AB0141 MYCOPHENOLATE MOFETIL, INHIBITOR OF INOSINE-5’-MONOPHOSPHATE DEHYDROGENASE, REGULATES DIFFERENTIATION, MATURATION AND FUNCTION OF HUMAN DENDRITIC CELL SUBSETS

Background:

Systemic lupus erythematosus (SLE) is a heterogeneous disease in which excessive inflammation, autoantibodies, and complement activation lead to multisystem tissue damage. Plasmacytoid dendritc cells (pDCs) play a central role in the pathogenesis of SLE through dysregulated type I IFN production, together with activated myeloid DCs (mDCs), amplifying vicious spiral of autoimmune disorders(1). Therefore, control of the aberrant DC activation may provide an alternative treatment strategy against SLE.

Objectives:

Mycophenolate mofetil (MMF), which has been used to treat lupus nephritis, specifically blocks proliferation of B and T lymphocytes by inhibition of inosine-5-monophosphate dehydrogenase (IMPDH). In addition, although there is evidence indicating the immunosuppressive effects of MMF on human monocyte-derived dendritic cells(2.3), there are no reports showing its effects on human blood DC subsets. Here we focused on the effects of MMF on the functions of the blood pDCs and mDCs.

Methods:

We isolated human blood DCs from healthy donors using cell sorting(4) and examined the function of mycophenolic acid (MPA), which is metabolic products of MMF, on DC subsets in response to TLR-ligands and serum from patients with active SLE. Written informed consent was obtained from all healthy adult donors and SLE patients.

Results:

We found that therapeutic plasma concentration range of MPA down-regulated expression of CD40, CD80 and CD86 dose-dependently on mDCs and pDCs without inducing apoptosis, in response to R848(TLR7/8 agonist) and CpG2216(TLR9 agonist), respectively. Of note, MPA profoundly suppressed IL-12 production and STAT4 expression in the mDCs and IFN-α production and IRF7 expression in the pDCs(Fig 1). We also obserbed inhibition of nuclear translocation of IRF-7 in pDCs treated with MPA by confocal microscopy(Fig 2). Furthermore,we identified that MPA had an inhibitory effect on SLE serum-induced IFN-α production by human PBMCs.

Conclusion:

Our data suggest that MMF can drive a wedge into the vicious spiral of autoimmune disorders through regulating the function of not only lymphocyte but also DC subsets. Thus, we unveiled a part mechanism of the therapeutic ability of MMF against SLE.

References:

[1]A Plasmacytoid Dendritic Cells-Type I Interferon Axis is Critically Implicated in the Pathogenesis of Systemic Lupus Erythematosus. Int. J. Mol. Sci. 2015: 16, 14158-14170.

[2]Mycophenolate mofetil inhibits differentiation, maturation and allostimulatory function of human monocyte-derived dendritic cells. Clin Exp Immunol. 2003;134:63-69.

[3]Mycophenolic acid inhibits maturation and function of human dendritic cells and B cells. Human Immunol. 2009;70: 692–700.

[4]Miyamoto et al. Arthritis Research & Therapy 2010, 12:R87.

Disclosure of Interests:

None declared

FRI0550 CAN CYTOKINE GENE POLYMORPHISMS BE USEFUL FOR THE THERAPEUTIC CHOICE IN JAPANESE PATIENTS WITH RHEUMATOID ARTHRITIS?

Background:

Rheumatoid arthritis (RA) is a common autoimmune disease. It is characterized by systemic synovitis with bone erosion and joint cartilage degradation(1). Production of autoantibody is important for autoimmune disease. Cytokines play crucial roles in its pathogenesis(2). SNP distribution varies between races. Few studies have examined SNP targeted at Japanese patients. The analysis of cytokine gene polymorphisms is important factor of pathophysiology and treatment.

Objectives:

This analysis was aimed to investigate the association between cytokine gene polymorphisms and autoantibody and therapeutic response in Japanese RA patients.

Methods:

This study subjects consisted of 100 RA patients and 50 healthy controls. We extracted data on patient sex, age, disease duration, rheumatoid factor (RF), anti cyclic citrullinated peptide (anti-CCP) antibody and therapeutic response including methotrexate (MTX) and biological DMARDs. Genomic DNA was isolated from peripheral blood, these were genotyped for TNFα, TGFβ1, IL-6, IL-10 and IFNγ polymorphisms. We analyzed these data using a chi-square test.

