Derivation and validation of a novel score to detect heart failure with preserved ejection fraction in patients with atrial fibrillation: the Fushimi AF registry

Background

Heart failure with preserved ejection fraction (HFpEF) is an important comorbidity of atrial fibrillation (AF). However, it is sometimes difficult to detect HFpEF among AF patients with preserved EF, since AF and HF share similar symptoms.

Purpose

The aim of this study was to identify factors associated with having HFpEF in AF patients with preserved EF, and derive a new score for HFpEF in AF patients.

Methods

The Fushimi AF Registry is a community-based prospective survey of the AF patients in Fushimi-ku, Kyoto, Japan. Follow-up data were available for 4,466 patients, and 3,083 patients had preserved EF (≥50%). Of the 3,083 patients, 444 had prior HF hospitalization at baseline and we defined these patients as HFpEF. We examined the factors associated with having HFpEF, and derived a new score for detecting HFpEF in AF patients. Thereafter, we validated this score in patients without prior HF hospitalization.

Result

The mean age of the patients with EF ≥50% was 73.6 years, and 41.3% were female. Compared with the patients without prior HF hospitalization, HFpEF patients were older, more often female, less in body weight, had more heart disease (valvular heart disease, cardiomyopathy, old myocardial infarction, and coronary artery disease), chronic kidney diseases (CKD), anemia (Hb <11 g/dL), sustained AF (persistent or permanent), left atrial enlargement (>45 mm), and dilation of cardio-thoracic ratio (CTR) (>54%) at baseline. In multivariate analysis, heart diseases, CKD, sustained AF, dilatation of CTR, left atrial enlargement, and anemia were significantly associated with HFpEF (Table 1). We derived a new score to diagnose HFpEF in AF patients (2 points for heart diseases, 1 point for CKD, sustained AF, dilatation of CTR, left atrial enlargement, and anemia; range 0 to 7 points). In a receiver-operating characteristic curve, optimal cut-off point for detecting HFpEF was 3 (Figure 1). We validated this score in patients without prior hospitalization for HF (n=2,639). Of these, 298 patients had HF symptoms of NYHA 2–4 (Symptomatic-HF), and 2,341 patients had neither prior HF hospitalization nor HF symptoms (No-HF). Notably, 207 patients (69.5%) in symptomatic-HF group and 748 patients (32.0%) in No-HF group were classified into HFpEF based on this new score. Furthermore, patients diagnosed as HFpEF by this score had higher incidence of new hospitalization for HF during the follow-up in both symptomatic-HF group and No-HF group. (Figure 2).

Conclusion

We derived a new score to diagnose HFpEF in AF patients based on the presence of prior HF hospitalization (2 points for heart diseases, 1 point for CKD, sustained AF, dilatation of CTR, left atrial enlargement, and anemia). In patients without prior HF hospitalization, sizable number of patients had high HFpEF score (≥3), and those patients showed higher incidence of new HF hospitalization.

Funding Acknowledgement

Type of funding source: None

Clinical outcomes of Japanese atrial fibrillation patients with combined valvular heart disease: the Fushimi AF Registry

Background

We previously reported that valvular heart disease (VHD) was not at the significant risk of stroke/systemic embolism (SE), but was associated with an increased risk of hospitalization for heart failure (HF) in Japanese atrial fibrillation patients. However, the impact of combined VHD on clinical outcomes has been little known.

Purpose

The aim of this study is to investigate the prevalence of combined VHD and its clinical characteristics and impact on outcomes such as stroke/SE, all-cause death, cardiac death and hospitalization for HF.

Method

The Fushimi AF Registry is a community-based prospective survey of AF patients in one of the wards of our city which is a typical urban district of Japan. We started to enroll patients from March 2011, and follow-up data were available for 4,466 patients by the end of November 2019. In the entire cohort, echocardiography data were available for 3,574 patients. 68 AF patients with prosthetic heart valves were excluded and we compared clinical characteristics and outcomes between 488 single VHD (103 Aortic valve disease (AVD), 315 mitral valve disease (MVD), 70 tricuspid valve disease (TVD)) and 158 combined VHD (46 AVD and MVD, 11 AVD and TVD, 66 MVD and TVD, 35 AVD and MVD and TVD).

Result

Compared with single VHD, patients with combined VHD were older (combined vs. single VHD: 78.5 vs. 76.0 years, respectively; p<0.01), more likely to have persistent/permanent type AF (73.4% vs. 63.9%, p=0.02) and prescription of warfarin (63.1% vs. 53.8%, p=0.04). Combined VHD was less likely to have diabetes mellitus (13.9% vs. 23.6%, p=0.01) and dyslipidemia (26.6% vs. 40.4%, p<0.01). Sex, body weight, hypertension, pre-existing HF were comparable between the two groups.

During the median follow-up of 1,474 days, the incidence rate of stroke/SE was not significantly different between the two groups (1.58 vs. 1.89 per 100 person-years, respectively, log rank p=0.10). The incidence rate of all-cause death (7.35 vs. 5.33, p=0.65), cardiac death (1.20 vs. 0.99, p=0.91) and hospitalization for HF (5.55 vs. 4.43, p=0.53) were also not significantly different. We previously reported AVD had significant impacts on cardiac adverse outcomes in AF patients, and we further analyzed event rates between combined VHD including AVD (AVD and MVD/TVD) and without AVD (MVD and TVD). Combined VHD with AVD group had higher incidence rate of all-cause death (10.7 vs. 5.79, p=0.03) than that without AVD group. However, the incidence rate of stroke/SE (1.98 vs. 1.56, p=0.59), cardiac death (0.98 vs. 1.14, p=0.68), hospitalization for HF (8.03 vs. 5.38, p=0.17) were not significantly different between the two groups.

Conclusion

As compared with single VHD, the risk of stroke/SE, all-cause death, cardiac death and hospitalization for HF in combined VHD was not significantly different. Among patients with combined VHD, those having AVD had higher incidence rate of all-cause death than those without AVD.

