153 Multiparametric assessment of diastolic function in heart failure

Background

The assessment of diastolic function is still challenging in the setting of heart failure (HF). We tested the hypothesis that applying a machine learning algorithm would detect heterogeneity in diastolic function and improve risk stratification in HF population.

Methods

This study included consecutive 279 patients with clinically stable HF referred for echocardiographic assessment, for whom diastolic function variables were measured according to the current guidelines. Cluster analysis, an unsupervised machine learning algorithm, was undertaken on these variables to form homogeneous groups of patients with similar profiles of the variables. Sequential Cox models paralleling the clinical sequence of HF assessment were used to elucidate the benefit of cluster-based classification over guidelines-based classification. The primary endpoint was a hospitalization for worsening HF.

Results

Cluster analysis identified 3 clusters with distinct properties of diastolic function that shared similarities with guidelines-based classification. The clusters were associated with brain natriuretic peptide level (p < 0.001, figure A). During follow-up period of 2.6 ± 2.0 years, 62 patients (22%) experienced the primary endpoint. Cluster-based classification exhibited a significant prognostic value (c2 = 20.3, p < 0.001, figure B), independent from and incremental to an established clinical risk score for HF (MAGGIC score) and left ventricular end-diastolic volume (hazard ratio = 1.677, p = 0.017, model c2: from 47.5 to 54.1, p = 0.015, figure D). Although guideline-based classification showed a significant prognostic value (c2 = 13.1, p = 0.001, figure C), it did not significantly improve overall prognostication from the baseline (model c2: from 47.5 to 49.9, p = 0.199, figure D).

Conclusion

Machine learning techniques help grading diastolic function and stratifying the risk for decompensation in HF.

Abstract 153 Figure.

P289 Aortic valve resistance risk-stratifies low-gradient aortic stenosis

Background

Grading the severity of aortic stenosis (AS) is challenging, since there is a discrepancy between aortic valve area (AVA) and mean pressure gradient (mPG). Arotic valve resistance (RES) has been proposed as a usuful descriptor of AS severity, but it is not commonly used for clinical decision-making, because its robust validation of clinical-outcome efficacy is lacking. This study aimed to investigate whether RES holds an incremental value for risk-stratifying AS.

Methods

This study recuited 565 AS patients (AVA < 1.5cm²) referred to echocardiography for valve assessment. The patients were divided into three different groups, according to the guidelines: high-gradient AS (HG-AS, mPG≥40mmHg, n = 157), low-gradient AS (LG-AS, mPG < 40mmHg + AVA ≤ 1.0cm², n = 155) and moderate AS (Mod-AS, mPG < 40mmHg + AVA > 1.0cm², n = 253). RES was calculated from Doppler measurement of mPG and stoke volume. The diagnositic cutoff point for RES was determined at 190 dynes × s×cm-5 by substituting AVA = 1.0cm² and mPG = 40mmHg into the definition formula of RES and Gorlin formula. The patients were followed up for 2 years. The endpoint was a composite of cardiac death, hospitalization for heart failure and aortic valve replacement necessitated by the development of AS-related symptoms.

Result

Kaplan-Meier analyses showed that LG-AS exhibited an intermediate outcome between HG-AS and Mod-AS (event-free survival at 2 years = 20.9% for HG-AS, 59.7% for LG-AS, 89.9% for Mod-AS, p < 0.001, figure A). When LG-AS was stratified by RES, the survival curves showed a significant separation (event-free survival at 2 years = 35.3% for high RES, 70.7% for low RES, p < 0.001, figure B). This trend persisted even when analysed separately for norml (stroke volume index > 35ml/m²) and low (stroke volume index ≤ 35ml/m²) flow state ((normal flow) event-free survival at 2 years = 38.7% for high RES, 70.4% for low RES, p = 0.023, figure C; (low flow) event-free survival at 2 years = 26.7% for high RES, 74.6% for low RES, p < 0.001, figure D).

Conclusion

This study confirmed the clinical efficacy of RES for risk-stratifying LG-AS patients.

Abstract P289 Figure.

P893 Left ventricular flow energetics predicts worsening heart failure in dilated cardiomyopathy

Background

Blood flows through healthy hearts form optimal flow structures; they store flow kinetic energy (KE) that can be used for ejection. In contrast, in failing hearts, intracardiac flows become disorganized so that they may be energetically inefficient. However, it remained unknown whether left ventricular (LV) flow energetics prognosticates in heart failure.