Results:

IL-10 (-819 C/T and -592 C/A) revealed that there were significant decrease in the frequency of IL-10 (-819) CC genotype and (-592) CC genotype as compared to controls in RA patients. Genotyping of IL-10 showed that there was significant decrease ACC/ACC genotype (Table 1).

IFNγ (+874 A/T) revealed that there was significant decrease in the frequency of TT genotype as compared to controls (Table 1).

No significant differences in TNFα, TGFβ1and IL-6 genotypes and alleles frequency were observed between RA patients and control.

TGFβ1(+869 A/T) in patients with anti-CCP antibody positive revealed that there was significant decrease in the frequency of TT genotype as compared to patients with anti-CCP antibody negative (Table 2).

No significant association between RF and any cytokine gene polymorphism.

Analyzing cytokine gene polymorphisms could be useful for treatment with MTX and biological DMARDs.

Table 1.

Table 2.

Conclusion:

IL-10 (-819 C/T, -592 C/A) and IFNγ (+874 A/T) polymorphism might be related to RA in Japanese population. In addition, TGFβ1(+869 A/T) polymorphism might be associated with the production of anti-CCP antibody. These results suggest that the analyzing cytokine gene polymorphisms may offer promise as useful factors in the choice of treatment for Japanese RA patients.

References:

[1] Scott DL, Wolfe F, Huizinga TW. Rheumatoid arthritis. Lancet. 2010; 376: 1094–108.

[2] McInnes IB, Schett G. Cytokines in the pathogenesis of rheumatoid arthritis. Nat Rev Immunol. 2007 Jun;7(6):429-42.

Disclosure of Interests:

None declared

Supporting evidence from optical coherence tomography for shortening dual antiplatelet therapy after drug-eluting stents implantation

INTRODUCTION

Dual antiplatelet therapy (DAPT) is required for coronary artery disease treated with drug-eluting stents (DES) implantation. Shortening DAPT duration would be beneficial for patients with high bleeding risk.

AREAS COVERED

Early healing patterns, especially stent strut coverage, assessed by optical coherence tomography (OCT) as a surrogate of neointima have been investigated to make decisions on whether short DAPT would be a safe alternative. This review evaluates the OCT evidence (i.e. neointimal coverage of stent struts within 3 months) for shortening DAPT duration after DES implantation.

EXPERT COMMENTARY

Shortening DAPT (i.e. within 3 months) duration after DES implantation might reduce complications including bleeding without increasing stent thrombosis. However, the optimal duration of DAPT after DES implantation is under discussion. Long-term assessment of short DAPT is required for the decision of the new guidelines regarding the recommended duration of DAPT.

Coronary Artery Disease Assessed by Computed Tomography-Based Leaman Score in Patients With Low-Risk Transcatheter Aortic Valve Implantation

We aimed to evaluate the burden of coronary artery disease (CAD) using the computed tomography (CT) Leaman score in low-risk transcatheter aortic valve implantation (TAVI) patients. The extent of CAD in low-risk patients with aortic stenosis who are candidates for TAVI has not been accurately quantified. The CT Leaman score was developed to quantify coronary CT angiography (CCTA) atherosclerotic burden and has been validated to evaluate the extent of CAD. CT Leaman score >5 has been associated with an increase in major adverse cardiac events over long-term follow-up. The study population included patients enrolled in the Low Risk TAVI trial who underwent CCTA before the procedure. For the CT Leaman score, we used 3 sets of weighting factors: (1) location of coronary plaques, (2) type of plaque, and (3) degree of stenosis. A total of 200 patients were enrolled in the Low Risk TAVI trial. Excluded were 31 patients who had no analyzable CCTA imaging. For the remaining 169 patients, the mean CT Leaman score was 6.27 ± 0.27, of whom 102 (60.4%) had CT Leaman score >5. Nearly all analyzed patients (97%) had coronary plaques. Furthermore, 33 patients (19.5%) had potentially obstructive coronary plaques (>50% stenosis by CCTA) in proximal segments. Most low-risk TAVI patients have significant CAD burden by CCTA. It should be a priority for future TAVI devices to guarantee unimpeded access to the coronary arteries for selective angiography and interventions.

