AB0493 COMPARISON OF EFFICACY AND SAFETY BETWEEN RITUXIMAB AND CYCLOPHOSPHAMIDE IN REMISSION INDUCTION THERAPY FOR JAPANESE ANCA-ASSOCIATED VASCULITIS(AAV) PATIENTS; A SINGLE CENTER RETROSPECTIVE ANALYSIS

Background:

Rituximab(RTX) and Cyclophosphamide(CY) has been indicated for ANCA-associated vasculitis(AAV) as remission induction therapy. However, older age and renal disfunction were independent predictor of treatment related adverse effects in remission induction with CY in recent reports1). Japanese AAV patients are characterized by the predominance of elderly, and the study about comparison of efficacy and safety between RTX and CY in elderly Japanese AAV patients are limited.

Objectives:

To compare the efficacy and safety between RTX versus CY as remission induction therapy in Japanese AAV patients.

Methods:

We analyzed 40 cases (20 cases received RTX and 20 cases received CY) who received remission induction therapy in our hospital between January 2016 and August 2019. Clinical and laboratory variables at diagnosis, rates of complete remission(CR) at 6 months, defined as Birmingham Vasculitis Activity Score (BVAS)=0 and prednisone 7.5 mg/day, AAV relapse at 12 months, and adverse effects were investigated.

Results:

Of 40 patients, mean age was 73.5±9.6 years (6 males and 34 females). Diagnosis of MPA and GPA were 30 cases and 10 cases, respectively. 37 cases (93%) were positive for MPO-ANCA. Treatment regimen was determined by attending physician. Baseline characteristic of each group (RTX group and CY group) are shown in Table1. Baseline charactor, disease activity, organ involvement, and the proportion of patients with relapsing disease were similar in the two treatment groups. At 6 months, there was no difference of remission rate between two groups (RTX: CY = 62%: 44%, p=0.35) (Figure 1). However, mean PSL dosage at 3 months was significantly lower in RTX group (10.0±4.6mg/day) as compared to CY group (15.8±9.5mg/day; p=0.025) (Figure 2). At 12 months, 1 case in CY group and no case in RTX group had relapse. Adverse effects through 12 months are shown in Table 2. 8 infections (30%) in CY group and 7 infections (35%) occurred in RTX group (p=0.64), respectively. 1 case in RTX group had died due to renal failure.

Table 1.

Comparison of clinical characteristics at baseline between RTX and CY groups.

RTX(n=20)CY(n=20)p valueDeath, n (%)1 (5)0 (0)0.50Infections, n (%)7 (35)8 (30)0.46Serious (grade 3), n (%)4 (15)3 (10)0.50Malignancy, n (%)1 (5)0 (0)0.50VTE, n (%)1 (5)0 (0)0.50AMI, n (%)1 (5)0 (0)0.50Leukopenia, n (%)3 (15)3 (10)0.70Necrosis of femoral head, n (%)0 (0)1 (5)0.50Mediastinal emphysema0 (0)1 (5)0.50

VTE: venous thrombotic emboli, AMI: acute myocardial infarction

Conclusion:

We indicated that PSL was tapered more rapidly in RTX group, although there was no difference of remission rate at 6 months and infection at 12 months between RTX and CY therapy. Therefore, remission induction therapy with RTX might be more safety for elderly Japanese AAV patients.

References:

[1]Little MA, Nightingale P, Verburgh CA, Hauser T, et al. Ann Rheum Dis 2010; 69:1036–1043.

Table 2.

Adverse effects through 12 months. % = patients with 1 effects

RTX(n=20)CY(n=20)p valueAge, year72.3 ± 11.074.8 ± 8.010.55female, n (%)16 (80)18 (90)0.33AAV type0.14 MPA, n (%)13 (65)17 (85) GPA, n (%)7 (35)3 (15)Newly diagnosis, n (%)7 (35)4 (20)0.24ANCA positivity MPO, n (%)20 (100)17 (85)0.12 PR3, n (%)1 (5)2 (10)0.50 negative, n (%)0 (0)2 (10)0.24 eGFR (mL/min)55.0 ± 29.558.1 ± 21.50.45Organ involvement General, n (%)14 (70)19 (95)0.046* Cutaneous, n (%)1 (5)3 (15)0.30 Eyes, n (%)4 (20)1 (5)0.17 ENT, n (%)5 (25)5 (25)1.00 Pulmonary, n (%)14 (70)15 (75)0.50 Renal, n (%)14 (70)13 (65)0.50 Neurologic, n (%)8 (40)4 (20)0.15BVAS13.8 ± 6.614.1 ± 7.60.73

RTX: Rituximab, CY: Cyclophosphamide, ANCA: antineutrophil cytoplasmic autoantibody, AAV: ANCA-associated vasculitis, GPA: granulomatosis with polyangiitis, MPA: microscopic polyangiitis, ENT: Ear, Nose, and Throat, BVAS Birmingham Vasculitis Activity Score, * p <0.05

Disclosure of Interests:

None declared

SAT0057 PREDICTING INADEQUATE RESPONSE TO JAK INHIBITORS BY CLUSTER ANALYSIS IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Oral Janus kinase inhibitors (JAKi) have dramatically altered outcomes in patients with rheumatoid arthritis (RA). However, there remains some proportion of patients who respond to inadequately JAKi treatment (JAKi-IR) [1,2]. The characteristics in RA patients associated with JAKi-IR have not been fully demonstrated.

Objectives:

To clarify the characteristics of JAKi-IR in patients with RA by cluster analysis.