Figure 1

Funding Acknowledgement

Type of funding source: None

Impact of glucose tolerance status on the relationship between vascular endothelial growth factor D and mortality in patients with suspected coronary artery disease: a subanalysis of the ANOX study

Background

Vascular endothelial growth factor D (VEGF-D) is a secreted glycoprotein that can act as lymphangiogenic and angiogenic growth factors through binding to its specific receptors, VEGFR-3 and VEGFR-2. VEGF-D signaling via VEGFR-3 plays an important role in lipoprotein metabolisms which may contribute to coronary artery disease (CAD). We recently reported that serum levels of VEGF-D are independently associated with mortality in patients with suspected or known CAD. However, the impact of glucose tolerance status on the relationship between VEGF-D and mortality in patients with suspected CAD is unclear.

Methods

Serum VEGF-D levels were measured in 1,717 patients with suspected CAD undergoing elective coronary angiography, enrolled in the development of novel biomarkers related to angiogenesis or oxidative stress to predict CV events (ANOX) study, and followed up for 3 years. After excluding 67 patients with no HbA1c data, 1,650 patients were divided into 3 groups according to the glucose tolerance status: diabetes (DM, n=693), prediabetes (preDM, n=541) defined as an HbA1c of 5.7 to 6.4%, and normal glucose tolerance (NGT, n=416) defined as an HbA1c of 5.6% or less. The outcomes were total death, CV death, and major adverse CV events (MACE) defined as a composite of CV death, nonfatal myocardial infarction, and nonfatal stroke.

Results

During the follow-up, 80 DM, 45 preDM, and 30 NGT patients died from any cause, 24 DM, 13 preDM, and 12 NGT died from CV disease, and 54 DM, 30 preDM, and 19 NGT developed MACE. After adjustment for established risk factors, VEGF-D levels were significantly associated with total death (hazard ratio [HR] for 1-SD increase, 1.28; 95% confidence interval [CI], 1.12–1.47), but not with CV death (HR, 1.20; 95% CI, 0.93–1.52) or MACE (HR, 1.23; 95% CI, 0.997–1.48) in DM; VEGF-D levels were not significantly associated with total death (HR, 0.97; 95% CI, 0.70–1.34), CV death (HR, 1.39; 95% CI, 0.92–2.11), or MACE (HR, 1.09; 95% CI, 0.74–1.50) in preDM; VEGF-D levels were not significantly associated with total death (HR, 1.34; 95% CI, 0.98–1.84), CV death (HR, 1.32; 95% CI, 0.78–2.13), or MACE (HR, 1.01; 95% CI, 0.66–1.46) in NGT. Even after incorporation of N-terminal pro-brain natriuretic peptide, contemporary sensitive cardiac troponin I, and high-sensitivity C-reactive protein into a model with established risk factors, the addition of VEGF-D levels further improved the prediction of total death (P=0.040 for continuous net reclassification improvement [NRI], P=0.007 for integrated discrimination improvement [IDI]), but not that of CV death or MACE in DM, while it did not significantly improved the prediction of total death, CV death, or MACE either in preDM or in NGT.

Conclusions

The VEGF-D level was independently associated with total death in DM, but not in preDM or in NGT. The relationship between VEGF-D and total mortality may depend on the presence of DM in patients with suspected CAD.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): The ANOX study is supported by a Grant-in-Aid for Clinical Research from the National Hospital Organization.

The relationship between diastolic blood pressure and the risk of cardiovascular events in patients with atrial fibrillation: the Fushimi AF registry

Background

Hypertension is one of the major risk factors of cardiovascular events in patients with atrial fibrillation (AF). However, relationship between diastolic blood pressure (DBP) and cardiovascular events in AF patients remains unclear.

Methods

The Fushimi AF Registry is a community-based prospective survey of AF patients in Japan. Follow-up data were available in 4,466 patients, and 4,429 patients with available data of DBP were examined. We divided the patients into three groups; G1 (DBP<70 mmHg, n=1,946), G2 (70≤DBP<80, n=1,321) and G3 (80≤DBP, n=1,162), and compared the clinical background and outcomes between groups.

Results

The proportion of female was grater in G1 group, and the patients in G1 group were older and had higher prevalence of heart failure (HF), diabetes mellitus (DM), chronic kidney disease (CKD). Prescription of beta blockers was higher in G1 group, but that of renin-angiotensin system-inhibitors and calcium channel blocker was comparable. During the median follow-up of 1,589 days, in Kaplan-Meier analysis, the incidence rates of cardiovascular events (composite of cardiac death, ischemic stroke and systemic embolism, major bleeding and HF hospitalization during follow up) were higher in G1 group and G3 group than G2 group (Figure 1). When we divided the patients based on the systolic blood pressure (SBP) at baseline (≥130 mmHg or <130 mmHg), the incidence of rates of cardiovascular events were comparable among groups. Multivariate Cox proportional hazards regression analysis including female gender, age (≥75 years), higher SBP (≥130 mmHg), DM, pre-existing HF, CKD, low left ventricular ejection fraction (<40%) and DBP (G1, G2, G3) revealed that DBP was an independent determinant of cardiovascular events (G1 group vs. G2 group; hazard ratio (HR): 1.40, 95% confidence intervals (CI): 1.19–1.64, G3 group vs. G2 group; HR: 1.23, 95% CI: 1.01–1.49). When we examined the impact of DBP according to 10 mmHg increment, patients with very low DBP (<60 mmHg) (HR: 1.50,95% CI:1.24–1.80) and very high DBP (≥90 mmHg) (HR: 1.51,95% CI:1.15–1.98) had higher incidence of cardiovascular events than patients with DBP of 70–79 mmHg (Figure 2). However, when we examined the impact of SBP according to 20 mmHg increment, SBP at baseline was not associated with the incidence of cardiovascular events (Figure 3).

