. The ESC 0/1h-algorithm ruled out 918 (56.2%) patients, with a sensitivity of 98.8% (95% confidence interval [CI], 97.0–99.5) and a NPV of 99.6% (95% CI, 98.9–99.8). A total of 428 patients (26.2%) remained in the observe zone. After applying the suggested 0–3 hour absolute change cut-off criteria of 7ng/L, 393 (92.0%) additional patients from the observe zone were triaged towards ruled out. However, the safety of this triage step was poor with 62 patients with NSTEMI missed, resulting in a sensitivity of 33.3% and a NPV of 84.2% for rule-out.

Conclusions

The suggested 0/3h absolute change cut-off of 7ng/L for patients remaining in the observe zone of the ESC 0/1h-algorithm does NOT allow safe rule-out of AMI and should therefore NOT be implemented into routine clinical care.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Swiss National Science Foundation, the Swiss Heart Foundation, the Stiftung für kardiovaskuläre Forschung Basel, the University of Basel and the University Hospital Basel

Effect of comprehensive vasodilation vs usual care on mortality and heart failure rehospitalization in women with acute heart failure

Background

Guidelines recommend evaluating the risk/benefit ratio of novel therapies individually in women and men, as the pathophysiology and the response to treatment may differ between women and men. Among patients with acute heart failure (AHF), a strategy of intensive vasodilation, compared with usual care, overall did provide comparable outcomes.

Purpose

To evaluate the effect of a strategy that emphasized early intensive and sustained vasodilation in women with AHF.

Methods

In a randomized, open-label blinded-end-point trial patients hospitalized for AHF were enrolled in 10 hospitals in Switzerland, Bulgaria, Germany, Brazil, and Spain. Inclusion criteria were AHF expressed by acute dyspnea and increased plasma concentrations of natriuretic peptides, systolic blood pressure ≥100mmHg, and a plan for treatment in a general ward. Patients were randomized 1:1 to a strategy of early intensive and sustained vasodilation throughout the hospitalization or usual care. The primary end point was a composite of all-cause mortality or rehospitalization for AHF at 180 days.

Results

Among 788 patients randomized, 781 completed the trial and were eligible for the primary end point analysis. Of these 288 (36.9%) were women. The primary end point, a composite of all-cause mortality or rehospitalization for AHF at 180 days, occurred in 53 female patients (37.9%) in the intervention group (including 28 deaths [20.0%]) and in 34 female patients (23.0%) in the usual care group (including 22 deaths [14.9%]) (absolute difference for the primary end point, 14.9%; adjusted hazard ratio, 1.67 [95% CI: 1.08–2.59]; P=0.02). Clinically significant adverse events with early intensive and sustained vasodilation vs usual care included hypotension (8% vs 2%).

Conclusion

Among women with AHF, a strategy of early intensive and sustained vasodilation, compared with usual care, had a detrimental effect on a composite outcome of all-cause mortality and AHF rehospitalization at 180 days.

Cox Proportional Hazard Curve

Funding Acknowledgement

Type of funding source: None

Incidence, characteristics, determinants and prognostic impact of recurrent syncope

Background

The incidence, characteristics, determinants, and prognostic impact of recurrent syncope are largely unknown, causing uncertainty for both patients and physicians.

Methods

We characterized recurrent syncope including sex-specific aspects and its impact on death and major adverse cardiovascular events (MACE) in a large prospective international multicenter study enrolling patients ≥40 years presenting with syncope to the emergency department (ED). Syncope etiology was centrally adjudicated by two independent and blinded cardiologists using all information becoming available during syncope work-up and 12-month follow-up. MACE were defined as a composite of all-cause death, acute myocardial infarction, surgical or percutaneous coronary intervention, life-threatening arrhythmia including cardiac arrest, pacemaker or implantable cardioverter defibrillator implantation, valve intervention, heart-failure, gastrointestinal bleeding or other bleeding requiring transfusion, intracranial hemorrhage, ischemic stroke or transient ischemic attack, sepsis and pulmonary embolism.

Results

Incidence of recurrent syncope among 1790 patients was 20% (95%-confidence interval (CI) 18% to 22%) within 24 months. Patients with an adjudicated final diagnosis of cardiac syncope (hazard ratio (HR) 1.50, 95%-CI 1.11 to 2.01) or syncope of unknown etiology even after central adjudication (HR 2.11, 95%-CI 1.54 to 2.89) had an increased risk for syncope recurrence (Figure). LASSO regression fit on all patient information available early in the ED identified more than three previous episodes of syncope as the only independent predictor for recurrent syncope (HR 2.13, 95%-CI 1.64 to 2.75). Recurrent syncope within the first 12 months after the index event carried an increased risk for all-cause death (HR 1.59, 95%-CI 1.06 to 2.38) and MACE (HR 2.24, 95%-CI 1.67 to 3.01), whereas recurrences after 12 months did not have a significant impact on outcome measures.