Methods:

This retrospective study comprised 120 RA patients who were treated with JAKi (Tofacitinib or Baricitinib) between July 2013 and September 2019 in five facilities. The disease status at the baseline, at 12 weeks after JAKi treatment and at the time point of withdrawing JAKi was assessed using the Disease Activity Score (DAS28) and the American College of Rheumatology (ACR) response criteria. JAKi-IR was defined as follows, primary non-response at 12 weeks after JAKi treatment: withdrawal of JAKi with ACR20 non-response or non-improvement in DAS28-CRP (ΔDAS28-CRP<1.2 from baseline), secondary non-response: withdrawal of JAKi without clinical remission after 12 weeks. Hierarchical cluster analysis was performed with the following variables: gender, age, disease duration, bone erosion, ACR functional classification (Class ≥3), comcomitant rheumatoid arthritis related interstitial lung disease (RA-ILD) or other autoimmune disease (AID), anti-citrullinated protein antibody (ACPA) positivity, rheumatoid factor (RF) at baseline, use/dose of methotrexate (MTX) and prednisolone (PSL), serum ESR/CRP, tender/swollen joint counts (TJC/SJC), visual analog scale by patients (VAS-Pt), and prior of biologic DMARDs.

Results:

The 120 enrolled patients were classified into 4 groups by cluster analysis(Figure1), The characteristics of each group are as follows, Group A(n=21): female + bone erosion + RF/ACPA positive + AID + MTX non-user, Group B(n=36): male + older age + RA-ILD + RF/ACPA positive + MTX non-user, Group C(n=35): RF/ACPA positive + absence of RA-ILD + MTX user, Group D (n=28): seronegative + MTX user + absence of RA-ILD + history of biologic DMARDs failure. The rate of JAKi-IR was A:9%, B:8%, C:20%, D:32%, and the significant difference between Group B and D was identified (p=0.02). In multiple comparison of 4 groups, no significant difference was identified (p=0.06) (Figure2).

Conclusion:

JAKi-IR would be more likely to be seronegative, MTX use, absence of RA-ILD and history of biologic DMARDs failure. Cluster analysis is an exploratory tool that aids in the analysis of huge amount of data.

References:

[1] Takeuchi T, Yamanaka H, Yamaoka K, Arai S, Toyoizumi S, DeMasi R, et al. Efficacy and safety of tofacitinib in Japanese patients with rheumatoid arthritis by background methotrexate dose: A post hoc analysis of clinical trial data. Mod Rheumatol. 2019;29(5):756-66.

[2] Tanaka Y, Atsumi T, Amano K, Harigai M, Ishii T, Kawaguchi O, et al. Efficacy and safety of baricitinib in Japanese patients with rheumatoid arthritis: Subgroup analyses of four multinational phase 3 randomized trials. Mod Rheumatol. 2018;28(4):583-91.

Disclosure of Interests:

Masanari Sugawara: None declared, Yuichiro Fujieda: None declared, Atsushi Noguchi: None declared, Shun Tanimura: None declared, Yuka Shimizu: None declared, Ikuma Nakagawa: None declared, Michihito Kono: None declared, Masaru Kato: None declared, Kenji Oku: None declared, 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.

AB0592 NAILFOLD CAPILLARY ABNORMALITIES PREDICT INTERSTITIAL LUNG DISEASE (ILD) COMPLICATION IN SYSTEMIC SCLEROSIS PATIENTS

Background:

Systemic sclerosis (SSc) have various organ involvements including pulmonary hypertension (PH), digital ulcers (DU), and interstitial lung disease (ILD). On the other hand, Nailfold capillary (NFC) abnormalities (enlarged/giant capillaries, fresh or old hemorrhages, avascular areas, ramified/bushy capillaries) detected by capillaroscopy are included in ACR/EULAR classification criteria for SSc as one of important findings. In addition, many studies have reported the relationship between NFC abnormalities and organ involvements (DU, PH) [1][2]. However, there are a few reports about the relationship between NFC abnormalities and ILD.

Objectives:

We clarify the association with NFC abnormalities and ILD in SSc patients.

Methods:

We enrolled SSc patients without PH from January 2016 to December 2019 in our institution. SSc patients were diagnosed according to EULAR classification criteria in 2013. ILD was detected by chest CT scans. We assessed severity of ILD with pulmonary function tests (PFT). Abnormal PFT was defined as vital capacity (%VC) or diffusion capacity (DLCO) < 70%. NFC abnormalities were detected with “OptiPiX capillaroscopy Clinic 1.7.x” and the number of capillaries was measured per 1mm in 2nd to 5th fingers of both hand. We defined enlarged and giant capillaries as >30 µm and >50 µm, respectively.

Results:

We enrolled 59 SSc patients (54 females, 5 males). Mean age is 65.0 ± 8.0 years. Thirty-one patients (52.5%) were complicated with ILD. Mean capillary counts are 6.6/mm. The number of patients with each NFC abnormalities (enlarged capillaries, giant capillaries, microhemorrhages, ramified, avascular areas) are 42, 32, 48, 38, and 33 cases, respectively. Two cases did not have NFC abnormalities. SSc patients with giant capillaries had fewer ILD complications (p <0.05, odds ratio 0.183 [0.059 – 0.57]). Other NFC abnormalities were not associated with ILD in SSc patients. We inspected %VC of 23 patients and DLCO of 20 patients with ILD. Eleven patients had abnormal PFT (5 patients had abnormal %VC and 9 patients had abnormal DLCO). Most of them had not enlarged capillaries than patient with normal PFT (odds ratio 0.11 [0.016 – 0.81]). Other NFC abnormalities including giant capillaries were not associated with abnormal PFT.

Conclusion:

We investigated the relationship between NFC abnormalities and ILD conplications in SSc patients. NFC abnormalities are associated with ILD complicacion and severity of ILD. It was suggested that no giant capillary in SSc patients may predict ILD complication. Moreover, no enlarged capillary may predict the severe ILD.

References:

[1]Valeria Riccieri et al. Systemic sclerosis patients with and without pulmonary arterial hypertension: a nailfold capillaroscopy study. Rheumatology, Volume 52, Issue 8, 1 August 2013, Pages 1525–1528

[2]Maurizio Cutolo et al. Nailfold Videocapillaroscopic Features and Other Clinical Risk Factors for Digital Ulcers in Systemic Sclerosis: A Multicenter, Prospective Cohort Study. Arthritis Rheumatol. 2016 Oct; 68(10): 2527–2539.