Conclusion

In Japanese patients with AF, DBP exhibited J curve association with higher incidence of cardiovascular events.

Funding Acknowledgement

Type of funding source: None

Influence of caffeine intake on intravenous adenosine-induced fractional flow reserve

Background

This study evaluated whether caffeine abstention is required before fractional flow reserve (FFR) measurement by intravenous adenosine triphosphate (ATP) administration in Japanese patients.

Methods and results

This study was a subanalysis of a previously published study and a total of 208 intermediate lesions that underwent FFR measurements were enrolled for this analysis. Hyperemia was induced by continuous intravenous ATP infusion at 150μg/kg/min (IVATP150) and 210μg/kg/min (IVATP210), and by intracoronary administration of nicorandil 2mg (ICNIC2mg) as a reference standard. The degree of change in the FFR value both after IVATP150 and after IVATP210, as compared with the FFR value after ICNIC2mg was similar between the caffeine and non-caffeine groups (−0.04±0.05 vs. −0.04±0.07, and 0.00±0.02 vs. 0.01±0.02, respectively). In patients who consumed caffeine before the FFR measurement, the degree of FFR change was independent of the time interval (<12 hours, 12–24 hours, and 24–48 hours) between caffeine intake and catheterization both after IVATP150 and ICNIC2mg and after IVATP210 and ICNIC2mg.

Conclusion

When compared with the FFR value after ICNIC2mg, the degree of change in the FFR value both after IVATP150 and after IVATP210 remained similar regardless of caffeine intake. Strict caffeine abstention before intravenous ATP-induced FFR measurement may not be required in clinical practice.

Funding Acknowledgement

Type of funding source: None

Adverse outcomes after worsening renal function in patients with atrial fibrillation: the Fushimi AF Registry

Background

Patients with atrial fibrillation (AF) commonly coexist with chronic kidney disease (CKD). Non-vitamin K antagonist oral anticoagulants (NOAC) are recommended for stroke prevention in patients with non-valvular atrial fibrillation (AF), and worsening renal function (WRF) as well as CKD is an important issue in using NOAC. However, little is known about the clinical outcomes of patients after WRF.

Purpose

We aimed to investigate outcomes after WRF in AF patients.

Methods

The Fushimi AF Registry is a community-based prospective survey of the AF patients in our city. Follow-up data including prescription status were available for 4,441 patients. Of them, 1,890 patients who have baseline and at least 1 follow-up creatinine clearance (CrCl) measurements, estimated by the Cockcroft-Gault formula, were analyzed in the present study. WRF was defined as a decrease of ≥20% from baseline CrCl measurement at any time point during follow-up. We evaluated demographics and outcomes after WRF in AF patients.

Results

During the median follow-up period of 2,194 days, mean CrCl decrease of 2.2 ml/min/year was observed and WRF occurred in 981 patients (51.9%). Patients with WRF were significantly more often female (with vs. without WRF; 40.3% vs. 35.4%; p=0.03), older (73.4 vs. 71.1 years of age; p<0.01), more often paroxysmal type (49.9% vs. 47.1%; p<0.01), and more likely to have prior stroke (17.9% vs. 12.7%; p<0.01), heart failure (30.8% vs. 24.8%; p<0.01), diabetes (31.7% vs. 27.1%; p=0.03), and coronary artery disease (19.9% vs. 12.1%; p<0.01) than those without WRF. Co-existing of CKD and mean CrCl at baseline were comparable (37.4% vs. 36.9%; p=0.82, 65.3 vs. 63.5 ml/min; p=0.66, respectively). Mean CHA2DS2-VASc score was significantly higher in WRF patients (3.55 vs. 3.03; p<0.01). On landmark analysis, all-cause mortality occurred in 135 patients (8.6 /100 person-years) after WRF and 82 patients (1.7 /100 person-years) without WRF, with an adjusted hazard ratio (HR) of 6.33 (95% confidence interval [CI], 4.33–9.50; p<0.01), adjusted by sex, age, body weight, serum creatinine, type of AF, oral anticoagulant prescription and comorbidities. Stroke or systemic embolism occurred in 45 patients after WRF (3.0 /100 person-years) and 78 (1.7 /100 person-years) patients without WRF (adjusted HR 1.60 [95% CI, 1.04–2.49; p=0.03]) (Figure).

Conclusions

AF patients after WRF had higher incidence of various adverse events.

Incidence of Adverse Outcomes

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): The Practical Research Project for Life-Style related Diseases including Cardiovascular Diseases and Diabetes Mellitus from Japan Agency for Medical Research and Development. Boehringer Ingelheim, Bayer Healthcare, Pfizer, Bristol-Myers Squibb, Astellas Pharma, AstraZeneca, Daiichi-Sankyo, Novartis Pharma, MSD, Sanofi-Aventis, and Takeda Pharmaceutical.

Clinical impact of regression from sustained to paroxysmal atrial fibrillation: the Fushimi AF registry

Background

Atrial fibrillation (AF) commonly progresses from paroxysmal type to sustained type in the natural course of the disease, and we previously demonstrated that the progression of AF was associated with increased risk of clinical adverse events. There are some patients, though less frequently, who regress from sustained to paroxysmal AF, but the clinical impact of the regression of AF remains unknown.

Purpose

We sought to investigate whether regression from sustained to paroxysmal AF is associated with better clinical outcomes.

Methods

Using the dataset of the Fushimi AF Registry, patients who were diagnosed as sustained (persistent or permanent) AF at baseline were studied. Conversion of sustained AF to paroxysmal AF during follow-up was defined as regression of AF. Major adverse cardiac events (MACE) were defined as the composite of cardiac death, stroke, and hospitalization for heart failure (HF). Event rates were compared between the patients with and without regression of AF. In patients with sustained AF at baseline, predictors of MACE were identified using Cox proportional hazards model.