Methods

This study included 61 patients with dilated cardiomyopathy (DCM). The temporal change in KE during early diastole (ED), atrial contraction (AC) and isovolumic contraction (IVC) was measured using Vector Flow Mapping particle tracking (Hitachi, figure top). LV inflow (total flow) were divided, based on whether they were ejected (direct flow, DF) or stayed in LV (retained flow, RF) in the following systole. KE of DF can be made use of for ejection, whereas KE of RF is supposed to be wasted. Diastolic function was graded, according to current EACVI/ASE guidelines. The patients were followed up for three years. Primary endpoint was hospitalization for worsening heart failure (WHF).

Results

12 patients had hospitalizations for WHF in the follow-up period. KE of total flow did not show any significant difference through the cardiac cycle between patients with and without WHF. KE of DF was slightly, but not significantly, smaller (ED: p = 0.252, AC: p = 0.119, IVC: p = 0.122), and KE of RF was slightly, but not significantly, larger (ED: p = 0.971, AC: p = 0.085, IVC: p = 0.134) in patients with WHF than those without events. The ratio of DF and RF (DF/RF ratio) showed significant differences between these two groups, especially from AC through IVC (figure, bottom-left). Cox proportional hazard analyses demonstrated that DF/RF ratio during IVC showed a significant correlation with clinical outcomes (p = 0.033, hazard ratio = 0.067). It remained significant even after adjusted for diastolic function grade (p = 0.046, hazard ratio = 0.074). Kaplan-Meier analysis confirmed the above results (figure, bottom-right). Conclusion: Efficiency of KE recruitment for LV ejection during IVC is associated with clinical outcomes in DCM.

Abstract P893 Figure. LISA

Combination gemcitabine plus S-1 versus gemcitabine plus cisplatin for advanced/recurrent biliary tract cancer: the FUGA-BT (JCOG1113) randomized phase III clinical trial

BACKGROUND

Gemcitabine plus cisplatin (GC) is the standard treatment of advanced biliary tract cancer (BTC); however, it causes nausea, vomiting, and anorexia, and requires hydration. Gemcitabine plus S-1 (GS) reportedly has equal to, or better, efficacy and an acceptable toxicity profile. We aimed to confirm the non-inferiority of GS to GC for patients with advanced/recurrent BTC in terms of overall survival (OS).

PATIENTS AND METHODS

We undertook a phase III randomized trial in 33 institutions in Japan. Eligibility criteria included chemotherapy-naïve patients with recurrent or unresectable BTC, an Eastern Cooperative Oncology Group Performance Status of 0 - 1, and adequate organ function. The calculated sample size was 350 with a one-sided α of 5%, a power of 80%, and non-inferiority margin hazard ratio (HR) of 1.155. The primary end point was OS, while the secondary end points included progression-free survival (PFS), response rate (RR), adverse events (AEs), and clinically significant AEs defined as grade ≥2 fatigue, anorexia, nausea, vomiting, oral mucositis, or diarrhea.

RESULTS

Between May 2013 and March 2016, 354 patients were enrolled. GS was found to be non-inferior to GC [median OS: 13.4 months with GC and 15.1 months with GS, HR, 0.945; 90% confidence interval (CI), 0.78-1.15; P = 0.046 for non-inferiority]. The median PFS was 5.8 months with GC and 6.8 months with GS (HR 0.86; 95% CI 0.70-1.07). The RR was 32.4% with GC and 29.8% with GS. Both treatments were generally well-tolerated. Clinically significant AEs were observed in 35.1% of patients in the GC arm and 29.9% in the GS arm.

CONCLUSIONS

GS, which does not require hydration, should be considered a new, convenient standard of care option for patients with advanced/recurrent BTC.

CLINICAL TRIAL NUMBER

This trial has been registered with the UMIN Clinical Trials Registry (http://www.umin.ac.jp/ctr/index.htm), number UMIN000010667.

Mechano-chromic protein-polymer hybrid hydrogel to visualize mechanical strain

In a proof-of-concept study, a mechano-chromic hydrogel was synthesized here, via chemoenzymatic click conjugation of fluorophore-labeled fibronectin into a synthetic hydrogel co-polymers (i.e., poly-N-isopropylacrylamide/polyethylene glycol). The optical FRET response could be tuned by macroscopic stretch.

Maternal dietary patterns during early pregnancy and birth weight in Japan

Background

The average birth weight in Japan has decreased by 200 g in the last 40 years. Only three studies were reported for the association between maternal dietary patterns and birth weight in East Asia, whose results were inconsistent. We examined what maternal dietary patterns were associated with the birth weight in Japan.