Disclosure of Interests:

None declared

0590 Reliability of Simple Sleep Evaluation Device at Split-Night Polysomnography

Introduction

Watch-PAT is a sleep evaluation device that measures the peripheral blood volume continuously with a probe attached to a fingertip and does not use an electroencephalogram or a nasal cannula. There has been no report on the usefulness of watch-PAT to determine the apnea diagnosis and continuous positive airway pressure (CPAP) use effects in split-night sleep study.

Methods

The consent of the study was obtained. Watch-PAT was simultaneously worn on a patient admitted for split-night polysomnography. The apnea-hypopnea index (AHI) obtained from PSG and the pAHI gained from the watch-PAT were measured when not using CPAP and when using CPAP respectively. And also we examined whether the reduction rates of AHI and pAHI could be correlated.

Results

38 subjects (32 men, age 55 ± 13 years old). BMI 28.3 ± 5.7 kg / m2. When CPAP was not used, AHI was 57.2 ± 23.3 / h and pAHI was 50.8 ± 20.3 / h (r = 0.93, p &lt; 0.0001), when CPAP was used, AHI was 5.2 ± 4.5 /h and pAHI was 6.2 ± 4.5 h (r = 0.82, p &lt; 0.0001), AHI reduction rate was 90.4 ± 8.0% and pAHI reduction rate was 85.4 ± 14.6% (r = 0.76, p &lt; 0.0001).

Conclusion

It was suggested that Watch-PAT had a good correlation with AHI at split night-sleep study.

Support

None

Seventeen-year clinical outcome of schizophrenia in Bali

Objective

To examine the 17-year clinical outcome of schizophrenia and its predictors in Bali.

Methods

Subjects were 59 consecutively admitted first-episode schizophrenia patients. Their clinical outcome was evaluated by standardized symptomatic remission criteria based on Positive and Negative Syndrome Scale (PANSS) scores and operational functional remission criteria at 17-year follow-up. The standardized mortality ratio (SMR) over 17 years was also calculated as another index of clinical outcome.

Results

Among these 59 patients, 43 (72.9%) could be followed-up, 15 (25.4%) had died, and one (1.7%) was alive but refused to participate in the study. Combined remission (i.e. symptomatic and functional remission) was achieved in 14 patients (23.7% of original sample). Duration of untreated psychosis (DUP) was a significant baseline predictor of combined remission. Mean age at death of deceased subjects was 35.7, and SMR was 4.85 (95% CI: 2.4–7.3), indicating that deaths were premature. Longer DUP was associated with excess mortality.

Conclusions

The long-term outcome of schizophrenia in Bali was heterogeneous, demonstrating that a quarter achieved combined remission, half were in nonremission, and a quarter had died at 17-year follow-up. DUP was a significant predictor both for combined remission and mortality.

Mucor pulmonary embolism in a patient with myelodysplastic syndrome

Mucormycosis is a life-threatening infectious disease that occurs most commonly in immunocompromised patients such as those with hematological malignancies. Its clinical symptoms and associated radiological findings vary and specific biomarkers and culture characteristics have not been defined. An 85-year-old man who had been treated for myelodysplastic syndrome and tuberculosis for several months presented with subacute fever and worsening left-side chest pain. Contrast-enhanced computed tomography images depicted massive tumor-like consolidation without enhancement, expanding from the left lower lobe. Emboli that did not respond to anticoagulants were detected in the left descending pulmonary artery. Despite intensive treatment he developed multiple organ failure and died 47 days after hospitalization. Gross pathology of a lung autopsy specimen revealed left lower pulmonary arterial emboli and pulmonary infarction, which was concluded to be the direct cause of death. The emboli were histopathologically identified as invasive mycelia in vessels. Mucor sp. was detected via real-time polymerase chain reaction and immunohistopathological analyses revealed that the mold in the blood vessels of lung tissue was partially positive for the mucor antigen. In the present case of Mucor sp. pulmonary emboli in a patient with myelodysplastic syndrome, radiographic findings were hard to distinguish from those typical of a lung abscess.

P1512 Combination of mitral annular peak systolic and early diastolic velocities with early transmitral peak flow velocity: a new prognostic echo index in patients with acute coronary syndrome

Background

One of the novel echocardiographic indices reflecting left ventricular (LV) diastolic filling is the combination of mitral annular peak systolic (s’) and early diastolic velocities (e’) with early transmitral peak flow velocity (E); E/(e’ x s’). This index is reported to be useful to predict a prognosis of heart failure patients regardless of their LV ejection fraction (LVEF).Purpose: The aim of this study was to examine whether or not E/(e’ x s’) could predict cardiac events in patients with acute coronary syndrome (ACS).Methods: We studies consecutive ACS patients hospitalized in our institution between December 2009 and February 2012. They underwent echo examination within 7 days after admission. By use of Doppler tissue imaging, e’ and s’ were respectively calculated by averaging the peak velocities measured at both septal and lateral mitral annulus in 4-chamber view. The exclusion criteria were as follows: atrial fibrillation, significant valvular diseases and inadequate echo images. Cardiac events were defined as re-hospitalization due to recurrent ACS and/or heart failure, and cardiac mortality.Results: In total, 168 patients were eligible for this study (mean age 67 ± 11 years, mean LVEF 51.7 ± 10.3 %). Median follow-up period was 22.5 months. During the follow-up, cardiac events occurred in 27 patients (16.1%). Between the patients with cardiac events and those without, there were significant differences in LV end-systolic volume (44.2 ± 29.1 vs 33.2 ± 13.6 ml, p &lt; 0.05), LV mass index (122.4 ± 38.9 vs 107.5 ± 26.4 g/m², p &lt; 0.05), left atrial volume index (31.7 ± 9.2 vs 27.6 ± 9.4 ml/m², p &lt; 0.05), LVEF (45.7 ± 13.5 vs 52.9 ± 9.2 %, p &lt; 0.05), s’ (5.1 ± 1.6 vs 7.1 ± 1.7 cm/sec, p &lt; 0.001), e’ (4.8 ± 1.3 vs 6.0 ± 1.9 cm/sec, p &lt; 0.05), E/e’ (16.4 ± 6.6 vs 12.5 ± 4.9, p &lt; 0.05), E/(e’ x s’) (3.78 ± 2.52 vs 1.94 ± 1.08, p &lt; 0.001), and serum B-type natriuretic peptide (334.7 ± 420.1 vs 113.8 ± 177.2 pg/ml, p &lt; 0.05). While Cox proportional hazard multivariate analysis detected that E/(e’ x s’) and E/e’ were independent predictors of cardiac events, E/(e’ x s’) was more powerful than E/e’ (p = 0.0002 vs p = 0.0072). ROC analysis revealed that 2.35 of E/(e’ x s’) was the optimal cutoff values to predict cardiac events in ACS patients (AUC 0.79). Patients with E/(e’ x s’) &lt;2.35 had significantly better prognosis than the rest (p &lt; 0.0001, Log-rank; Figure)Conclusion: E/(e’ x s’) could be a useful echo marker to predict cardiac events in ACS patients.