Results

Among 2,253 patients who were diagnosed as sustained AF at baseline, regression of AF was observed in 9.0% (202/2,253, 2.0 per 100 patient-years) during a median follow-up of 4.0 years. Of these, 24.3% (49/202, 4.6 per 100 patient-years) of the patients finally recurred to sustained AF during follow-up. The proportion of asymptomatic patients was lower in patients with regression of AF than those without (with vs without regression; 49.0% vs 69.5%, p<0.01). The percentage of beta-blocker use at baseline was similar between the two groups (37.2% vs 33.8%, p=0.34). The prevalence of patients who underwent catheter ablation or electrical cardioversion during follow-up was higher in patients with regression of AF (catheter ablation: 15.8% vs 5.5%; p<0.01, cardioversion: 4.0% vs 1.4%; p<0.01, respectively). The rate of MACE was significantly lower in patients with regression of AF as compared with patients who maintained sustained AF (3.7 vs 6.2 per 100 patient-years, log-rank p<0.01). Figure shows the Kaplan-Meier curves for MACE, cardiac death, hospitalization for heart failure, and stroke. In patients with sustained AF at baseline, multivariable Cox proportional hazards model demonstrated that regression of AF was an independent predictor of lower MACE (adjusted hazard ratio [HR]: 0.50, 95% confidence interval [CI]: 0.28 to 0.88, p=0.02), stroke (HR: 0.51, 95% CI: 0.30 to 0.88, p=0.02), and hospitalization for HF (HR: 0.50, 95% CI: 0.29 to 0.85, p=0.01).

Conclusion

Regression from sustained to paroxysmal AF was associated with a lower incidence of adverse cardiac events.

Funding Acknowledgement

Type of funding source: None

Plasma natriuretic peptide level is an independent determinant of major clinical outcomes in atrial fibrillation patients without heart failure: the Fushimi AF Registry

Background

Atrial fibrillation (AF) increases the risk of death, stroke/systemic embolism and heart failure (HF). Plasma natriuretic peptide (NP) level is an important prognostic marker in HF patients. However, little is known regarding the prognostic significance of plasma NP level in AF patients without HF.

Purpose

The aim of this study is to investigate the relationship between plasma NP level and clinical outcomes such as all-cause death, stroke/systemic embolism and HF hospitalization during follow-up period in AF patients without HF.

Methods

The Fushimi AF Registry is a community-based prospective survey of AF patients in our city. The inclusion criterion of the registry is the documentation of AF at 12-lead electrocardiogram or Holter monitoring at any time, and there are no exclusion criteria. We started to enroll patients from March 2011, and follow-up data were available for 4,466 patients by the end of November 2019. From the registry, we excluded 1,220 patients without a pre-existing HF (defined as having one of the following; prior hospitalization for HF, New York Heart Association class ≥2, or left ventricular ejection fraction <40%). Among 3,246 AF patients without HF, we investigated 1,189 patients with the data of plasma BNP (n=401) or N-terminal pro-BNP (n=788) level at the enrollment. We divided the patients according to the quartile of each plasma BNP or NT-pro BNP level and compared the backgrounds and outcomes between these 4 groups stratified by plasma NP level.

Results

Of 1,189 patients, the mean age was 72.1±10.2 years, 454 (38%) were female and 684 (58%) were paroxysmal AF. The mean CHADS2 and CHA2DS2-VASc score were 1.6±1.1 and 2.9±1.5, respectively. Oral anticoagulants were prescribed in 671 (56%) at baseline. The median (interquartile range) BNP and N-terminal pro-BNP level were 84 (38, 176) and 500 (155, 984) pg/ml, respectively. Patients with high plasma NP level were older, and demonstrated lower prevalence of paroxysmal AF, higher CHADS2 and CHA2DS2-VASc scores and higher prevalence of chronic kidney disease and oral anticoagulants prescription (all P<0.01). A total of 165 all-cause death, 114 stroke/systemic embolism and 103 HF hospitalization occurred during the median follow-up period of 5.0 years. Kaplan-Meier curves demonstrated that higher plasma NP level was significantly associated with the incidences of all-cause death, stroke/systemic embolism and HF hospitalization in AF patients without HF (Figure 1A). Multivariable Cox regression analysis revealed that plasma NP level could stratify the risk of clinical outcomes even after adjustment by type of AF, CHA2DS2-VASc score, chronic kidney disease and oral anticoagulant prescription (Figure 1B).

Conclusion

Plasma NP level is a significant prognostic marker for all-cause death, stroke/systemic embolism and HF hospitalization in AF patients without HF, suggesting the importance of measuring plasma NP level in AF patients even without HF.

Figure 1

Funding Acknowledgement

Type of funding source: None

Impact of anemia on the relationship between vascular endothelial growth factor C and mortality in patients with suspected or known coronary artery disease: a subanalysis of the ANOX study

Background

The lymphatic system has been suggested to play an important role in cholesterol metabolism and cardiovascular (CV) disease. Recently, we demonstrated that serum levels of vascular endothelial growth factor C (VEGF-C), a central player of lymphangiogenesis, are inversely and independently associated with the risk of all-cause mortality in patients with suspected or known coronary artery disease (CAD). However, the impact of anemia on the relationship between VEGF-C and mortality in those patients is unclear.

Methods

Serum VEGF-C levels were measured in 2,418 patients with suspected or known CAD undergoing elective coronary angiography, enrolled in the development of novel biomarkers related to angiogenesis or oxidative stress to predict CV events (ANOX) study, and followed up for 3 years. Anemia was defined as a hemoglobin level of less than 13 g/dL in men and <12 g/dL in women. Patients were divided into 2 groups according to the presence (anemic, n=882) or absence (non-anemic, n=1,536) of anemia. The primary outcome was all-cause death. The secondary outcomes were CV death, and major adverse CV events (MACE) defined as a composite of CV death, nonfatal myocardial infarction, and nonfatal stroke.