Methods

Totally 22,493 pregnant women were recruited between July 2013 and September 2016 into the Tohoku Medical Megabank Project Birth and Three-Generation Cohort Study. We included 17,287 women who had a full-term single healthy baby into the analysis. Consumption of food and beverage items was evaluated based on food frequency questionnaire at the first-trimester. Dietary patterns were analyzed using a machine learning method of k-means clustering algorithm. Birth weight was obtained from the medical record. The association between dietary patterns and birth weight was analyzed using multiple liner regression model adjusted for potential confounders with multiple imputation method for missing values.

Results

Dietary patterns were classified into seven groups by cluster analysis: “high in rice (reference) (n = 8046)”, “middle in vegetables, beans, mushrooms, seaweeds and miso-soup (n = 4842)”, “high in fruits (n = 1176)”, “high in bread, dairy and alcohol (n = 1091)”, “high in meat and fish (n = 1049)”, “high in coffee, black tea, soft drinks and confections (high in coffee) (n = 585)”, and “high in vegetables, beans, mushrooms, seaweeds and miso-soup (n = 498)” groups. In multiple liner regression models, birth weight was 22.6 g (95%CI: 0.1 to 45.2 g) heavier in “high in fruits” group than in reference group and 39.4 g (95%CI: 8.6 to 70.3 g) lighter in “high in coffee” group than in reference group. The other groups were not statistically significant.

Conclusions

High consumption of fruits and high consumption of coffee, black tea, soft drinks and confections during early pregnancy were associated with increased and decreased birth weight, respectively.

Key messages

We found maternal dietary patterns during early pregnancy using a machine learning method of k-means clustering algorithm. We found maternal dietary patterns which associated with the birth weight in Japan.

P6513Temporal trends in coronary intervention strategies and the impact on one-year clinical events: data from a Japanese multi-center real-world cohort study

Background

While it is clear that device technology of percutaneous coronary intervention (PCI) has advanced over the course of the last 40 years and the evidence for improvements in the efficacy of PCI is clear, it is less clear whether the prognosis following PCI continues to improve year by year.

Methods

The Kumamoto Intervention Conference Study Real-World Registry is a multi-center registry that enrolls consecutive patients undergoing PCI in 17 centers in Kyushu area, Japan. To elucidate the clinical impact of recent changes in treatment strategies, 8,841 consecutive participants (historical PCI: n=4,038, enrolled between January 2013 and December 2014, and current PCI: n=4,803, between January 2015 and March 2017) with 1-year follow-up data were analysed. Baseline demographic data, cardiovascular risk factors, and the medication being taken at discharge were documented. The primary endpoint was defined as a major adverse cardiac event (MACE), comprising cardiovascular death or non-fatal MI, including stent thrombosis (ST), occurring within 1 year of PCI.

Results

Regarding the relationships between presenting symptoms and PCI status, ACS, STEMI, NSTEMI, and UAP were similarly common, but the proportion of patients with multi-vessel disease was lower and the proportion with type B2/C lesions was higher in the current PCI group (p=0.004 and p<0.001, respectively). The prevalences of left main trunk lesions and Killip classes III or IV were comparable between the groups, but in-stent restenotic lesions were significantly more frequent in the historical PCI group (p<0.001). In addition to the change in the DAPT regimen, more optimal medical therapy was introduced during this time period, including the use of β-blockers, ACE-Is, and statins.

The incidences of MACE were comparable between historical PCI and current PCI (2.2% vs. 2.1%, p=0.693), even though complex lesions were more frequent during the more recent period. During this period, the use of radial approaches, drug eluting stents, and coronary imaging increased, but the use of intra-aortic balloon pumping (IABP) or thromboaspiration decreased. The incidences of major adverse cardiac or cerebrovascular events (MACCE), cardiac death, non-fatal MI, and stent thrombosis were similar between the historical and current periods (Figure). Multivariate analysis for overall patients, after adjustment, showed that multi-vessel disease, type B2/C lesions, ACS, and DES use were significant independent predictors of MACE.

Figure 1. Comparison of Clinical Events

Conclusion

An improvement in the prognosis associated with PCI has not occurred in recent years. However, the lesions being treated are becoming more complex, and the selection of evidence-based approaches, the use of coronary imaging, and the optimal medication treatments may have contributed to comparable outcomes being maintained.

Acknowledgement/Funding

Daiichi Sankyo Co., Ltd. Japan.