Abstract P1512 Figure.

P684 Paradoxical cerebral infarction due to massive pulmonary embolism in extracorporeal cardiopulmonary resuscitation and surgical embolectomy

Introduction

Paradoxical cerebral infarction is a mechanism of acute ischemic stroke; however, definitive images to diagnose paradoxical embolism are not often obtained. We report a case of paradoxical cerebral embolism complicated with cardiac arrest due to massive pulmonary embolism.

Case report

A 40-year-old man presented due to sudden-onset chest pain, and was admitted to our hospital. He was restless and had cold sweat; we could not measure blood pressure. Electrocardiography showed wide QRS complex with right bundle branch block, and T wave inversion in leads V1 and III. Transthoracic echocardiography showed diffuse severe left ventricular hypokinesis, with slightly better inferior wall motion compared to other segments. Few minutes after arriving, he experienced cardiac arrest; chest compression was initiated. He was transported to the catheter laboratory, and veno-arterial extracorporeal membrane oxygenation was initiated subsequently. To diagnose the cause of arrest, we performed coronary angiography, which revealed no occluded coronary artery. Pulmonary angiograms showed bilateral proximal pulmonary artery occlusion with massive thrombi (panel A). Surgical embolectomy was performed after cardiac team discussion. After ICU admission post-surgery, pericardial effusion was increased, and the blood drained continuously from the chest tube; a large amount of blood transfusion was required. Reopen chest haemostasis was utilised. After the second ICU admission, anisocoria was observed; subsequent computed tomography showed low density and midline shift in almost the entire left cerebral hemisphere (Panel B). Carotid duplex ultrasound revealed a large thrombus saddled at the left carotid artery bifurcation (Panel C and D). We rechecked the transthoracic echocardiogram at arrival to reveal the cause of the cerebral infarction, which showed the thrombus to be at the ascending aorta (Panel E). We thought that the thrombi had moved from the lower limb to the right atrium. The massive pulmonary embolism increased the pulmonary artery and right atrial pressure, resulting in the lower pressure of the left atrium compared to that of the right atrium. The thrombi passed through the patent foramen ovale into the left atrium, moved into the left ventricle, and embolised the left internal carotid artery (Panel F). He expired due to severe neurologic injury from brain herniation.

Conclusion

In this case, although the pulmonary embolism was massive and led to cardiac arrest, the deteriorated haemodynamics improved by extracorporeal cardiopulmonary resuscitation and surgical embolectomy. However, we could not rescue the patient because of the severe neurological injury due to paradoxical embolism. Paradoxical cerebral infarction in pulmonary embolism is rare; however, we should pay careful attention to early detection of paradoxical cerebral infarction in pulmonary embolism and treatment for return of the patient to the former lifestyle.

Abstract P684 figure

P1508 Left ventricular diastolic function plays a different role on mortality depending on the severity of systolic dysfunction in acute heart failure patients with reduced ejection fraction

Background

It remains to be clarified whether clinical significance of left ventricular (LV) diastolic function differs depending on the severity of LV systolic dysfunction in patients with acute heart failure (AHF). The aim of this study was to examine the prognostic role of LV diastolic function in AHF patients with various systolic dysfunction.Methods: We studied consecutive hospitalized AHF patients with LV ejection fraction (LVEF) &lt;50%. The exclusion criteria were as follows: atrial fibrillation, severe mitral regurgitation, and inadequate echo image quality. They underwent echocardiography on admission. The eligible patients (n = 289, 165 males, 76 ± 10 years) were divided into 4 groups based on LVEF and left atrial pressure (LAP) grade estimated as in the ESC guidelines: Group I (LVEF 40-49% (mildly reduced LVEF)/normal LAP, n = 28), II (mildly reduced EF/increased LAP, n = 38), III (LVEF &lt;40% (severely reduced LVEF)/normal LAP, n = 110), and IV (severely reduced LVEF/increased LAP, n = 113). Cardiac death was examined up to 60 months.Results: In total, 58 patients (20%) died because of cardiac events during the follow-up (mean 20 ± 19 months). In patients with mildly reduced LVEF, Group I showed significantly less cardiac death ratio than II (n = 1 vs 10, Group I vs II, p = 0.03). On the other hand, in patients with severely reduced LVEF, there was no significant difference in cardiac death ratio between Group III and IV (n = 23 vs 24, Group III vs IV, p = 0.80). That is, LAP grade was a prognostic marker when the patients had mild LV systolic dysfunction, whereas it did not contribute to the prediction of cardiac mortality when patients showed severely reduced LV systolic function. Group I showed significantly better prognosis than those with severe LV systolic dysfunction regardless of LAP grade (Group III, IV) (Group I vs III, p = 0.04; Group I vs IV, p = 0.04).Conclusions: LV diastolic function may have a different clinical significance depending on the severity of LV systolic dysfunction in AHF patients.