Conclusion

Recurrence rates of syncope are substantial and vary depending on syncope etiology. There seem to be no reliable patient characteristics available early on the ED that allow for the prediction of recurrent syncope with only a history of more than three previous syncope being associated with a higher risk for future recurrences. Importantly, recurrent syncope within the first 12 months carries an increased risk for death and MACE.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Swiss National Science Foundation, Swiss Heart Foundation

The bovine cumulus proteome is influenced by maturation condition and maturational competence of the oocyte

In vitro maturation (IVM) of oocytes has still a negative impact on the developmental competence of oocytes. Therefore, this study analysed the cumulus proteome of individual cumulus-oocyte complexes (COCs) with and without maturational competence, matured under in vivo or in vitro conditions (n = 5 per group). A novel, ultrasensitive mass spectrometry (MS) based protein profiling approach, using label-free quantification, was applied. The detected cumulus proteome included 2226 quantifiable proteins and was highly influenced by the maturation condition (479 differentially expressed proteins) as well as maturational competence of the corresponding oocyte (424 differentially expressed proteins). Enrichment analysis showed an overrepresentation of the complement and coagulation cascades (CCC), ECM-receptor interaction and steroid biosynthesis in cumulus of COCs that matured successfully under in vivo conditions. Verification of the origin of CCC proteins was achieved through detection of C3 secretion into the maturation medium, with significantly increasing concentrations from 12 (48.4 ng/ml) to 24 hours (68 ng/ml: p < 0.001). In relation, concentrations in follicular fluid, reflecting the in vivo situation, were >100x higher. In summary, this study identified important pathways that are impaired in IVM cumulus, as well as potential markers of the maturational competence of oocytes.

OP0154-HPR EFFECT OF NURSE-LED-CARE ON PATIENT OUTCOMES IN RHEUMATOID ARTHRITIS IN GERMANY: A MULTICENTRE RANDOMISED CONTROLLED TRIAL

Background:

Inflammatory rheumatic disorders are very complex and require high medical resources. However, there is a shortage of care for these patients, which results in suboptimal reach of therapy objectives. Nevertheless, these very objectives need to be pursued quickly to prevent permanent joint damage. In order to ensure adequate care, multidisciplinary teams which include clinical nurse specialists are required. These clinical nurse specialists play an important role in improving standard-of-care in addition to the rheumatologist. The current standard of care ensures that essential medical provision remains intact, however, psychological, social, rehabilitative and educational needs are often skipped due to time constraints. While studies from e.g. the UK and Denmark have already supported the non-inferiority of nurse-led care (NLC)1, no such studies have yet been published in Germany.

Objectives:

To demonstrate the non-inferiority of NLC to the current standard-of-care, rheumatologist-led care (RLC), for patients with seropositive rheumatoid arthritis (RA) with induction, escalation or change of therapy regarding disease activity as well as different patient reported outcomes (PROs).

Methods:

This trial was conducted as a prospective multi-centered RCT with a non-inferiority design over the course of 12 months. Based on power calculations, 236 adults with RA were included in the study and randomized to either NLC or RLC. The primary outcome measure is disease activity (DAS28), assessed at baseline (T0), 6 weeks (T1), 3,6, 9, and 12 months (T3, T6, T9, T12). Secondary measures are health related quality of life (RAID), functionality (FFbH) and depression (PHQ9).

Results:

There are no significant differences between intervention group (IG) (n=117) and control group (CG) (n=119) at baseline. The mean age of the IG is 58.80 years (SD=12.09) and of the CG 58.34 years (SD=11.72). 72.4% of the IG and 78.1% of the CG are female. The mean duration of symptoms was 147 months (SD=144.63) for the IG and 116 months (108.89) for the CG. The mean DAS28 for the IG is 4.36 (SD=1.24) and 4.51 (SD=1.24) for the CG.

A mixed one-way repeated measures ANOVA showed that the DAS28 improves significantly over time, Huyn-FeldtF(4.42, 751.72) = 105.701,p< .001, partialη2= 0.383, but the interaction of the DAS28 and the randomization is not significant, Huyn-FeldtF(4.42, 751.72) = 1.464,p= 0.260, partialη2= 0.009. No main effect for randomization was found, meaning that the IG and CG did not differ significantly,F(1, 170) = 1.005,p= 0.317, partialη2= 0.006.

The Mann-Whitney-Test showed that the change of the secondary outcomes does not depend on the randomization FFbHU= 4978.50,Z= -.755,p=.450. RAIDU= 5121.00,Z= -.539,p=.590. PHQ9U= 4800.50,Z= -1.281,p=.200. The secondary outcomes improve significantly over time, as shown by a Wilcoxon Signed Rank test for the FFbHZ= -5.589,p< .001, the RAIdZ= -9.884,p< .001 and the PHQ9Z= -7.960,p< .001.

Conclusion:

The results support the non-inferiority of NLC in the management of RA regarding the primary and secondary outcome measures and provide first evidence that NLC could improve care and help carry the doctors’ workflow.

Figure 1.Figure 2.

References:

[1]de Thurah A, Esbensen BA, Roelsgaard IK, et al. Efficacy of embedded nurse-led versus conventional physician-led follow-up in rheumatoid arthritis: a systematic review and meta-analysis. RMD Open 2017;3:e000481.