P3755Left atrial enlargement as an independent risk factor for ischemic stroke in Japanese atrial fibrillation patients: pooled analysis of five major Japanese atrial fibrillation registries

Background

Atrial fibrillation (AF) increases the risk of ischemic stroke. It remains unknown whether left atrial diameter determined by routine trans-thoracic echocardiography is a risk factor for ischemic stroke in non-valvular AF (NVAF) patients.

Purpose

The aim of this study is to investigate the impact of left atrial enlargement (LAE) on the incidence of ischemic stroke in a large-scale cohort of Japanese NVAF patients.

Methods

We combined the data of 5 major AF registries in Japan, J-RHYTHM Registry, Fushimi AF Registry, Shinken Database, Keio interhospital Cardiovascular Studies, and Hokuriku AF Registry. After excluding patients without echocardiographic data, 7,672 NVAF patients were analyzed in the present study (mean age, 69.3±12.3 years; mean CHADS2 score, 1.6±1.3). We compared clinical characteristics and the incidence of ischemic stroke between NVAF patients with LAE (left atrial diameter >45 mm; LAE group) and those without (non-LAE group).

Results

The mean left atrial diameter was 43.1±8.6 mm, and the LAE group accounted for 40.0% (n=3,066) of the entire cohort. Compared with non-LAE group (60.0%, n=4,606), the LAE group was older (LAE vs. non-LAE; 70.3±12.0 vs. 68.0±12.5, p<0.01), more often non-paroxysmal type (73.7% vs. 32.1%, p<0.01), had higher CHADS2 (1.86±1.34 vs. 1.46±1.29, p<0.01) and CHA2DS2-VASc (3.02±1.83 vs. 2.53±1.78, p<0.01) scores, and more frequently received oral anticoagulant (72.9% vs. 55.0%, p<0.01).

During the median follow-up period of 774.5 days (interquartile range: 567–1466 days), ischemic stroke occurred in 241 patients (131 vs. 110 patients; 1.52 vs. 0.82 per 100 person-years). In Kaplan Meier analysis, LAE was associated with a higher incidence of ischemic stroke (unadjusted hazard ratio (HR): 1.83, 95% confidence interval (CI): 1.42–2.36; log rank p<0.01) (Figure). LAE was independently associated with increased risk of ischemic stroke (adjusted HR: 1.63, 95% CI: 1.25–2.11; p<0.01) after adjustment by the components of CHADS2 score and the use of oral anticoagulant, on multivariate Cox proportional hazard analysis.

Conclusion

In this large-scale cohort of Japanese patients with AF, LAE was an independent predictor of ischemic stroke, suggesting that this simple echocardiographic parameter could refine thromboembolic risk stratification of NVAF patients.

Acknowledgement/Funding

Japan Agency for Medical Research and Development, AMED

P4785Clinical characteristics and 1-year outcomes in atrial fibrillation patients with or without history of intracranial haemorrhage treated with edoxaban: snapshot analysis of the Global ETNA-AF program

Background

Patients with atrial fibrillation (AF) who survive an intracranial haemorrhage (ICH) are at high risk of stroke, death, and recurrent haemorrhage. Effectiveness and safety of the nonvitamin K antagonist oral anticoagulant (NOAC) edoxaban in this patient population has not been reported.

Purpose

This snapshot analysis from the global ETNA-AF program compared 1-year outcomes in AF patients with and without history of ICH treated with edoxaban from Europe, Japan, and Korea/Taiwan.

Methods

Global ETNA-AF (EU: NCT02944019, Japan: UMINehz745.116117011, Korea/Taiwan: NCT02951039) is a multinational, multicentre, prospective, noninterventional program of AF patients receiving edoxaban in regular clinical care. Demographics, baseline characteristics, and outcomes at 1-year follow-up were reported for 19416 patients with and without a history of ICH.

Results

Of the 19416 patients, 297 had a history of ICH. At 1-year follow-up, incidences of International Society on Thrombosis and Haemostasis (ISTH) major bleeding (including ICH) and clinically relevant nonmajor bleeding (CRNMB) were generally low. The rate of ischaemic stroke was higher in patients with a history of ICH than in those without prior ICH.