P765 Does detection of thrombus in left atrial appendage increase risk of ischemic stroke and mortality?

Background

Left atrial appendage (LAA) thrombus is one of causes of cardiogenic stroke and detection of LAA thrombus by transoesophageal echocardiography (TOE) strongly suggest cardiogenic stroke. It was reported that cardiogenic stroke patients had higher in-hospital mortality about 19%; however, little is known about LAA thrombus and mortality after indexed detection of LAA thrombus. We investigated LAA thrombus detection and their prognosis including ischemic stroke and survival.

Methods

The patients who were performed TOE between 2005 and 2016 in our hospital were enrolled in this study. Patients were divided into 2 groups based on thrombus detection in the LAA, and baseline characteristics and outcomes including prevalence of 5-y stroke-free and survival from the indexed TOE were compared.

Results

Among the 1260 study patients, the follow-up duration was median 971 d (interquartile range 345 d – 2017 d), and 67% of the patients were performing TOE for atrial fibrillation (AF), 20% for cerebral infarction, and 14% for valvular heart disease. Non-valvular AF was seen in 64% of the study patients and rheumatic AF was in 2%. The age (74 y [66 y – 79 y] vs 70 y [62 y – 76 y], p &lt; 0.001), the prevalence of male sex (67% vs 69%, p = 0.63), and hemoglobin level (13.9 g/dl [12.5 – 15.1 g/dl] vs 13.8 g/dl [12.4 – 14.9 g/dl], p = 0.49) were similar between the patients with LAA thrombus and those without. The CHA2DS2-VASc score (p = 0.008), the prevalence of receiving anticoagulation before TOA (34% vs 24%, p = 0.01), those of after TOA (98% vs 66%, p &lt; 0.001), serum creatinine (0.92 mg/dl [0.80 – 1.10 mg/dl] vs 0.85 mg/dl [0.71 – 1.00 mg/dl], p &lt; 0.001), d-dimer level (1.7 mcg/ml [0.9 – 3.5 mcg/ml] vs 0.8 mcg/ml [0.5 – 2.2 mcg/ml], p &lt; 0.001), and plasma brain natriuretic peptide (315 pg/ml [128 – 515 pg/ml] vs 126 pg/ml [47 – 284 pg/ml], p &lt; 0.001) were higher in the patients with LAA thrombus than those without. The 5-y ischemic stroke-free rate was lower in the patients with LAA thrombus than those without (p &lt; 0.001) (Figure, Panel A); however, the 5-y survival was similar between the 2 groups (p = 0.93) (Panel B).

Conclusions

The patients who were detected thrombus in the LAA had higher incidence of ischemic stroke, but the survival rate were similar. The higher rate of receiving anticoagulation therapy in the patients with LAA thrombus may be the cause of this discrepancy. Further studies are necessary to clarify this issue.

Abstract P765 Figure

The IMPACT Study - Single Inhaler Triple Therapy (FF/UMEC/VI) Versus FF/VI And UMEC/VI In Patients With COPD: Efficacy And Safety In A Japanese Population

Purpose

The Informing the Pathway of COPD Treatment (IMPACT) study demonstrated that single-inhaler triple therapy fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) reduces moderate/severe exacerbation rates and improves lung function and health status versus FF/VI or UMEC/VI dual therapy in patients with symptomatic COPD and a history of exacerbations. This analysis evaluated the efficacy and safety of FF/UMEC/VI in patients enrolled in Japan.

Patients and methods

IMPACT was a 52-week, randomized, double-blind, multicenter study comparing FF/UMEC/VI 100/62.5/25 µg with FF/VI 100/25 µg or UMEC/VI 62.5/25 µg in patients ≥40 years with symptomatic COPD and ≥1 moderate/severe exacerbation in the previous year. Endpoints included annual rate of on-treatment moderate/severe exacerbations (primary endpoint), time-to-first on-treatment moderate/severe exacerbation and change from baseline at Week 52 in trough FEV₁, post-bronchodilator FEV₁, St. George’s Respiratory Questionnaire, and COPD Assessment Test score. Safety was also assessed.

Results

The Japan subgroup accounted for only 4% (378/10,355) of the overall IMPACT intent-to-treat (ITT) population. In the Japan subgroup, FF/UMEC/VI reduced the annual rate of on-treatment moderate/severe exacerbations by 15% (95% CI: −20, 40) versus FF/VI (compared with 15% [10, 20] in the ITT) and 36% (95% CI: 6, 57) versus UMEC/VI (compared with 25% [19, 30] in the ITT). FF/UMEC/VI reduced moderate/severe exacerbation risk (time-to-first), improved lung function and health status at Week 52 versus both dual therapies. These results were in the same direction and of a generally similar magnitude to those seen in the overall ITT population. No new safety signals were identified in the Japan subgroup compared with the ITT population. Pneumonia incidence was higher with FF/UMEC/VI and FF/VI versus UMEC/VI.

Conclusion

These results highlight the favorable benefit–risk profile of FF/UMEC/VI single-inhaler triple therapy compared with FF/VI or UMEC/VI dual therapy in patients in Japan with symptomatic COPD and ≥1 exacerbation in the prior year.

Nutritional factors affecting length of hospital stay in patients undergoing cardiovascular surgery

Cardiovascular surgery is a highly invasive intervention that is often performed in elderly patients at risks of complications because of malnutrition and reduced immunity. This study investigated nutritional factors that affected length of hospital stay in patients undergoing cardiovascular surgery. Among 68 patients who underwent surgery at the Department of Cardiovascular Surgery of Gifu Municipal Hospital between April 2013 and March 2015, 55 with complete data were included in the analysis. Data on serum albumin (ALB), transferrin (Tf), pre-albumin (PA) and retinol binding protein (RBP) levels were collected. The median length of hospital stay was 29 days (stays of ≥30 days were considered long-term hospitalization). Multivariate analysis (multiple logistic regression) included age (≥ 65 years), sex (female), and ALB (≤ 3.0 g/dL), Tf (≤ 150.0 mg/dL), PA (≤ 10.0 mg/dL) and RBP (≤ 1.5 mg/dL) levels. ALB [odds ratio (OR) 10.37, 95% CI (confidence interval): 1.185-90.80, P = 0.035] and Tf [OR 4.743, 95% CI: 1.375-16.36, P = 0.014] were significantly associated with length of hospital stay. Nutritional management of patients and careful monitoring of ALB and Tf levels can shorten length of hospital stay in patients undergoing cardiovascular surgery.