Disclosure of Interests:

Juliana R Hoeper: None declared, Georg Gauler Consultant of: Abbvie, Lilly, MSD, Speakers bureau: Abbvie, Celgene, Novartis, Sanofi,, Dirk Meyer-Olson Grant/research support from: Novartis, Sandoz Hexal, Consultant of: Abbvie, Amgen, Bristol Myers Squibb, Chugai, Lilly, Mylan, Novartis, Sandoz Hexal, Sanofi, Speakers bureau: Abbvie, Bristol Myers Squibb, Chugai, Lilly, Novartis, Pfizer, Sandoz Hexal, Sanofi, Karin Rockwitz Consultant of: Janssen Cilag, Speakers bureau: Janssen Cilag, Patricia Steffens-Korbanka Consultant of: Abbvie, Chugai, Novartis, Sanofi, Mylan, Lilly, Speakers bureau: Abbvie, Chugai, Novartis, Sanofi, Lilly, Carsten Stille: None declared, Jochen Walter Consultant of: Pfizer, Speakers bureau: AbbVie, Frauenhofer Institut, Gilead, Janssen-Cilag, Medac, Novartis, Pfizer, Martin Welcker Grant/research support from: Abbvie, Novartis, UCB, Hexal, BMS, Lilly, Roche, Celgene, Sanofi, Consultant of: Abbvie, Actelion, Aescu, Amgen, Celgene, Hexal, Janssen, Medac, Novartis, Pfizer, Sanofi, UCB, Speakers bureau: Abbvie, Aescu, Amgen, Biogen, Berlin Chemie, Celgene, GSK, Hexal, Mylan, Novartis, Pfizer, UCB, Joerg Wendler Consultant of: Janssen, AbbVie, Sanofi, Speakers bureau: Roche, Chugai, Janssen, AbbVie, Novartis, Jan Zeidler: None declared, Kirsten Hoeper Consultant of: AbbVie, Celgene,, Speakers bureau: Abbvie, Chugai, Novartis, Lilly, Celgene, Sandoz Hexal

THU0478 IS NEUROPATHIC PAIN IN INFLAMMATORY RHEUMATIC DISORDERS AN UNDERESTIMATED PROBLEM? RESULTS FROM THE GERMAN PAINDETECT DATABASE

Background:

The aim of the study was to investigate the impact and relevance of neuropathic pain in inflammatory rheumatic disorders (IRD) and osteoarthritis (OA).

Objectives:

Pain is one of the main symptoms in patients with IRD and OA. To enhance a mechanistic based treatment of pain the differentiation between nociceptive and neuropathic pain via screening tools (e.g. painDETECT questionaire) might possibly be helpful. The goal of the study was to investigate (1) if neuropathic pain is a significant burden for patients with IRD and (2) if pain patterns differs from degenerative joint diseases such as OA in over 9.000 patients in each group.

Methods:

painDETECT is a questionnaire that has been evaluated and used in numerous clinical trials to detect neuropathic pain in various diseases. The collected data is centrally managed and evaluated. In total (end of 2019) 395.984 patients have been documented. Out of the painDETECT database 9256 patients with IRD and 9436 patients with OA were extracted, analyzed and compared on their neuropathic pain pattern (screening was performed using the painDETECT-questionaire., PDQ). Secondary parameters were: intensity of pain, functional status, depression, chronicity and sleep disorder. Patients had been recruited from general practitioners (GPs), Rheumatologists, Orthopedics and Neurologists from 862 office-based physicians into the painDETECT-database. This project is an open label registry study in Germany.

Results:

The median PDQ-score of patients with inflammatory rheumatic disorders adds up to 14,2 (1-38) and of OA patients to 13,8. 28.7% of inflammatory rheumatic disorders and 27.2% of OA-patients showed signs for neuropathic pain by positive PDQ. The difference was according to this high patient numbers statistically significant (P=0.0015). VAS-Score, Depressions-Score, Chronicity -Score and Functional -Score showed no clinically relevant differences between these two groups.

Conclusion:

Nearly one third of patients with IRD as well as patients with OA showed neuropathic pain components by using PDQ. Despite increasingly better disease control through more effective therapies, pain still remains a major burden for many patients and has a profound impact on their quality of life. The present data indicate a surprisingly high symptoms of neuropathic pain even in IRD patients and should be considered in the management of our patients. A new documentation system for Rheumatologists (RheumaAssist) could help to address these questions.

Percentage of PDQ-categories (negative/unclear/positive) for patients with inflammatory rheumatic disorders (IRD) or Arthrosis (OA)

Acknowledgments:

This investigation was supported within a grant of Pfizer Deutschland GmbH.