Europe (N=7672) Korea/Taiwan (N=1701) Japan (N=10043) History of ICH, n (%) Yes No Yes No Yes No 36 (0.5) 636 (99.5) 27 (1.6) 1674 (98.4) 234 (2.3) 9809 (97.7) Age, median (IQR) 75 (69, 78) 74 (68, 80) 70 (66, 76) 72 (66, 77) 76 (71, 82) 75 (68, 81) Gender, male % 72.2 57.4 70.4 59.9 60.7 59.3 Weight, median (IQR) kg 80.0 (75.0, 88.0) 80.0 (70.0, 92.0) 68.0 (54.0, 77.0) 65.0 (58.0, 73.0) 57.0 (50.0, 65.0) 59.0 (51.0, 68.0) CHA2DS2-VASc, mean (SD) 4.2 (1.44) 3.1 (1.38) 3.9 (1.63) 3.0 (1.43) 4.0 (1.56) 3.4 (1.64) HAS-BLED, mean (SD) 4.3 (1.23) 2.6 (1.12) 3.9 (1.55) 2.4 (10.7) 3.7 (1.07) 2.3 (1.12) CrCl [mL/min], median (IQR) 70.5 (58.8, 85.1) 70.4 (53.8, 90.1) 63.7 (45.8, 84.2) 61.6 (48.4, 78.1) 58.5 (46.0, 73.2) 60.2 (46.1, 77.0) Edoxaban 60/30 mg, % 83.3 / 16.7 77.1 / 22.9 55.6 / 44.4 50.2 / 49.8 21.8 / 78.2 27.8 / 72.2 1-year outcome, n (%/year)   Major bleeding (ISTH) 2 (5.94) 66 (0.92) 0 (0) 13 (0.82) 3 (1.92) 66 (0.96)   Intracranial haemorrhage 1 (2.91) 19 (0.26) 0 (0) 5 (0.32) 1 (0.64) 18 (0.26)   Major GI* bleeding 0 (0.00) 20 (0.28) 0 (0) 2 (0.13) 2 (1.28) 30 (0.43)   CRNMB 0 (0.00) 102 (1.43) 0 (0) 11 (0.70) 6 (3.82) 219 (3.20)   Ischaemic stroke 1 (2.93) 41 (0.57) 1 (4.04) 11 (0.70) 4 (2.57) 78 (1.13) *Gastrointestinal.

Conclusion

Our data underpin the need for effective stroke prevention. In AF patients with a history of ICH, data suggest that edoxaban can be safely and effectively administered in patients with and without prior ICH in regular clinical care.

Acknowledgement/Funding

Daiichi Sankyo

3285Impact of intravascular ultrasound-guided percutaneous coronary intervention in patients with diabetes mellitus and chronic kidney disease

Background

Several studies have shown favorable results using IVUS-guided PCI. Nevertheless, patient background in which use of IVUS is effective is not well elucidated. Patients with diabetes mellitus (DM) or chronic kidney disease (CKD) tend to have complex coronary artery lesions. We sought to assess the impact of IVUS guidance on clinical outcomes in these patients.

Methods

Kumamoto Intervention Conference Study is a multicenter registry which has enrolled consecutive patients who underwent PCI in 16 centers in Japan. Between August 2008 and March 2014, 11,195 consecutive patients were enrolled in this registry. To elucidate the efficacy of IVUS usage in DM and CKD patients, 10,822 consecutive subjects with 1-year follow-up data were analyzed. In this patient population, 69.2% (n=7,493) of patients were treated with IVUS-guided PCI. Patients were divided into 4 groups: the No Risk Group, the DM only Group, the CKD only Group, and the DM+CKD Group.

Results

Maximum stent diameter, post dilatation rate, usage of distal protection device, and rotational atherectomy rate were significantly higher in the IVUS-guided PCI patients in all 4 groups. 1-year MACE (cardiovascular death, non-fatal myocardial infarction, and MI with stent thrombosis) was significantly lower in the IVUS-guided PCI patients than angiography-guided PCI patients in each subset, except for the No Risk Group. In contrast to angiography-guided PCI patients, there were no significant differences among the 4 groups as regards 1-year MACE in the IVUS-guided PCI patients except for the DM+CKD Group. In multiple regression analysis, IVUS usage was an independent negative predictor for 1-year MACE in the DM only Group (HR=0.374, 95% CI 0.194–0.719, p=0.003) and in the CKD only Group (HR=0.604, 95% CI 0.379–0.962, p=0.010). When the No Risk Group was used as a reference, the HR has increased according to increased risk factors in the angiography-guided PCI patients, but such tendency was not necessarily observed in the IVUS-guided PCI patients (Table).