Results

During the follow-up, 164 anemic and 90 non-anemic patients died from any cause, 64 anemic and 24 non-anemic patients died from CV disease, and 96 anemic and 69 non-anemic patients developed MACE. After adjustment for established risk factors, VEGF-C levels were significantly and inversely associated with all-cause death (hazard ratio [HR] for 1-SD increase, 0.71; 95% confidence interval [CI], 0.59–0.84), CV death (HR, 0.60; 95% CI, 0.44–0.79), and MACE (HR, 0.76; 95% CI, 0.60–0.95) in anemic, while VEGF-C levels were not significantly associated with all-cause death (HR, 0.87; 95% CI, 0.69–1.11), CV death (HR, 1.32; 95% CI, 0.85–1.93), or MACE (HR, 1.12; 95% CI, 0.87–1.42) in non-anemic patients. Even after incorporation of N-terminal pro-brain natriuretic peptide, contemporary sensitive cardiac troponin I, and high-sensitivity C-reactive protein into a model with established risk factors, the addition of VEGF-C levels further improved the prediction of all-cause death (P<0.001 for continuous net reclassification improvement [NRI], P=0.006 for integrated discrimination improvement [IDI]) and CV death (P<0.001 for NRI, P=0.005 for IDI), but not that of MACE (P=0.021 for NRI, P=0.059 for IDI) in anemic, whereas the addition of VEGF-C levels did not improved the prediction of all-cause death (P=0.234 for NRI, P=0.415 for IDI), CV death (P=0.190 for NRI, P=0.392 for IDI) or MACE (P=0.897 for NRI, P=0.128 for IDI) in non-anemic patients.

Conclusions

The VEGF-C level was inversely and independently associated with all-cause and CV mortality in anemic, but not in non-anemic patients with suspected or known CAD. The inverse relationship between VEGF-C and mortality may depend on the presence of anemia.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): The ANOX study is supported by a Grant-in-Aid for Clinical Research from the National Hospital Organization.

Impact of chronic kidney disease on the relationship between vascular endothelial growth factor C and mortality in patients with suspected coronary artery disease: a subanalysis of the ANOX study

Background

The lymphatic system has been suggested to play an important role in cholesterol metabolism and cardiovascular (CV) disease. Recently, we demonstrated that serum levels of vascular endothelial growth factor C (VEGF-C), a central player of lymphangiogenesis, are inversely and independently associated with the risk of all-cause mortality in patients with suspected or known coronary artery disease (CAD). However, the impact of chronic kidney disease (CKD) on the relationship between VEGF-C and mortality in patients with suspected CAD is unclear.

Methods

Serum VEGF-C levels were measured in 1,717 patients with suspected but no history of CAD undergoing elective coronary angiography, enrolled in the development of novel biomarkers related to angiogenesis or oxidative stress to predict CV events (ANOX) study, and followed up for 3 years. Patients were divided into 2 groups according to the presence (CKD, n=674) or absence (non-CKD, n=1,043) of CKD. The primary outcome was all-cause death. The secondary outcomes were CV death, and major adverse CV events (MACE) defined as a composite of CV death, nonfatal myocardial infarction, and nonfatal stroke.

Results

During the follow-up, 95 CKD and 66 non-CKD patients died from any cause, 37 CKD and 13 non-CKD died from CV disease, and 61 CKD and 43 non-CKD developed MACE. After adjustment for established risk factors, VEGF-C levels were significantly and inversely associated with all-cause death (hazard ratio [HR] for 1-SD increase, 0.72; 95% confidence interval [CI], 0.57–0.90) and CV death (HR, 0.69; 95% CI, 0.48–0.97), but not with MACE (HR, 0.78; 95% CI, 0.60–1.03) in CKD, while VEGF-C levels were significantly and inversely associated with all-cause death (HR, 0.69; 95% CI, 0.52–0.91), but not with CV death (HR, 0.91; 95% CI, 0.50–1.66) or MACE (HR, 1.09; 95% CI, 0.81–1.44) in non-CKD. Even after incorporation of N-terminal pro-brain natriuretic peptide, contemporary sensitive cardiac troponin I, and high-sensitivity C-reactive protein into a model with established risk factors, the addition of VEGF-C levels further improved the prediction of all-cause death (P=0.047 for continuous net reclassification improvement [NRI], P=0.048 for integrated discrimination improvement [IDI]), but not that of CV death (P=0.016 for NRI, P=0.245 for IDI) or MACE (P=0.166 for NRI, P=0.311 for IDI) in CKD, whereas the addition of VEGF-C levels did not improve the prediction of all-cause death (P=0.053 for NRI, P=0.012 for IDI), CV death (P=0.864 for NRI, P=0.602 for IDI) or MACE (P=0.999 for NRI, P=0.154 for IDI) in non-CKD.

Conclusions

The VEGF-C level inversely and independently predicted all-cause mortality in CKD, but not in non-CKD patients with suspected CAD. The inverse relationship between VEGF-C and all-cause mortality in patients with suspected CAD seems to be remarkable in the presence of CKD.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): The ANOX study is supported by a Grant-in-Aid for Clinical Research from the National Hospital Organization.

Impact of anemia on the relationships of growth differentiation factor 15 with mortality and cardiovascular events in patients with suspected or known coronary artery disease: the ANOX study

Background

Growth differentiation factor 15 (GDF-15) is a stress-responsive cytokine that plays an important role in the regulation of the inflammatory response, growth and cell differentiation. An elevated GDF-15 was found in various conditions including anemia and stable coronary artery disease (CAD), and it was reported to predict mortality and cardiovascular (CV) events in general population and in patients with established CAD. However, the impact of anemia on the relationships of GDF-15 with mortality and CV events in patients with suspected or known CAD is unclear.

Methods

Serum GDF-15 levels were measured in 2,418 patients with suspected or known CAD undergoing elective coronary angiography, enrolled in the development of novel biomarkers related to angiogenesis or oxidative stress to predict CV events (ANOX) study, and followed up for 3 years. Anemia was defined as a hemoglobin level of less than 13 g/dL in men and <12 g/dL in women. Patients were divided into 2 groups according to the presence (anemic, n=882) or absence (non-anemic, n=1,536) of anemia. The primary outcome was all-cause death. The secondary outcomes were CV death, and major adverse CV events (MACE) defined as a composite of CV death, nonfatal myocardial infarction, and nonfatal stroke.