Disclosure of Interests: :

Philipp Sewerin Grant/research support from: AbbVie Deutschland GmbH & Co. KG

Bristol-Myers Squibb Celgene GmbH

Lilly Deutschland GmbH

Novartis Pharma GmbH Pfizer Deutschland GmbH

Rheumazentrum Rhein-Ruhr, Consultant of: AMGEN GmbH AbbVie Deutschland GmbH & Co. KG Biogen GmbHBristol-Myers Squibb Celgene GmbH Chugai Pharma arketing Ltd. / Chugai Europe GmbHHexal Pharma Janssen-CilagGmbH Johnson & Johnson Deutschland GmbHLilly Deutschland GmbH / Lilly Europe / Lilly Global Novartis Pharma GmbH Pfizer Deutschland GmbH Roche Pharma Rheumazentrum Rhein-Ruhr Sanofi-Genzyme Deutschland GmbH Swedish Orphan Biovitrum GmbH UCB Pharma GmbH, Speakers bureau: AMGEN GmbH AbbVie Deutschland GmbH & Co. KG Biogen GmbHBristol-Myers Squibb Celgene GmbH Chugai Pharma arketing Ltd. / Chugai Europe GmbHHexal Pharma Janssen-CilagGmbH Johnson & Johnson Deutschland GmbHLilly Deutschland GmbH / Lilly Europe / Lilly Global Novartis Pharma GmbH Pfizer Deutschland GmbH Roche Pharma Rheumazentrum Rhein-Ruhr Sanofi-Genzyme Deutschland GmbH Swedish Orphan Biovitrum GmbH UCB Pharma GmbH, Rainer Freynhagen Consultant of: AOP Orphan Pharma, Grünenthal, Lilly, Merck, Mitsubishi Tanabe Pharma, Pfizer, Scilex Pharmaceutics

, Speakers bureau: AOP Orphan Pharma, Grünenthal, Lilly, Merck, Mitsubishi Tanabe Pharma, Pfizer, Scilex Pharmaceutics

, Thomas Tölle Consultant of: AOP Orphan, Almiral Hermal, Bionest Partners, Benkitt Renkiser, Grünenthal, Hexal, Indivior, Kaia Health, Lilly, Medscape Mundipharma, MSD, Novartis, Pfizer, Recordati Pharma, Sanofi-Aventis, and TAD Pharma, Speakers bureau: AOP Orphan, Almiral Hermal, Bionest Partners, Benkitt Renkiser, Grünenthal, Hexal, Indivior, Kaia Health, Lilly, Medscape Mundipharma, MSD, Novartis, Pfizer, Recordati Pharma, Sanofi-Aventis, and TAD Pharma, Michael Hammer Consultant of: Abbvie, Pfizer, Medac and Janssen, Speakers bureau: Abbvie, Pfizer, Medac and Janssen, Christoph Baerwald Consultant of: CGB received speaker or consulting fees from AbbVie, Paid instructor for: CGB received speaker or consulting fees from AbbVie, Speakers bureau: CGB received speaker or consulting fees from AbbVie, Jochen Walter Consultant of: Pfizer, Speakers bureau: AbbVie, Frauenhofer Institut, Gilead, Janssen-Cilag, Medac, Novartis, Pfizer, Ralf Schröder Shareholder of: Pfizer Pharma GmbH, Employee of: Pfizer Pharma GmbH, Matthias Schneider Grant/research support from: GSK, UCB, Abbvie, Consultant of: Abbvie, Alexion, Astra Zeneca, BMS, Boehringer Ingelheim, Gilead, Lilly, Sanofi, UCB, Speakers bureau: Abbvie, Astra Zeneca, BMS, Chugai, GSK, Lilly, Pfizer, Sanofi, Ralf Baron Consultant of: RB received speaker or consulting fees from AbbVie, Paid instructor for: RB received speaker or consulting fees from AbbVie, Speakers bureau: RB received speaker or consulting fees from AbbVie

Probing particle heteroaggregation using analytical centrifugation

The controlled aggregation of colloidal particles is not only a widespread natural phenomenon but also serves as a tool to design complex building blocks with tailored shape and functionalities. However, the quantitative characterization of such heteroaggregation processes remains challenging. Here, we demonstrate the use of analytical centrifugation to characterize the heteroaggregation of silica particles and soft microgels bearing similar surface charges. We investigate the attachment as well as the stability of the formed heteroaggregates as a function of particle to microgel surface ratio, microgel size and the influence of temperature. The attachment of microgels onto the colloidal particles induces a change in the sedimentation coefficient, which is used to quantitatively identify the number of attached microgels. We corroborate the shift in sedimentation coefficient by computer simulations of the frictional properties of heteroaggregates via a modified Brownian dynamic algorithm. The comparison between theoretical investigations and experiments suggest that the microgels deform and flatten upon attachment.

The FiberTAG project: Tagging dietary fibre intake by measuring biomarkers related to the gut microbiota and their interest for health

The scientific rationale for dietary fibre intake recommendations comes from the recognition of their benefits for health based on studies first published many years ago. It remains unclear which are the key physiological effects generated by dietary fibre in view of the diversity of the food components considered as dietary fibre, of the relevance of their classification (soluble and insoluble) and from the recent discoveries putting forward their interactions with the gut microbiota. The project FiberTAG (Joint Programming Initiative 'A Healthy Diet for a Healthy Life' 2017-2020 https://www.fibertag.eu/) aims to establish a set of biomarkers (markers of gut barrier function and bacterial co-metabolites including volatile compounds and lipid derivatives), measured in different biological compartments (faeces, blood or breath) linking dietary fibre intake and gut microbiota-related health effects. The FiberTAG consortium brings together academic and industrial partners from Belgium, France, Germany and Canada to share data and samples obtained from existing as well as new intervention studies in order to evaluate the relevance of such biomarkers. The FiberTAG consortium is currently working on five existing cohorts (prospective observational or nutritional interventions in healthy or obese patients), and a number of new intervention studies to analyse the effect of insoluble dietary fibre (wheat bran and chitin-glucan, provided by the industrial partners) in healthy individuals or in obese patients at high cardiometabolic risk.