Risk Stratification of DM and CKD Variable IVUS-Guided PCI Angiography-Guided PCI HR 95% CI P HR 95% CI P The No Risk Group Reference – – Reference – –   vs. the DM only Group 0.627 0.321–1.227 0.173 2.036 1.090–3.804 0.026   vs. the CKD only Group 1.334 0.795–2.237 0.275 2.730 1.541–4.836 0.001   vs. the DM+CKD Group 2.114 1.287–3.474 0.014 2.225 1.160–4.266 0.016

Conclusion

The efficacy of IVUS usage as regards 1-year MACE was confirmed in DM and CKD patients, but not observed in patients without them or in the combination of DM and CKD patients.

Acknowledgement/Funding

None

P5508Impact of CD14++CD16+ monocytes on coronary plaque vulnerability assessed by optical coherence tomography in coronary artery disease patients

Background

Diabetes mellitus has been known as an important factor of coronary artery disease (CAD) progression despite of widespread with lipid-lowering therapy. Although we have reported that large glucose fluctuation is associated with the development of cardiovascular disease in both diabetes mellitus (DM) and non-DM patients, the underlying mechanisms remain unclear.

Monocytes play a key role for atherosclerotic plaque formation. Monocytes in human peripheral blood are divided into three subsets: CD14++CD16− monocytes, CD14++CD16+ monocytes, and CD14+CD16++ monocytes. The CD14++CD16+ monocyte subset has recently received attention because it is reported to be associated with future cardiovascular events such as acute myocardial infarction. However, their impact on coronary plaque vulnerability in coronary artery disease (CAD) patients with or without DM remains unclear.

Purpose

The aim of this study was to investigate the impact of CD14++CD16+ monocyte levels on coronary plaque vulnerability and glucose fluctuation in stable CAD patients with well-regulated lipid levels.

Methods

This prospective observational study included 50 consecutive patients with CAD (DM [n=22], Non-DM [n=28]), receiving lipid-lowering therapy and undergoing coronary angiography and optical coherence tomography (OCT). Patients were divided into 3 tertiles according to the CD14++CD16+ monocyte percentages assessed by flow cytometry. Standard OCT parameters including lipid arc, lipid length, fibrous cap thickness (FCT) on lipid rich plaque, were assessed for 97 angiographically intermediate lesions (diameter stenosis: 30–70%). The presence of thin-cap fibroatheroma (TCFA), defined as a thin fibrous cap (<65μm) overlying a lipid-rich plaque (>90°), was also assessed. Daily glucose fluctuation assessed by using continuous glucose monitoring system was analyzed by measuring the mean amplitude of glycemic excursion (MAGE).

Results

CD14++CD16+ monocytes negatively correlated with FCT on lipid rich plaque (r=0.508, p<0.01) (Figure. 1). The presence of thin-cap fibroatheroma (TCFA) was increased stepwise according to the tertile of CD14++CD16+ monocytes (0 [tertile 1] vs. 5 [tertile 2] vs. 10 [tertile 3], p<0.01). CD14++CD16+ monocytes were a significant determinant of TCFA (OR 1.279, p=0.001). Although CD14++CD16+ monocytes were not significantly correlated with MAGE in DM patients (r=0.259, p=0.244), a significant relationship was found between CD14++CD16+ monocytes and MAGE in non-DM patients (r=0.477, p=0.018) (Figure 2).

Conclusions

CD14++CD16+ monocytes were associated with coronary plaque vulnerability in CAD patients with well-regulated lipid levels both in DM and non-DM patients. Cross-talk between glucose fluctuation and CD14++CD16+ monocytes may enhance plaque vulnerability, particularly in non-DM patients. CD14++CD16+ monocytes could be a possible therapeutic target for coronary plaque stabilization.

P5480Impact of Silent Myocardial Ischemia on One Year Mortality after Successful Coronary Intervention: Data from Japanese Multicenter (KICS) Registry

Introduction

Under the awareness of appropriate use criteria, the significance of PCI for the patients with silent myocardial ischemia (SMI) decreases. On the other hand, the prognoses of SMI patients have been reported to be equivalent to those of symptomatic effort angina pectoris (EAP) patients. We aimed to clarify the prognosis of SMI after PCI and elucidate the factors influencing the mortality.

Methods

The Kumamoto Intervention Conference Study is multicenter registry enrolling consecutive patients undergoing PCI in 16 centers in Japan. Overall, 17,688 consecutive patients were enrolled during April 2008 to March 2017. To compare the clinical events between SMI and EAP, 8,278 subjects, excluding acute coronary syndrome, post successful PCI were enrolled with 1-year follow-up data.