Results

During the follow-up, 164 anemic and 90 non-anemic patients died from any cause, 64 anemic and 24 non-anemic patients died from CV disease, and 96 anemic and 69 non-anemic patients developed MACE. After adjustment for established risk factors, GDF-15 levels were significantly associated with all-cause death (hazard ratio [HR] for 1-SD increase, 1.75; 95% confidence interval [CI], 1.51–2.04), CV death (HR, 1.67; 95% CI, 1.30–2.13), and MACE (HR, 1.46; 95% CI, 1.18–1.81) in anemic, while GDF-15 levels were also significantly associated with all-cause death (HR, 1.47; 95% CI, 1.27–1.69), CV death (HR, 1.56; 95% CI, 1.18–1.99), and MACE (HR, 1.25; 95% CI, 1.004–1.50) in non-anemic patients. Even after incorporation of N-terminal pro-brain natriuretic peptide, contemporary sensitive cardiac troponin I, and high-sensitivity C-reactive protein into a model with established risk factors, the addition of GDF-15 levels further improved the prediction of all-cause death (P<0.001 for continuous net reclassification improvement [NRI], P<0.001 for integrated discrimination improvement [IDI]), CV death (P=0.026 for NRI, P=0.023 for IDI), and MACE (P=0.025 for NRI, P=0.042 for IDI) in anemic, whereas it did not improved the prediction of all-cause death (P=0.072 for NRI, P=0.079 for IDI), CV death (P=0.289 for NRI, P=0.179 for IDI) or MACE (P=0.397 for NRI, P=0.230 for IDI) in non-anemic patients.

Conclusions

The GDF-15 level significantly improved the prediction of all-cause death, CV death, and MACE in anemic, but not in non-anemic patients with suspected or known CAD. The relationships of GDF-15 with mortality and CV events seem to be remarkable in the presence of anemia.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): The ANOX study is supported by a Grant-in-Aid for Clinical Research from the National Hospital Organization.

Impact of smoking status on the relationships of growth differentiation factor 15 with mortality and cardiovascular events in patients with suspected or known coronary artery disease: the ANOX study

Background

Growth differentiation factor 15 (GDF-15) is a stress-responsive cytokine that plays an important role in the regulation of the inflammatory response, growth and cell differentiation. An elevated GDF-15 was found in various conditions including cigarette smoking and stable coronary artery disease (CAD), and it was reported to predict mortality and cardiovascular (CV) events in general population and in patients with established CAD. However, the impact of smoking status on the relationships of GDF-15 with mortality and CV events in patients with suspected or known CAD is unclear.

Methods

Serum GDF-15 levels were measured in 2,418 patients with suspected or known CAD undergoing elective coronary angiography, enrolled in the development of novel biomarkers related to angiogenesis or oxidative stress to predict CV events (ANOX) study, and followed up for 3 years. Patients were divided into 3 groups according to the smoking status: current (n=428), past (n=1,035), and never smokers (n=955). The outcomes were total death, CV death, and major adverse CV events (MACE) defined as a composite of CV death, nonfatal myocardial infarction, and nonfatal stroke.

Results

During the follow-up, 48 current, 120 past, and 86 never smokers died from any cause, 17 current, 47 past, and 24 never smokers died from CV disease, and 35 current, 80 past, and 50 never smokers developed MACE. After adjustment for established risk factors, GDF-15 levels were significantly associated with total death (hazard ratio [HR] for 1-SD increase, 1.30; 95% confidence interval [CI], 1.03–1.65), but not with CV death (HR, 1.09; 95% CI, 0.69–1.62) or MACE (HR, 0.95; 95% CI, 0.64–1.34) in current smokers; GDF-15 levels were significantly associated with total death (HR, 1.73; 95% CI, 1.46–2.05) and CV death (HR, 1.41; 95% CI, 1.09–1.85), but not with MACE (HR, 1.20; 95% CI, 0.96–1.48) in past smokers; GDF-15 levels were significantly associated with total death (HR, 1.62; 95% CI, 1.32–1.95), CV death (HR, 1.76; 95% CI, 1.22–2.46), and MACE (HR, 1.64; 95% CI, 1.27–2.07) in never smokers. Even after incorporation of N-terminal pro-brain natriuretic peptide, contemporary sensitive cardiac troponin I, and high-sensitivity C-reactive protein into a model with established risk factors, the addition of GDF-15 levels further improved the prediction of total death (P<0.001 for continuous net reclassification improvement [NRI], P=0.001 for integrated discrimination improvement [IDI]) and MACE (P<0.001 for NRI, P=0.045 for IDI), but not that of CV death, in never smokers, while it did not significantly improved the prediction of total death, CV death, or MACE either in current or in past smokers.

Conclusions

The GDF-15 level was independently associated with total death and MACE in never, but not in current or past smokers with suspected or known CAD. The relationships of GDF-15 with mortality and CV events seem to be attenuated by the presence of current and past smoking.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): The ANOX study is supported by a Grant-in-Aid for Clinical Research from the National Hospital Organization.

Effects of PCSK9 inhibitor on adverse limb outcomes in patients with critical limb ischemia

Background

The proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9-I), evolocumab, reduced the risk of cardiovascular event in patients with peripheral artery disease in FOURIER trial. However, the effects of evolocumab on favorable limb outcomes in patients with critical limb ischemia (CLI) is still unclear.

Purpose

The aim of this study was to evaluate the impacts of evolocumab on favorable limb outcomes and lipid profile in patients with CLI.