A multiwavelength emission detector for analytical ultracentrifugation

In this study, a new detector for multiwavelength emission analytical ultracentrifugation (MWE-AUC) is presented, which allows measuring size- or composition-dependent fluorescence properties of nanoparticle ensembles. Validation of the new setup is carried out via comparison to a benchtop photoluminescence spectrometer and the established extinction-based multiwavelength analytical ultracentrifuge (MWL-AUC). The results on fluorescent proteins and silica particles demonstrate that the new device not only correctly reproduces sedimentation and diffusion coefficients of the particles but provides also meaningful fluorescence spectra. As an application example for a sample exhibiting a broad particle size distribution, spectra and size of graphene oxide nanoplatelets are extracted simultaneously. Narrowly distributed CdSe/ZnS quantum dots showing size- and structure-dependent shifts of their fluorescence spectra are analyzed as well. The combination of MWE- and MWL-AUC provides a comprehensive framework for the optical characterization for nanoparticles and macromolecules in terms of their extinction and emission properties.

P2617Activity of the adrenomedullin system to personalize post-discharge treatment in acute heart failure

Objectives

Activity of the adrenomedullin system was quantified by using bioactive-adrenomedullin (bio-ADM), the biologically active moiety, and midregional proadrenomedullin (MR-proADM), a prohormone fragment, to 1) identify acute heart failure (AHF) phenotypes with disproportional benefit or harm from specific treatments at hospital discharge, 2) predict mortality, and 3) compare the prognostic utility of both biomarkers.

Methods

This prospective multicentre study using central adjudication of AHF measured bio-ADM in all patients and MR-proADM in a predefined subgroup in a blinded fashion on admission. Both biomarkers were measured at discharge as well. Interaction with specific treatments at hospital discharge and the biomarkers' prognostic utility during 365 days' follow-up were assessed.

Results

Among 1,886 patients with adjudicated AHF, 514 patients (27.3%) died during the 365 days' follow-up. Patients with bio-ADM plasma concentrations above the median were at a much higher risk of death (HR 1.87, 95% CI 1.57–2.24; p<0.001). After adjusting for age, creatinine plasma concentrations, and medical treatment at discharge, those patients derived disproportional benefit if treated with diuretics and/or angiotensin-converting-enzyme inhibitors/angiotensin receptor blocker (interaction p-values <0.05). These findings were confirmed only for the diuretics treatment when quantifying the adrenomedullin system using MR-proADM plasma concentrations (n=764). For predicting mortality, both biomarkers performed well and MR-proADM had a higher predictive accuracy as compared to bio-ADM (p<0.001).

Table 1. Interaction p-values in multivariate models using a cox proportional hazard analysis for predicting all-cause mortality at 365 days including age, bio-ADM or MR-proADM, creatinine at discharge, and medication at discharge Diuretics ACE inhibitors or ARB Beta blockers Aldosterone antagonists lg bio-ADM*, ng/l <0.001 0.011 0.760 0.175 lg bio-ADM†, ng/l <0.001 0.020 0.807 0.396 lg MR-proADM*, nmol/l 0.031 0.095 0.169 0.441 lg MR-proADM†, nmol/l 0.001 0.126 0.741 0.272 *At admission; †at discharge. ACE: Angiotensin-converting-enzyme; ARBs: Angiotensin receptor blocker; bio-ADM: bioactive adrenomedullin; MR-proADM: midregional proadrenomedullin.

Figure 1

Conclusion

Quantifying the activity of the adrenomedullin system helps to personalize post-discharge treatment and risk-prediction in AHF.

Acknowledgement/Funding

Swiss National Science Foundation, Swiss Heart Foundation, University of Base, Sphingotec

P792Cardiac myosin-binding protein C for the diagnosis and long-term prognosis of acute heart failure

Background

Cardiac myosin-binding protein C (cMyC) is a novel biomarker quantifying cardiac injury. Its utility for the diagnosis, prognosis, and therapy guidance in acute heart failure (AHF) is unclear.

Methods

In a prospective diagnostic multicentre study, unselected patients presenting with acute dyspnoea to the emergency department were enrolled. cMyC, high-sensitive cardiac troponin T (hs-cTnT), and N-terminal pro-B-type natriuretic peptide (NT-proBNP) plasma concentrations were measured. Two independent cardiologists/internists centrally adjudicated the final diagnosis using all individual patient's information. Co-primary outcome measures were cMyC's: diagnostic safety and efficacy; prognostic accuracy.