Factor Xa inhibitors for preventing recurrent thrombosis in patients with antiphospholipid syndrome: a longitudinal cohort study

OBJECTIVE

The objective of this study was to clarify the efficacy and safety of factor Xa inhibitors for antiphospholipid syndrome patients in real world utilization.

METHODS

This is a retrospective cohort study comprised of all consecutive patients with antiphospholipid syndrome in our department over a period of 28 years. Patients treated with factor Xa inhibitors were extracted from the cohort. As a control group, patients treated with warfarin were selected from the same cohort with matched age, gender, coexistence of systemic lupus erythematosus, and the presence of antiplatelet therapy, after which we used a propensity score for each of the risk factors as an additional covariate in multivariate Cox proportional hazard regression. The primary endpoint was set as thrombotic and hemorrhagic event-free survival for five years.

RESULTS

Among 206 patients with antiphospholipid syndrome, 18 had a history of anti-Xa therapy (five rivaroxaban, 12 edoxaban, one apixaban). Fourteen out of 18 patients on anti-Xa therapy had switched to factor Xa inhibitors from warfarin. Event-free survival was significantly shorter during anti-Xa therapy than that during warfarin therapy (hazard ratio: 12.1, 95% confidence interval: 1.73-248, p = 0.01) ( Figure 1(a) ). Similarly, event-free survival in patients treated with factor Xa inhibitors was significantly shorter compared with controls (hazard ratio: 4.62, 95% confidence interval: 1.54-13.6, p = 0.0075). In the multivariate Cox proportional hazard model, event-free survival in patients with anti-Xa therapy remained significantly shorter (hazard ratio: 11.9, 95% confidence interval: 2.93-56.0, p = 0.0005).

CONCLUSIONS

Factor Xa inhibitors may not be recommended for antiphospholipid syndrome.

Bronchoscopic Surgery for a Solitary Tracheal Tumor of Tracheobronchopathia Osteochondroplastica

Tracheobronchopathia osteochondroplastica is a rare benign condition in which multiple cartilaginous or bony submucosal nodules project into the trachea or bronchi. A 71-year-old man complained of cough for 3 months. Computed tomography scanning revealed a calcified tracheal tumor near the tracheal bifurcation. Pulmonary function testing indicated airflow limitation, and bronchoscopic examination confirmed a solitary rigid tumor. Bronchoscopic resection was performed under general anesthesia, and the tumor was detached by cauterizing its stem with high-frequency coagulation. The tumor was pathologically indicative of tracheobronchopathia osteochondroplastica. After surgery, the clinical signs of cough and dyspnea resolved and pulmonary function normalized.

P2610Increase in comfortable walking speed during hospitalization predicts the readmission due to decompensated heart failure in heart failure patients with preserved ejection fraction

Background

Heart failure patients with preserved ejection fraction (HFpEF) have reduced exercise capacity and poor prognosis as well as those with reduced ejection fraction (HFrEF). Both cardiac function and exercise capacity have been known as prognostic factors for patients with HFrEF. However, few reports documented the relations of comfortable walking speed (CWS) during hospitalization to exercise capacity and prognosis. is used as a clinical measure to assess their exercise capacity and prognosis. However, few reports documented the correlations of CWS with exercise capacity and prognosis in patients with HFpEF.

Purpose

This study aimed to investigate whether CWS at hospital discharge and the increase in CWS during hospitalization predicted the readmission due to decompensated heart failure in patients with HFpEF and HFrEF.

Methods

Patients who were hospitalized due to heart failure with New York Heart Association (NYHA) Functional Classification III or IV were prospectively followed up for 3 years after hospital discharge. Consequently, 264 patients, 173 males and 92 females, aged 73.2±6.8 years were studied. Patients were divided into 3 groups based on their ejection fraction (EF): HFpEF group (EF≥50%; n=98), HFrEF group (EF<40%; n=138) and heart failure with mid-range ejection fraction (HFmrEF) group (40%≤EF≤49%; n=28). We assessed clinical characteristics including age, gender, height, NYHA functional classification, etiology of CHF, plasma brain natriuretic peptide and left ventricular ejection fraction (LVEF) on admission, and measured CWS several days after admission and at discharge. We determined significant factors affecting the readmission and their cut-off values using univariate and multivariate logistic regression analyses and the area under the receiver operating characteristics curves in the three groups.

Results

Forty patients (40.8%), 54 (39.1%) and 6 (21.4%) were readmitted in the HFpEF, HFrEF and HFmrEF groups, respectively, within 3 years after the discharge. Univariate logistic regression analysis detected the age, LVEF, CWS at discharge and the CWS increase during hospitalization as significant limiting factors for readmission in the HFpEF and HFrEF groups (P<0.05, respectively). The multivariate logistic regression analysis detected the CWS increase during hospitalization as significant limiting factor for readmission in the HFpEF and HFrEF groups (P<0.001 and P<0.05, respectively). The odds ratios of readmission were 1.86 (P<0.01) and 1.44 (P<0.001) with each 5-meter decrease of CWS increase during hospitalization and predictive cut-off values of the CWS increase were 7.5 and 8.5 meters/min in the HFpEF and HFrEF groups, respectively.

Conclusion

This study demonstrated that the CWS increase during hospitalization was a strong predictor for readmission due to decompensated heart failure in patients not only with HFrEF but also with HFpEF and each predictive the cut-off value was 7.5 and 8.5 meters/min.