Methods

This was a single center, prospective observational study. A total of 39 patients with CLI were enrolled between November 2016 to May 2019. The subjects were divided into 2 groups based on evolocumab administration: evolocumab-treated group: E group (mean 69.4±11.7 years, n=14) and evolocumab non-treated group: Non-E group (mean 74.0±8.8 years, n=25). Baseline characteristics were assessed at admission. Lipid profile was evaluated at admission, 1, 3, 6, 12 and 18 months. The primary outcome was defined 18-month amputation-free survival (AFS). The secondary outcomes were defined 18-month overall survival (OS) and wound-free limb salvage. Mean follow-up period was 18±11 months.

Results

The patients in E group had greater reduction in levels of LDL cholesterol and non-HDL cholesterol than those in Non-E group over time. The reduction in MDA-LDL level was maintained at 1, 3, 6, 12 months, respectively. The 18-month AFS rate in the E-group was significantly higher than those in the Non-E group (log-rank p=0.02). The patients receiving evolocumab had a lower hazard regarding AFS (hazard ratio, 0.12; 95% confidence interval, 0.02–0.94; P=0.043) and a higher proportion of wound-free limb salvage at 12 months (E group [92%] vs Non-E group [57%], P=0.034) and 18 months (92% vs 52%, P=0.03). Otherwise, evolocumab administration was not associated with 18-month OS (log-rank p=0.053).

Conclusions

Evolocumab administration may be associated with the favorable outcome of 18-month AFS in the patients with CLI. Additionally, long-term administration of evolocumab over 12 months may improve wound-free limb salvage.

Effects of evolocumab on limb outcomes

Funding Acknowledgement

Type of funding source: None

FRI0115 FILGOTINIB PROVIDED RAPID AND SUSTAINED IMPROVEMENTS IN FUNCTIONAL STATUS, PAIN, AND HEALTH-RELATED QUALITY OF LIFE, AND REDUCED FATIGUE OVER TIME IN PATIENTS WITH RHEUMATOID ARTHRITIS WHO ARE METHOTREXATE-NAÏVE: RESULTS FROM THE FINCH 3 STUDY

Background:

In the FINCH 3 study, filgotinib (FIL)—a potent, selective, oral small molecule Janus kinase 1 inhibitor1—in combination with methotrexate (MTX), demonstrated significant improvements in the signs and symptoms of rheumatoid arthritis (RA) vs MTX alone in patients (pts) who were MTX-naïve.2For pts with RA, rapid control of pain and fatigue along with maintenance of physical function and health-related quality of life (HRQoL) are important outcomes of their care.3Thus, patient-reported outcomes (PROs) can provide physicians with evidence to guide treatment decisions beyond the guideline-recommended treatment targets of reducing immune inflammation to prevent joint damage, physical disability, and mortality.4

Objectives:

To evaluate the rate and magnitude of change in PROs assessing functional status, pain, HRQoL, and fatigue from FINCH 3.

Methods:

In the FINCH 3 study (NCT02886728), pts with active RA who were MTX-naïve received FIL 200 mg daily + MTX, FIL 100 mg + MTX, FIL 200 mg (+ placebo [PBO]), or MTX (+ PBO) for up to 52 weeks. PROs were recorded prospectively and included HAQ-DI (functional status) and VAS pain scale (day 1, week [W]2, W4, W8, W12, W16, W20, W24, W30, W36, W44, W52), SF-36 (HRQoL), and FACIT-Fatigue (day 1, W4, W12, W24, W36, W52). The least squares mean of the change from baseline (CFB) at each time point up to W52 and p values (each FIL arm vs MTX) were analysed using a mixed-effects model for repeated measures. For HAQ-DI, the proportion of pts who achieved the minimum clinically important difference (MCID; reduction ≥0.22) between each FIL arm and MTX was analysed using logistic regression analysis. P values for the comparisons of PROs were not adjusted for multiplicity, except for HAQ-DI CFB at W24 for FIL 200 mg + MTX and FIL 100 mg + MTX vs MTX.

Results:

Of the 1249 pts randomised and treated (FIL 200 mg + MTX, n = 416; FIL 100 mg + MTX, n = 207; FIL 200 mg, n = 210; MTX, n = 416), 1025 (82.1%) completed the study. Compared with MTX alone, a nominally significantly greater CFB in functional status and pain from W2 to W24 was observed in all FIL arms; the benefit was sustained from W30 to W52 (Fig 1). By W2, a nominally significantly greater proportion of pts achieved the HAQ-DI MCID or greater (≥0.22) in all FIL arms (FIL 200 mg + MTX: 61.9%, p <0.001; FIL 100 mg + MTX: 58.5%, p <0.001; FIL 200 mg: 53.9%, p = 0.004) compared with MTX (42.2%). By W8, ≥72% of pts in all FIL arms vs 63% of pts in the MTX arm achieved the HAQ-DI MCID; a numerically greater proportion of pts in FIL arms vs MTX achieved HAQ-DI MCID through W52. SF-36 physical component summary and FACIT-Fatigue scores were nominally significantly improved with FIL treatment vs MTX alone at various time points (Fig 2A, B). Improvements in SF-36 mental component summary scores were nominally significant for pts in all FIL arms vs MTX alone as early as W4, and the CFB reached at W12 for FIL arms was generally sustained up to W52 (Fig 2A).

Conclusion:

For pts with moderate to severe RA who were MTX-naïve, FIL—with or without concomitant MTX—led to more rapid and sustained improvements in functional status, pain, fatigue, and HRQoL, compared with MTX alone.

References:

[1]Van Rompaey, et al.J Immunol. 2013;131:3568–77.

[2]Westhovens, et al.Arthritis Rheumatol. 2019;71 (suppl 10):1606–8.

[3]Fautrel B, et al.Rheumatol Int.2018;38:935–47.

[4]Smolen JS, et al.Ann Rheum Dis.2017;76:960–77.