Results

Among 1,330 recruited patients, 247 from an AHF substudy were not included in the diagnostic analysis. Accordingly, 548 patients (51%) in this analysis had an adjudicated diagnosis of AHF. For the rapid rule-out of AHF, the cMyC cut-off concentration at 16 ng/L achieved a sensitivity of 95% (95% CI, 93–97%), a negative predictive value of 88% (95% CI, 84–92%), and allowed to rule-out 21% of the patients. Correspondingly, cMyC's efficacy and safety in the triage of AHF were slightly lower than NT-proBNP's. Of the 790 AHF patients in the prognostic analysis, 222 (28%) died during the 360 days' follow-up. Patients with cMyC plasma concentrations above the median had significantly shorter mean time to death (274 versus 320 days, p=0.001). Compared to hs-cTnT and discharge NT-proBNP, cMyC showed non-inferior prognostic accuracy. No significant interactions between cMyC and cardiac medical therapies at discharge in predicting 360 days survival were present.

Conclusion

cMyC performs well in the rapid triage and prognosis of AHF.

Acknowledgement/Funding

European Union, Swiss National Science Foundation, Swiss Heart Foundation, Cardiovascular Research Foundation Basel, University Hospital of Basel

P1579Impact of Renal Dysfunction on Real-world Outcome of the ESC 0/1-hour Algorithm

Background

The ESC recommends the use of a 0/1h-algorithm for rapid triage of patients with suspected non-ST-elevation myocardial infarction (NSTEMI) using high-sensitivity cardiac troponin (hs-cTn) concentrations irrespective of renal function. Patients with renal dysfunction (RD, defined as a GFR <60ml/min) are at higher risk of NSTEMI and are presenting more often with elevated levels of hs-cTn even in absence of NSTEMI, which may contribute to an impaired efficacy and safety of the ESC 0/1h-algorithm.

Purpose

We aimed to assess and directly compare the real-world adherence, effectiveness, efficacy, and ultimately safety of the ESC 0/1h-algorithm when applied in patients with RD and normal renal function.

Methods

In a prospective international multicenter study enrolling unselected patients presenting with suspected NSTEMI to the ED, patients were assessed according to the ESC 0/1h-algorithm embedded in routine clinical care. Safety was quantified by the 30-day incidence of major adverse cardiac events (MACE, defined as the composite of cardiovascular death and myocardial infarction including the index event) in the rule-out group and in outpatients.

Results

Among 2296 enrolled patients, RD was present in 129 (6%) patients. NSTEMI prevalence was substantially higher in RD as compared with normal renal function (19% versus 9%, p<0.001). Adherence to the ESC 0/1h-algorithm protocol was excellent with no violations observed in patients with RD as compared with 132 (6%) violations in patients with normal renal function (p=0.004). Effectiveness was very high in RD and comparable to normal renal function: 94% of patients triaged towards rule-out by the ESC 0/1h-algorithm did not require additional cardiac investigations including hs-cTnT measurements at later time points (e.g. 3–12h) or coronary CT-angiography in the ED as compared with 98% in normal renal function. Median time to discharge or transfer from the ED was significantly longer in RD (285 minutes [q1174, q3392]) as compared with normal renal function (150 minutes [q1132, q3222]). Efficacy of the ESC 0/1h-algorithm was lower in RD as it triaged 13% of patients towards rule-out and 34% towards rule-in of NSTEMI as compared with 65% and 12% in normal renal function, respectively (p<0.001). Overall, 30% of patients with RD underwent outpatient management as compared with 73% in normal renal function (p<0.001). Safety of rule-out and outpatient management were excellent in RD with a 30-day MACE incidence of both 0% and comparable with 0.2% and 0.1% in normal renal function, respectively (p=0.010).

Conclusions

These real-world data document for the first time the excellent adherence, effectiveness, and safety of the ESC 0/1h-algorithm when routinely applied in patients with RD. Compared with patients with normal renal function, fewer patients with RD could be triaged towards rule-out or were treated as outpatients, most likely due to the higher prevalence of NSTEMI and comorbidities in RD.

P3532Quantifying hemodynamic cardiac stress and cardiomyocyte injury in hypertensive and normotensive acute heart failure

Background

Better characterization of the different pathophysiological mechanisms involved in normotensive and hypertensive acute heart failure (AHF) might help to develop novel individualized treatment strategies.

Methods

The extent of hemodynamic cardiac stress and cardiomyocyte injury was quantified by measuring B-type natriuretic peptide (BNP) as well as high-sensitive cardiac troponin T (hs-cTnT) in 1,152 unselected patients presenting with AHF to the emergency department (derivation cohort). Systolic blood pressure (SBP) of 90 - 140 mmHg at presentation was used to define normotensive AHF. Findings regarding hemodynamic cardiac stress and cardiomyocyte injury were validated in a second independent AHF cohort (validation cohort; n=324).

Results

In the derivation cohort 667 (58%) patients had hypertensive AHF. Hemodynamic cardiac stress, as quantified by BNP levels, was significantly higher in normotensive AHF as compared to hypertensive AHF (1,105 pg/mL versus 827 pg/mL, p<0.001). In addition, the extent of cardiomyocyte injury, as quantified by hs-cTnT, was significantly higher in normotensive AHF as compared to hypertensive AHF (41 ng/L versus 33 ng/L, p<0.001). These findings were confirmed in the validation cohort.