Results

In this study, 2,071 patients were classified as SMI and 6,207 patients were EAP. Male, lower body mass index (BMI), diabetes, chronic kidney disease (CKD), smoking habits, prior myocardial infarction (MI), composite of cerebrovascular disease and composite of peripheral arterial disease were all significantly higher in the SMI group. Although nonfatal MI and stent thrombosisduring 12-monthswere comparable between the 2 groups, all-cause mortality and cardiac death during 12-months were significantly higher in the SMI group than in the EAP group (3.9% vs 1.8%, p<0.001, 1.4% vs 0.5%, p<0.001, respectively). On the other hand, Repeat Revascularization rate during 12-months was significantly lower in the SMI group than in the EAP group (15.7% vs 19.5%, p<0.001).Kaplan-Meier analysis for cardiac death showed a significant difference between the 2 groups (Figure). In a multiple logistic regression analysis, in addition to lower BMI and CKD, SMI was an independent predictor for cardiac death. Even after adjustment by propensity-score matching with predictive factors for cardiac event, SMI showed a higher cardiac death rate compared with EAP (1.4% vs 0.5%, p=0.004), and it remained as a significant predictor.

Conclusion

In this study, SMI itself was associated with higher mortality after PCI. Strict follow-up and assessment of residual ischemia should be necessary for SMI patients.

1436Overexpression of Cytotoxic T-Lymphocyte Associated Antigen-4 suppresses aortic immunoinflammatory responses and prevents angiotensin II-induced abdominal aortic aneurysm formation in mice

Aims

Vascular inflammation via T-cell-mediated immune responses has been shown to be critically involved in the pathogenesis of abdominal aortic aneurysm (AAA). T-cell coinhibitory molecule cytotoxic T-lymphocyte–associated antigen-4 (CTLA-4) is known to act as a potent negative regulator of immune responses. However, the role of this molecule in the development of AAA remains completely unknown. In the present study, we determined the effects of CTLA-4 overexpression on experimental AAA.

Methods and results

We continuously infused 12-week-old CTLA-4 transgenic (CTLA-4-Tg)/apolipoprotein E–deficient (Apoe−/−) mice (n=35) or control Apoe−/− mice (n=40) fed a high-cholesterol diet with angiotensin II by implanting osmotic mini-pumps and evaluated the development of AAA. Ninety percent of angiotensin II-infused mice developed AAA, with 50% mortality because of aneurysm rupture. Overexpression of CTLA-4 significantly reduced the incidence (66%), mortality (26%), and diameter (18%) of AAA (incidence: P=0.0104; mortality: P=0.031; diameter: P=0.011). These protective effects were associated with a decreased number of effector CD4+ T cells and the downregulated expression of costimulatory molecules CD80 and CD86, ligands for CTLA-4, on CD11c+ dendritic cells in lymphoid tissues. In addition, by performing in situ zymography of the abdominal aortic aneurysm lesions, we observed a trend toward a decrease in MMP activity in the aneurysmal lesion following overexpression of CTLA-4. Finally, CTLA-4-Tg/Apoe−/− mice had reduced macrophage and CD4+ T cell accumulation and MMP activity in the aneurysmal lesion, leading to attenuated aortic inflammation, preserved vessel integrity, and decreased susceptibility to AAA and aortic rupture.

Conclusion

Our findings suggest that CTLA-4 protects against AAA by suppressing immunoinflammatory responses and could be an attractive therapeutic target for AAA.

P3392Potential of imaging-guided PCI for event suppression in Japanese acute myocardial infarction patients: J-MINUET substudy

Background

Intravascular ultrasound (IVUS) and Optical Coherence Tomography (OCT) has been widely used in clinical settings. Although favorable results of imaging-guided percutaneous coronary intervention (PCI) compared with angio-guided PCI were observed in several studies, impacts of institutional-based usage frequency, about imaging-guided PCI, have not been well elucidated.

Methods

To elucidate the impact of imaging-guided PCI and the effects of frequency of its usage, we analyzed data of the Japanese registry of acute Myocardial INfarction diagnosed by Universal dEfiniTion (J-MINUET). This was a prospective and multicenter registry consisting of 3,283 AMI patients, who were hospitalized within 48 hours of onset from July 2012 to March 2014. Clinical follow-up data was obtained for 3 years. In this sub-study, a total of 2,788 patients who underwent urgent PCI having detailed procedural information were enrolled. We analyzed the differences of utilization rates of imaging-guided PCI among the participating institutions and the impacts for the clinical events. The participating institutions were divided into 3 groups by the frequency of IVUS usage: low frequency institutions: under 50%; moderate frequency institutions: 50% to 90%; and, high frequency institutions: over 90%.