P4548Early drop in systolic blood pressure and worsening renal function in the elderly acute heart failure: how does heart rate interact?

Background

Renal dysfunction is a frequent finding in patients hospitalized for acute heart failure (AHF). Worsening renal function (WRF) during hospitalization was found to be related with a poor outcome independently of baseline renal function. Early drop in systolic blood pressure (SBP) has shown to predict WRF in AHF. However, there have been few studies that reported the impact of on-admission heart rate (HR) on the relationship between early SBP drop and WRF in the elderly AHF.

Purpose

We assessed the hypothesis that early SBP drop predict WRF in the elderly patients with AHF, and investigated that on-admission HR might have an interaction with that relationship.

Methods

SBP and HR were measured on admission and 6 times during 48 hours in the 245 elderly AHF inpatients (82.9±6.0 years old, male 49.4%). WRF was defined as a serum creatinine increase of ≥0.3 mg/dL by Day 5. Early drop in SBP was calculated as the difference between admission and the lowest value measured during the first 48 hour of hospitalization.

Results

Early SBP drop (51.3 vs 32.5mmHg, p<0.01) and on-admission HR (79.3 vs 89.6bpm, p<0.05) were significantly different between the group with WRF (n=36) and the group without WRF (n=209). In the multiple logistic regression analysis adjusted for the confounders including age, gender, hypertension, left ventricular ejection fraction, total cholesterol, BNP, baseline creatinine, beta-blockade use, intravenous loop diuretic, isosorbide dinitrate and carperitide use, early SBP drop (OR: 1.003, 95% CI: 1.003–1.03, p<0.04) and on-admission HR (OR: 0.98, 95% CI: 0.96–0.99, p<0.01) were significantly associated with WRF. The interaction term of early SBP drop by on-admission HR did not have a significant association with WRF (p=0.3).

Conclusions

In the elderly AHF patients, exaggerated early SBP drop and lower on-admission HR were shown as significant independent predictors of WRF. These two factors were additively associated with WRF. Too much reduction in SBP and that in HR might be harmful to renal circulation in AHF.

P986Future risk of bradyarrhythmias in patients with hypertrophic cardiomyopathy and implantable cardioverter defibrillator indication

Background

Subcutaneous-implantable cardioverter defibrillator (S-ICD) has been shown to be effective for prevention of sudden cardiac death. Patients with hypertrophic cardiomyopathy (HCM) having ICD indication are considered to introduce either S-ICD or transvenous-ICD, however it is uncertain which is better since S-ICD is not suitable for patients who need pacing and data on the necessity for pacing in HCM patients are limited.

Purpose

The purpose of this study was to investigate the risk factors associated with the future risk of bradyarrhythmias needed to be paced in patients with HCM and ICD indication.

Methods

This is a retrospective, single-center cohort study. Of 169 HCM patients diagnosed in our institution, 80 with ICD indication in accordance with the Japanese guideline in 2011 were enrolled as study subjects (31 females, mean age 63±15 years). They were divided into two groups – patients who progressed to bradyarrhythmias which needed pacing during the follow-up period (Brady group) and those who not (Non-brady group). Baseline characteristics at the time of diagnosis of HCM including demographic information, the results of clinical examination such as blood test, echocardiography and electrocardiography (ECG) were compared between the Brady and Non-brady group.

Results

During a mean follow-up period of 6.8±5.4 years, 9 patients (11%) progressed bradyarrhtyhmias which needed pacing. Symptomatic sick sinus syndrome (SSS) was the primary cause (7 SSS, 1 atrial fibrillation [AF] with bradycardia, 1 after atrioventricular nodal ablation). Comparing between the Brady and Non-brady group, there was no significant difference in clinical variables such as age, heart rate, PR interval and QRS duration in ECG, EF levels, BNP levels, beta-blocker usage rate, prevalence of hypertension or diabetes mellitus. On the other hand, women were more in Brady group than in Non-brady group (7/9, 78% vs. 24/71, 34%; p=0.01). Furthermore, more patients in Brady group had documented AF at the beginning and during follow-up period (7/9, 78% vs. 25/71, 36%; p=0.02) and took anti-arrhythmic drugs (AAD) (8/9, 89% vs. 19/71, 27%; p<0.001) including amiodarone than those in Non-brady group.

Conclusion

In HCM patients with ICD indication, around 10% of patients have a potential risk of bradyarrhythmias needed to be paced, especially in female, those with AF and/or AAD usage.

Pregnancy outcomes in women with rheumatic diseases: a real-world observational study in Japan

OBJECTIVES

We aimed to evaluate the obstetric complications and the risk factors for these events in pregnant women with rheumatic diseases (RDs).

METHODS

A single-center retrospective study of women with RDs at Hokkaido University Hospital between 2007 and 2016 was conducted. Clinical features and maternal and fetal outcomes were retrospectively collected. The rate of pregnancy complications was compared with the general obstetric population (GOP) in Japan.

RESULTS

Overall, 132 pregnancies in 95 women with RDs were recorded. Underlying RDs were systemic erythematosus (SLE) (n = 57), antiphospholipid syndrome (APS) (n = 35), rheumatoid arthritis (n = 9), and other RDs (n = 31). Antiphospholipid antibodies (aPL) were detected in 44 pregnancies (32%). Glucocorticoid was used in 82 pregnancies (62%), and tacrolimus in 20 pregnancies (15%). There were 24 disease flares (18%), but no RD-related death was documented. We recorded 112 live births, 6 abortions, 8 miscarriages, and 6 stillbirths. Pregnancies with RDs appeared to have frequent, emergency cesarean sections and preterm deliveries compared with GOP (30% vs 15% and 21% vs 14%, respectively). The median [interquartile range] birthweight in SLE and APS was lower than GOP (2591 [2231-2958] g and 2600 [2276-2920] g vs 2950 [2650-3250] g, respectively). In pregnancies with SLE, low complement levels presented the risk of maternal complications (odds ratio [95% CI]; 3.9 [1.0-14.9], p = 0.046) and anti-DNA antibody positivity was significantly correlated with the risk of fetal complications (3.5 [1.1-11.2], p = 0.036). In pregnancies with APS, maternal age over 35 years and duration of disease longer than 9 years (7.4 [1.3-40.8], p = 0.021, and 11.16 [1.1-118.8], p = 0.046, respectively) were significantly correlated with the risk of fetal complications.