Novel Indices of Coronary Physiology

Fractional flow reserve is the current invasive gold standard for assessing the ischemic potential of an angiographically intermediate coronary stenosis. Procedural cost and time, the need for coronary vessel instrumentation, and the need to administer adenosine to achieve maximal hyperemia remain integral components of invasive fractional flow reserve. The number of new alternatives to fractional flow reserve has proliferated over the last ten years using techniques ranging from alternative pressure wire metrics to anatomic simulation via angiography or intravascular imaging. This review article provides a critical description of the currently available or under-development alternatives to fractional flow reserve with a special focus on the available evidence, pros, and cons for each with a view towards their clinical application in the near future for the functional assessment of coronary artery disease.

17β-Hydroxysteroid dehydrogenase type 12a responsible for testicular 11-ketotestosterone synthesis in the Japanese eel, Anguilla japonica

The production of 11-ketotestosterone (11KT), an important steroid hormone in piscine spermatogenesis, is regulated by the pituitary gonadotropins [Gths: follicle-stimulating hormone (Fsh) and luteinizing hormone (Lh)] and it is synthesized by catalytic reactions involving several steroidogenic enzymes. Among these enzymes, the role of 17β-hydroxysteroid dehydrogenases (Hsd17bs) that exhibited 17-ketosteroid reducing activity (17KSR activity) responsible for 11KT synthesis is still poorly understood. In the present study, for the deeper understanding of testicular 11KT biosynthesis, we first investigated the steroidogenic pathway to produce 11KT in Japanese eel testis. In vitro incubation of the testis with androstenedione (A4) and the subsequent analysis of the metabolites by thin-layer chromatography indicated that 11KT was synthesized from A4 via 11β-hydroxyandrostenedione (11OHA4) and 11-ketoandrostenedione (11KA4), which indicated that the steroidogenic enzyme exhibiting the 17KSR activity responsible for converting 11KA4 to 11KT is crucial for 11KT production. Subsequently, cDNAs encoding three candidate enzymes, Hsd17b type3 (Hsd17b3), Hsd17b type12a (Hsd17b12a), and 20β-hydroxysteroid dehydrogenase type2 (Hsd20b2), potentially with the 17KSR activity were isolated and characterized in the Japanese eel. The isolated hsd17b3, hsd17b12a, and hsd20b2 cDNAs putatively encoded 308, 314, and 327 amino acid residues with high homology to those of other vertebrate counterparts, respectively. The Hsd17b3, Hsd17b12a, and Hsd20b2 expressed either in HEK293T or in Hepa-E1 converted 11KA4 to 11KT. Tissue-distribution analysis by quantitative real time PCR revealed that hsd17b12a and hsd20b2 mRNAs were detected in the testis, while hsd17b3 mRNA was not detectable. Furthermore, we examined the effects of Gths on the 17KSR activity and the expression of the candidate genes in the immature testis. The 17KSR activity was upregulated by administration of Gths. Furthermore, only expression of hsd17b12a among three candidates was upregulated by Gths as well as the 17KSR activity. These findings strongly suggested that Hsd17b12a is one of the enzymes with 17KSR activity responsible for 11KT synthesis in the testis of Japanese eel.

P251 Right ventricular free wall dissection clearly detected and recorded by echocardiography: a fatal complication after inferior myocardial infarction

An 81-year-old man was transferred to our institution by ambulance because of poor feeding, general fatigue and slight disorientation lasting for a week. On arrival, he was awake and able to speak, however, his blood pressure was low at 61/43 mmHg in spite of his medical history of hypertension. His ECG showed abnormal Q waves and ST elevation in II, III, aVF leads. The echo exam detected severe hypokinesis in the left ventricular inferior wall and reduced ejection fraction at 30%. Pericardial effusion was not observed in the first echo exam. The patient was diagnosed as cardiogenic shock due to recent inferior myocardial infarction. Coronary angiography was performed, which detected total occlusion of mid right coronary artery, followed by a successful percutaneous coronary intervention (PCI) with a drug-eluting stent under the support of intra-aortic balloon pumping. Nevertheless, his blood pressure remained low and intravenous adrenaline administration was necessary during and even after PCI. To detect the cause of prolonged low blood pressure, echo was performed again immediately after PCI. The echo exam detected new findings: right ventricular posterior free wall was dissected and abnormal shunt flows were obviously observed from left ventricle to right atrium through the dissection cavity during systole. An urgent surgical repair was considered as the only option for his survival, however, his family did not accept it because the operation itself was too risky. On the next day of his admission, he passed away. Right ventricular free wall dissection is a very rare but fatal complication after inferior myocardial infarction, nevertheless, we could detect it by echocardiography with clearly recorded images.