Table 1. Cardiac stress and myocardial necrosis as quantified by BNP and hs-cTnT plasma concentrations Overall Hypertensive AHF Normotensive AHF p-value BNP in pg/ml, median (IQR) 974 (536–1,712) 827 (448–1,419) 1,105 (611–1,956) <0.001 hs-cTnT in ng/L, median (IQR) 37 (22–67) 33 (19–59) 41 (24–71) <0.001 BNP = B-type natriuretic peptide; hs-cTnT = high-sensitivity cardiac Troponin T; IQR = inter-quartile range.

Figure 1

Conclusion

Biomarker profiling revealed that the extent of hemodynamic stress and cardiomyocyte injury is different in patients with normotensive and hypertensive AHF. This characterization could help to understand AHF phenotypes better, which in turn may lead to more specific management in future, thus improving the dismal prognosis in these patients.

Acknowledgement/Funding

European Union, Swiss National Science Foundation, Swiss Heart Foundation, Cardiovascular Research Foundation Basel, University of Basel

P1765Hyperacute T-wave in the early diagnosis of acute myocardial infarction

Background

The clinical significance of prominent T-waves, also referred as hyperacute T-waves, in the early diagnosis of acute myocardial infarction (AMI) is unknown.

Purpose

To evaluate the clinical utility of hyperacute T-waves in the early diagnosis of AMI.

Methods

In a prospective diagnostic study enrolling patients presenting to the emergency department (ED) with symptoms suggestive of AMI, final diagnoses were adjudicated by two independent cardiologists based on clinical information including cardiac imaging. Electronic electrocardiogram data were available in 2946 consecutive patients. Patients with left ventricular hypertrophy, complete left bundle branch block or pacemaker were excluded from further analysis. In the remaining 2382 patients, the T-wave amplitude was automatically derived from the standard 10 seconds 12-lead ECG recorded at presentation to the ED using an established algorithm.

Results

Median (IQR) time from chest pain onset (CPO) to ED presentation was 5 (IQR [2.5, 12.2]) hours. A total of 219 patients (9%) presented to the ED within 1h or less from CPO. AMI was the final diagnosis in 18% (NSTEMI in 15%, STEMI in 3%) of patients. High T-wave amplitude in leads AVF, III and V1 were associated with AMI. Optimal cut-offs were derived to achieve a predefined positive predictive value (PPV) of at least 75%. These criteria were 473mV, 357mV and 483mV for AVF, III and V1, respectively. With these cut-offs 1.4%, 4.2% and 0.9% of all patients with AMI were detected and specificity was 99.9% (95% CI [99.7%, 100%]), 99.7% (95% CI [99.4%, 99.9%]) and 99.9% (95% CI [99.8%, 100%]). However, majority of the patients with AMI correctly identified by the hyperacute T-wave had also significant ST-element elevations (AVF: 5 out of 6; [83.3%]; III: 10 out of 18 [56%]; V1:1 out of 4; [25%]).

Conclusion

In patients presenting to the ED with symptoms suggestive of AMI, only leads AVF, III and V1 showed hyperacute T-waves with high PPV. However, incidence of this finding is very low. In addition, majority of the cases correctly identified by hyperacute T-waves also had concomitant ST-segment elevations. Therefore, hyperacute T-waves have only very limited utility in the early diagnosis of AMI in the ED.

Acknowledgement/Funding

Swiss National Science Foundation, the Swiss Heart Foundation, the KTI, the European Union,the Stiftung für kardiovaskuläre Forschung Basel

P1656Incremental value of interleukin-6 and C-reactive protein to the MEESSI acute heart failure risk score

Background

The MEESSI-acute heart failure (AHF) risk score has high accuracy in the prediction of 30-day mortality in patients presenting with AHF and may be considered the current gold standard for this indication.

Purpose

As the original MEESSI model does not include measurements of inflammatory biomarkers, the impact of interleukin-6 or C-reactive protein (CRP) on the model's goodness of fit is unknown.

Methods

In a prospective multicenter diagnostic study the presence of AHF was centrally adjudicated by two independent cardiologists among patients presenting with acute dyspnea to the ED. The MEESSI-AHF risk score was calculated using a recalibrated model containing 12 independent risk factors. The incremental value of interleukin-6 and CRP was examined by the use of logistic regression analysis and enter method variable selection with an entry criterion of p<0.05. Goodness of fit tests were performed to measure the updated model's discrimination and calibration.

Results

In 1247 patients with adjudicated AHF, the MEESSI-AHF risk score was calculated. Of these, 1113 patients (89.3%) had available measurements of interleukin-6 and CRP. In the logistic regression analysis both biomarkers had a highly significant impact on the MEESSI model (p<0.001, respectively). Compared to the original MEESSI-Model (c-statistic, 0.79 (95% CI, 0.75–0.83)) the addition of interleukin-6 (c-statistic, 0.81 (95% CI, 0.77–0.85)) or CRP (c-statistic, 0.83 (95% CI, 0.79–0.86)) significantly improved the model's discrimination (p=0.022 and p=0.011, respectively). When assessing the cumulative mortality, the gradient in 30-day mortality over six predefined risk groups was increased by addition of interleukin-6 or CRP. 30-day mortality rates in the lowest and highest risk groups of the original model were 0.4% and 32.5% compared to 0% and 34.9% in the model updated with interleukin-6 and 0.6% and 37.6% in the model updated with CRP. All compared models showed good overall calibration (Hosmer-Lemeshow p=0.302 (original model), p=0.136 (model updated by interleukin-6) and p=0.902 (model updated by CRP)).