Results

In this cohort registry, patients were enrolled from 28 institutions. The utilization rate of coronary imaging varied widely depending on each institution from 15.4% to 100% (mean 85.7%±24.3, median 97.4%). When the institutions were divided into 3 groups by the frequency of intravascular imaging usage, four low frequency institutions enrolled 295 patients, five moderate frequency institutions enrolled 624 patients, and 19 high frequency institutions enrolled 1,491 patients. Although the incidence of MACE (death, MI, stroke, cardiac failure, or revascularization for unstable angina) decreased stepwise (33.2%, 23.7%, and 19.7%) (gray bar in the Figure), the event rates of the imaging-guided PCI cases among the 3 groups were comparable (21.6%, 21.9%, and 19.6%) (white bar in the Figure). On the other hand, a gradual event reduction between the 3 groups was observed in the angio-guided PCI cases (black bar in the Figure). In comparison of MACE rate between imaging-guided and angio-guided PCI, there were statistically significant differences in the low frequency and moderate frequency institutions (p=0.001 and p=0.012, respectively). In contrast, comparable event rates were observed in the high frequency institutions (p=0.441).

MACE rate by imaging usage frequency

Conclusions

In Japanese ACS patients treated with imaging-guided PCI, better suppression of clinical events during 3-year was found in the institutions with the more frequent use of intravascular imaging, mainly due to stepwise event suppression in the cases of angio-guided PCI. On the other hand, the clinical benefit of coronary imaging was obtained independently of the frequency of use and its experience.

Ephrin type-A receptor 2 on tumor-derived exosomes enhances angiogenesis through the activation of MAPK signaling

Exosomes are potent players in the development of metastases and they play an important role in cancer angiogenesis and exacerbation. However, it is unclear how proteins on exosomes affect development of blood vessel networks. In this study, we focused on relationships between membrane proteins on exosomes and angiogenesis using human umbilical vein endothelial cells (HUVEC). Lung tumor cell-derived exosomes induced tube formation and growth of endothelial cells in vitro in a dose-dependent manner involving MAPK activation, but this was not seen in normal lung epithelial cells. Ephrin type-A receptor 2 (EphA2) was identified by proteomic analysis and an inhibition assays showed it is a major MAPK activator on exosomes. Thus EphA2 on exosomes participates in angiogenesis as a ligand of the ephrin signaling pathway. These results support the development of novel therapeutic strategies such as blockade of remote cancer communications through exosomes.

P5668A decision-support tool framework to predict adverse outcome in patients with atrial fibrillation: J-Rhythm registry substudy

Background

Atrial fibrillation (AF) is associated with increased mortality and morbidity. Modelling the risk of thrombosis, major bleeding and total mortality are often limited by the inadequate number of independent predictors.

Purpose

We compared the predictive accuracy of the decision-support tool framework and conventional risk score in AF patients.

Methods

We used data of AF patients enrolled into the nationwide AF registry. A random forest model was implemented to predict each outcome, and its predictive power was tested by a 5-fold cross-validation.

Results

We analyzed 7,937 patients with AF (age 70±10 years, female 31%). The type of AF was paroxysmal (37%), persistent (14%), and permanent (49%). The number of antithrombotic treatments were follows: warfarin only (n=5461), antiplatelet only (n=581), both warfarin and antiplatelet (n=1471) and no antithrombotic agents (424). The mean CHA2DS2-VASc score was 2.8±1.6 and HAS-BLED score was 2.7±1.2, respectively. We selected 20 from 50 clinical parameters and compared by the area-under-curve with the CHA2DS2-VASc score for thromboses and the HAS-BLED score for major bleeding. During the 2-year follow-up, 126 patients (1.6%) had thromboses, 140 (1.8%) had major bleeding, and 195 (2.5%) died. A random forest model had a higher value of the area-under-curve for predicting thromboses compared with the CHA2DS2-VASc (0.66 vs. 0.61, P<0.05), and had a significantly higher area-under-curve for major bleeding compared with the HAS-BLED (0.67 vs. 0.61, P<0.05). The area-under-curve for the all-cause mortality was 0.77.

Conclusions

A random forest model has a higher accuracy than conventional risk scheme in predicting thromboses and major bleeding, in addition to total mortality.