Abstract P251 Figure.

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 < 0.05), LV mass index (122.4 ± 38.9 vs 107.5 ± 26.4 g/m², p < 0.05), left atrial volume index (31.7 ± 9.2 vs 27.6 ± 9.4 ml/m², p < 0.05), LVEF (45.7 ± 13.5 vs 52.9 ± 9.2 %, p < 0.05), s’ (5.1 ± 1.6 vs 7.1 ± 1.7 cm/sec, p < 0.001), e’ (4.8 ± 1.3 vs 6.0 ± 1.9 cm/sec, p < 0.05), E/e’ (16.4 ± 6.6 vs 12.5 ± 4.9, p < 0.05), E/(e’ x s’) (3.78 ± 2.52 vs 1.94 ± 1.08, p < 0.001), and serum B-type natriuretic peptide (334.7 ± 420.1 vs 113.8 ± 177.2 pg/ml, p < 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’) <2.35 had significantly better prognosis than the rest (p < 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.

Functional analysis of recombinant single-chain Japanese eel Fsh and Lh produced in FreeStyle 293-F cell lines: Binding specificities to their receptors and differential efficacy on testicular steroidogenesis

Pituitary gonadotropins, follicle-stimulating hormone (Fsh) and luteinizing hormone (Lh), play central roles in the control of gonadal development of vertebrates. In mammals, Fsh and Lh exclusively activate their respective cognate receptors: Fsh receptor (Fshr) in the Sertoli cell and Lh/choriogonadotropin receptor (Lhcgr) in the Leydig cell. In teleosts, the distinct functions of Fsh and Lh and information on cellular localization of their receptors are still poorly understood. Recently we established FreeStyle 293-F cell lines producing recombinant Japanese eel Fsh and Lh (reFsh and reLh), which form a single chain consisting of a common α-subunit and β-subunits. In this study, we conducted functional analyses of reFsh and reLh, focusing on the binding specificities to their receptors and effects on testicular steroidogenesis in vitro. Assays with gonadotropin receptors-expressing COS-7 cells indicated reFsh stimulated its cognate receptor, meanwhile reLh activated both receptors. Although results of in vitro incubations showed that reFsh and reLh induced testicular 11-ketotestosterone production in a dose and time-dependent manner by upregulating expression of steroidogenic enzymes, the effective doses of reLh were apparently lower and the effects of reLh emerged faster in comparison with reFsh. Results of quantitative real-time PCR using testicular cell fractions showed that fshr and lhcgr1 mRNA were detected both in Sertoli and Leydig cells. These analyses revealed that reFsh and reLh were biologically active and hence will be useful for future studies. Moreover, our data showed that both eel Fsh and Lh acted as steroidogenic hormones through their receptors in testicular somatic cells; however, Lh was more potent on androgen production, implying differential functions on spermatogenesis.

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) <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 <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.

P1386 A change in left ventricular global longitudinal strain is a prognostic indicator in congestive heart failure patients with preserved ejection fraction

Purposes

We examined how changes in left ventricular (LV) global longitudinal strain (GLS) were associated with prognosis in patients with preserved LV ejection fraction (LVEF) after congestive heart failure (HF) admission.

Methods

We studied 123 consecutive patients (age 70 ± 15 years, 55% male) who had been hospitalized due to congestive HF with preserved LVEF (> 50%). The exclusion criteria were atrial fibrillation and inadequate echo image quality for strain analyses. The patients underwent speckle-tracking echocardiography and measurement of plasma NT-ProBNP levels on the same day at the time of hospital admission as well as in the stable condition after discharge. Differences in GLS, LVEF and NT-ProBNP (delta GLS, LVEF and NT-ProBNP ; 2nd – 1st measurements) were calculated. The study end points were all-cause mortality and cardiac events.