Disclosure of Interests:

Rieke Alten Grant/research support from: Pfizer, Galapagos, Galapagos NV, Gilead, Gilead Sciences, Inc., Novartis, Consultant of: Pfizer, Speakers bureau: Pfizer, William Rigby Consultant of: Gilead Sciences, Inc., Alena Pechonkina Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Zhaoyu Yin Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Ken Hasegawa Shareholder of: Gilead Sciences, Inc., Employee of: Gilead Sciences, Inc., Thijs Hendrikx Shareholder of: Galapagos (share/warrant holder), Employee of: Galapagos, Tatsuya Atsumi Grant/research support from: Eli Lily Japan K.K., Alexion Pharmaceuticals, Inc., Bristol-Myers Squibb Co., AbbVie Inc., Daiichi Sankyo Co., Ltd., Pfizer Inc., Chugai Pharmaceutical Co., Ltd., Mitsubishi Tanabe Pharma Co., Astellas Pharma Inc., Consultant of: Gilead Sciences, Inc., Eli Lilly Japan K.K., UCB Japan Co. Ltd., AbbVie Inc., Daiichi Sankyo Co., Ltd., Pfizer Inc., Chugai Pharmaceutical Co., Ltd., Speakers bureau: Eli Lilly Japan K.K., UCB Japan Co. Ltd., Bristol-Myers Squibb Co., AbbVie Inc., Eisai Co. Ltd., Otsuka Pharmaceutical Co., Ltd., Daiichi Sankyo Co., Ltd., Pfizer Inc., Chugai Pharmaceutical Co., Ltd., Mitsubishi Tanabe Pharma Co., Takeda Pharmaceutical Co., Ltd., Astellas Pharma Inc., Rene Westhovens Grant/research support from: Celltrion Inc, Galapagos, Gilead, Consultant of: Celltrion Inc, Galapagos, Gilead, Speakers bureau: Celltrion Inc, Galapagos, Gilead

P18 The utility and validity of intracoronary administration of nicorandil alone for the measurement of fractional flow reserve in patients with intermediate coronary stenosis

Backgrand

Recently, intracoronary nicorandil (ICN) administration in addition to intravenous adenosine 5"-triphosphate (IVATP) is generally used to achieve maximal hyperemia for evaluating fractional flow reserve (FFR). This study investigated the usefulness and safety of ICN alone compared with  IVATP and ICN during IVATP for the achievement of maximal hyperemia in patients with suspected angina pectoris. 

Methods

Two-hundred-ten angiographically intermediate lesions in two-hundred-seven patients who underwent FFR assessments were enrolled. FFR was measured after ICN (2mg/5seconds), IVATP (150µg/kg/min) for 2 minutes, IVATP (210µg/km/min) for 2 minutes, and ICN (2mg/5seconds) during IVATP (150µg/kg/min). Maximal hyperemia was defined as the lowest FFR measured among each method.

Results

During the protocol, 92% of patients achieved maximal hyperemia with ICN2mg, 54% with IVATP 150µg/kg/min, 91% with IVATP 210µg/kg/min, and 99% with ICN2mg during IVATP 150µg/kg/min, respectively. The FFR obtained with ICN2mg were strongly correlated with those obtained with ICN2mg during IVATP150µg/kg/min (r²=0.93, P&lt; 0.001). The mean aortic pressure drop during hyperemia was significantly lower in ICN2mg than in IVATP 150µg/kg/min, IVATP 210µg/kg/min, and ICN2mg during IVATP 150µg/kg/min(9 ± 10, 11 ± 14, 24 ± 17, and 27 ± 19mmHg, p &lt; 0.001, respectively). Despite no side effects reported during hyperemia with ICN2mg alone, transient atrioventricular block was observed in 1(1%) patient with IVATP 150µg/kg/min and 9(4%) patients with IVATP 210µg/kg/min. Also, 20 (10%) patients with  IVATP 150µg/kg/min and 56(27%) with IVATP210µg/kg/min experienced chest discomfort during hyperemia.

Conclusions

The intracoronary administration of NIC2mg is safe and well tolerated, and shortens the procedure. Furthermore, intracoronary NIC2mg produced a more pronounced hyperemia than IVATP and may be the preferred mode of application for the assessment of FFR.

Prospects for observing and localizing gravitational-wave transients with Advanced LIGO, Advanced Virgo and KAGRA

We present our current best estimate of the plausible observing scenarios for the Advanced LIGO, Advanced Virgo and KAGRA gravitational-wave detectors over the next several years, with the intention of providing information to facilitate planning for multi-messenger astronomy with gravitational waves. We estimate the sensitivity of the network to transient gravitational-wave signals for the third (O3), fourth (O4) and fifth observing (O5) runs, including the planned upgrades of the Advanced LIGO and Advanced Virgo detectors. We study the capability of the network to determine the sky location of the source for gravitational-wave signals from the inspiral of binary systems of compact objects, that is binary neutron star, neutron star-black hole, and binary black hole systems. The ability to localize the sources is given as a sky-area probability, luminosity distance, and comoving volume. The median sky localization area (90% credible region) is expected to be a few hundreds of square degrees for all types of binary systems during O3 with the Advanced LIGO and Virgo (HLV) network. The median sky localization area will improve to a few tens of square degrees during O4 with the Advanced LIGO, Virgo, and KAGRA (HLVK) network. During O3, the median localization volume (90% credible region) is expected to be on the order of 10 5 , 10 6 , 10 7 Mpc 3 for binary neutron star, neutron star-black hole, and binary black hole systems, respectively. The localization volume in O4 is expected to be about a factor two smaller than in O3. We predict a detection count of 1 - 1 + 12 ( 10 - 10 + 52 ) for binary neutron star mergers, of 0 - 0 + 19 ( 1 - 1 + 91 ) for neutron star-black hole mergers, and 17 - 11 + 22 ( 79 - 44 + 89 ) for binary black hole mergers in a one-calendar-year observing run of the HLV network during O3 (HLVK network during O4). We evaluate sensitivity and localization expectations for unmodeled signal searches, including the search for intermediate mass black hole binary mergers.