CONCLUSION

Pregnancies with RDs were at increased risk of having both maternal complications and adverse neonatal outcomes, indicating these pregnancies should be closely monitored.

Benralizumab for the Prevention of COPD Exacerbations

BACKGROUND

The efficacy and safety of benralizumab, an interleukin-5 receptor alpha-directed cytolytic monoclonal antibody, for the prevention of exacerbations in patients with moderate to very severe chronic obstructive pulmonary disease (COPD) are not known.

METHODS

In the GALATHEA and TERRANOVA trials, we enrolled patients with COPD (at a ratio of approximately 2:1 on the basis of eosinophil count [≥220 per cubic millimeter vs. <220 per cubic millimeter]) who had frequent exacerbations despite receiving guideline-based inhaled treatment. Patients were randomly assigned to receive benralizumab (30 or 100 mg in GALATHEA; 10, 30, or 100 mg in TERRANOVA) every 8 weeks (every 4 weeks for the first three doses) or placebo. The primary end point was the treatment effect of benralizumab, measured as the annualized COPD exacerbation rate ratio (benralizumab vs. placebo) at week 56 in patients with baseline blood eosinophil counts of 220 per cubic millimeter or greater. Safety was also assessed.

RESULTS

In GALATHEA, the estimates of the annualized exacerbation rate were 1.19 per year (95% confidence interval [CI], 1.04 to 1.36) in the 30-mg benralizumab group, 1.03 per year (95% CI, 0.90 to 1.19) in the 100-mg benralizumab group, and 1.24 per year (95% CI, 1.08 to 1.42) in the placebo group; the rate ratio as compared with placebo was 0.96 for 30 mg of benralizumab (P = 0.65) and 0.83 for 100 mg of benralizumab (P = 0.05). In TERRANOVA, the estimates of the annualized exacerbation rate for 10 mg, 30 mg, and 100 mg of benralizumab and for placebo were 0.99 per year (95% CI, 0.87 to 1.13), 1.21 per year (95% CI, 1.08 to 1.37), 1.09 per year (95% CI, 0.96 to 1.23), and 1.17 per year (95% CI, 1.04 to 1.32), respectively; the corresponding rate ratios were 0.85 (P = 0.06), 1.04 (P = 0.66), and 0.93 (P = 0.40). At 56 weeks, none of the annualized COPD exacerbation rate ratios for any dose of benralizumab as compared with placebo reached significance in either trial. Types and frequencies of adverse events were similar with benralizumab and placebo.

CONCLUSIONS

Add-on benralizumab was not associated with a lower annualized rate of COPD exacerbations than placebo among patients with moderate to very severe COPD, a history of frequent moderate or severe exacerbations, and blood eosinophil counts of 220 per cubic millimeter or greater (Funded by AstraZeneca [GALATHEA and TERRANOVA] and Kyowa Hakko Kirin [GALATHEA]; GALATHEA and TERRANOVA ClinicalTrials.gov numbers, NCT02138916 and NCT02155660.).

Long-term Safety and Clinical Benefit of Mepolizumab in Patients With the Most Severe Eosinophilic Asthma: The COSMEX Study

PURPOSE

The goal of this study was to assess the long-term safety and efficacy of mepolizumab in patients with the most severe eosinophilic asthma.

METHODS

This multicenter, open-label, long-term, Phase IIIb study (COSMEX [COSMOS Extension]; 201312/NCT02135692) enrolled patients from the 52-week, open-label extension study COSMOS (A Study to Determine Long-term Safety of Mepolizumab in Asthmatic Subjects) that previously enrolled patients from the double-blinded, placebo-controlled Phase III studies MENSA (Mepolizumab as Adjunctive Therapy in Patients with Severe Asthma) and SIRIUS (Steroid Reduction with Mepolizumab Study). To enter COSMEX, patients had to have life-threatening/seriously debilitating asthma before entering MENSA or SIRIUS and to have completed these previous studies with demonstrated improvement while receiving mepolizumab. In COSMEX, patients received mepolizumab 100 mg subcutaneously every 4 weeks as add-on therapy for up to 172 weeks. Primary endpoints were adverse event frequency and exacerbation rate per year; also assessed were forced expiratory volume in 1 s, Asthma Control Questionnaire-5 score, and daily oral corticosteroid (OCS) use.

FINDINGS

Of the 340 patients enrolled, 339 received mepolizumab; median treatment duration within this extension study was 2.2 years, equating to 718 patient-years of additional exposure. No new safety signals were identified. Patients receiving mepolizumab throughout this study and previous studies had lasting reductions in exacerbation rate and daily OCS use and improvements in forced expiratory volume in 1 s and Asthma Control Questionnaire-5 score. In COSMEX, the on-treatment exacerbation rate (95% CI) was 0.93 (0.81-1.06) event/year for clinically significant exacerbations, 0.13 (0.10-0.18) event/year for exacerbations requiring hospitalization/emergency department visit, and 0.07 (0.05-0.10) event/year for exacerbations requiring hospitalization. In patients requiring systemic/oral corticosteroids with ≥128 weeks of continuous enrollment across SIRIUS, COSMOS, and COSMEX, mepolizumab maintained the median daily OCS dose at 1.3-2.8 mg during COSMEX, with additional patients no longer requiring OCS after extended mepolizumab treatment.

IMPLICATIONS

This study indicates that long-term mepolizumab treatment is well tolerated and associated with sustained clinical benefits in patients with severe eosinophilic asthma. ClinicalTrials.gov identifier: NCT02135692.