Discrimination original_updated

Conclusion

There is significant incremental value of interleukin-6 and CRP to the MEESSI score as indicated by the improved goodness of fit compared to the original model.

Acknowledgement/Funding

European Union, the Swiss National Science Foundation, the Swiss Heart Foundation, the Cardiovascular Research Foundation Basel,

P14.112 Long-term application of TTFields in glioblastoma: a multiple-case study

BACKGROUND

Tumor treating fields (TTFields) is an antimitotic cancer therapy that utilizes low-intensity, intermediate-frequency alternating electrical fields to treat glioblastoma (GBM). Increased compliance with TTFields is independently prognostic for improved survival and was correlated with significantly improved overall and progression-free survival versus temozolomide (TMZ) alone. We present two exemplary cases of primary GBM treated with TTFields on long-term and adjuvant chemotherapy to explore treatment adherence, feasibility and safety issues.

MATERIAL AND METHODS

We present case details of two patients from our comprehensive cancer center, both of whom have primary GBM and are long-term TTFields users. One patient began TTFields at first diagnosis whilst the other had already survived to two years at the time of TTFields commencement. Their histories and disease status under continuous, ongoing TTFields therapy with concomitant, extended chemotherapy are explored.

RESULTS

Patient A is a 52-year-old male with IDH1-wildtype, MGMT promoter-methylated GBM. He began TTFields 24 months after initial diagnosis. Before starting TTFields, he had two resections, one owing to early locoregional progression, and had underwent standard, dual radiochemotherapy and started adjuvant TMZ. He has now completed 931 days of treatment with an average daily usage of 82% and has survived 55 months from first diagnosis. Since beginning TTFields, he has undergone a further two resections and another radiotherapy course. His chemotherapy regime has been modified several times, from standard-dose to dose-intensified TMZ, then later switched to lomustine and irinotecan-containing protocols. Patient B is a 68-year-old male, also with IDH1-wildtype, MGMT promoter-methylated GBM. He began TTFields six months after first diagnosis and after one tumor resection, concomitant radiochemotherapy and initiation of long-term TMZ therapy. He has now undergone 636 days of TTFields treatment with an average daily usage of 74%. In addition, 28 cycles of TMZ have been completed.

CONCLUSION

During a mean treatment duration of 784 days and alongside extended-course adjuvant chemotherapy, TTFields was well tolerated. Both patients are alive and still receiving treatment. Compliance has remained within the target range. Significant adverse events or treatment interruptions have not occurred. The patients have remained symptomatically stable and their quality of life has been maintained.

P14.114 Tumor treating fields in glioblastoma clinical practice guidelines: a European and North American landscape analysis

BACKGROUND

Tumor treating fields (TTFields) are low-intensity alternating electric fields delivered at intermediate frequencies to disrupt cancer cell division and inhibit tumor growth, with significantly longer mean lifetime survival of 1.8 additional years in glioblastoma (GBM). International, national and local clinical practice guidelines have implications for clinical, personal and policy decision-making. Furthermore, they may impact on patients’ decisions to choose treatment at a given institution or even lead to commencement of legal proceedings for withholding therapies recommended by international guidelines. We performed an in-depth landscape analysis of clinical practice guidelines for GBM in Europe and North America to explore variation in treatment recommendations with a specific focus on TTFields.

MATERIAL AND METHODS

A systematic search was conducted of web sites of international guideline developers, relevant cancer agencies and the MEDLINE and Web of Science literature databases. The following information was extracted from each document meeting the inclusion criteria: whether TTFields is discussed and/or recommended in the guideline, the indications for and role of TTFields in the care protocol, the strength of the recommendation and any constraints placed on the situations where this therapy can or may be offered, including on cost grounds, where applicable. Dates of production and validity periods of the guidelines were also noted. In addition, standard operating procedures (SOPs) from several accredited comprehensive cancer centres in Germany, covering GBM care are compared, with a series of clinical vignettes presented.

RESULTS

The guidelines produced by the National Comprehensive Cancer Network (USA), National Institute for Health and Care Excellence (UK), German Society for Neurology, German Society for Haematology and Medical Oncology, European Association for Neuro-Oncology and European Society for Medical Oncology were critically compared. Wide variation in recommendations relating to the TTFields therapy was observed. Many guidelines had not been updated to reflect the results of the EF-14 study.

CONCLUSION

Discrepancy in the adoption of TTFields across clinical practice guidelines and SOPs has potential implications for care practices. This ultimately affects patient outcomes, safety and quality of care. Ideally, guidelines should be updated dynamically when new evidence indicates a need for a substantive change in the guideline based on a priori criteria. An ongoing revision process for guidelines, perhaps with shorter validity periods or a more flexible approach, may facilitate more expedient adoption of novel therapies in clinical practice guidelines and in practice. Meanwhile, therapies significantly improving OS and PFS should be recommended to patients and this should be documented.