Results

Mean periods of echo performance after hospitalization were 2 ±１days (1st echo) and 240 ± 289 days (2nd echo), respectively. During the follow-up (974 ± 626 days), 12 patients died and 25 patients were hospitalized because of HF worsening. In multivariate analysis, delta GLS and follow-up GLS were prognostic factors, whereas baseline and follow-up LVEF, NT-ProBNP, changes in LVEF and NT-ProBNP could not predict cardiac events. Delta GLS (p = 0.002) turned out to be the best independent prognosticator. Receiver operating characteristics analysis revealed that -0.6% of delta GLS was the optimal cut-off value to predict cardiac events and mortality (sensitivity 76%, specificity 67%, AUC 0.75). Kaplan-Meier analysis showed that patients with delta GLS more than -0.6% experienced significantly less cardiac events during the follow-up period (p < 0.0001, log-rank).

Conclusion

A change in LV GLS after congestive HF admission was a predictor of the prognosis in patients with preserved LVEF. It would be useful to check the changes in GLS in those with preserved LVEF after discharge.

1043 Association of left ventricular global longitudinal strain with myocardial perfusion evaluated by 13N-ammonia positron emission tomography in hemodialysis patients with preserved ejection fraction

Background

Global longitudinal strain (GLS) is an echocardiographic marker to detect subclinical left ventricular systolic dysfunction prior to the appearance of reduced left ventricular ejection fraction (LVEF). Reduced GLS identified in patients with maintenance hemodialysis (HD) has been reported to be a predictor of their higher mortality and cardiovascular events. On the other hand, pharmacological stress 13N-ammonia positron emission tomography (13N-NH3-PET) has been an established and reliable imaging modality to evaluate myocardial perfusion expressed as coronary flow reserve (CFR) or maximal stress myocardial blood flow (MBF). CFR and MBF are powerful parameters to detect coronary artery disease and to predict cardiovascular events and mortality. However, association between GLS and those myocardial perfusion parameters are not fully understood.

Purpose：The aim of this study was to evaluate the relationship between GLS and the myocardial perfusion parameters of 13N-NH3-PET in HD patients with preserved LVEF.

Methods

We studied 24 HD patients (mean age 67 years, 67% male) who underwent ATP stress 13N-NH3-PET as well as transthoracic echocardiography including 2-dimensional speckle tracking imaging for suspected ischemic heart disease. Exclusion criteria were as follows: LVEF <50%, moderate to severe valvular diseases, and atrial fibrillation. Myocardial perfusion abnormality (MPA) was defined as CFR <2.0 and/or stress MBF <2.0.

Results

Mean GLS in all patients was -16.2 ± 3.6%. The patients were divided into 2 groups based on GLS: patients with reduced GLS (<-16%) (Group A, N = 11) and those with preserved GLS (≧-16%) (Group B, N = 14). There were no significant differences between 2 groups in age, gender, body mass index, left ventricular mass index, and average E/e’. Nevertheless, Group A had significantly lower stress MBF than Group B (1.7 ± 0.41 vs 2.0 ± 0.33, p = 0.031). In addition, Group A showed more frequent MPA compared with Group B (81.8% vs 42.9%, p = 0.043). There was a moderate correlation between GLS and stress MBF (r = 0.62, p = 0.0012), whereas no significant correlation was noted between GLS and CFR (r = 0.079, p = 0.71).

Conclusion

Reduced GLS was significantly associated MPA. MPA may be one of the major contributors to the reduction in GLS in HD patients with preserved LVEF.

Prognostic Value of Human Peripheral Monocyte Subsets for Future Coronary Events in Patients Without Significant Coronary Artery Stenosis

BACKGROUND

Monocytes in human peripheral blood are heterogeneous and can be divided into 2 groups, inflammatory and pro-inflammatory, according to the differential expression of CD14 and CD16. Pro-inflammatory monocytes (CD14⁺CD16⁺) seem to contribute to the development of coronary artery disease. This study aimed to investigate the involvement of specific human peripheral monocyte subsets in the development of future coronary events.Methods and Results:We enrolled 271 patients who were suspected to have either stable angina pectoris or silent myocardial ischemia and underwent coronary angiography (CAG). Two monocyte subsets (CD14⁺CD16^-and CD14⁺CD16⁺) were measured by flow cytometry. Patients who did not undergo coronary artery revascularization at initial CAG were followed as the medical therapy group, which included 136 patients among whom 15 had future coronary events. The frequency of CD14⁺CD16⁺monocytes was significantly higher in patients who had future coronary events than in those who did not (P<0.01). Furthermore, the frequencies of CD14⁺CD16⁺monocyte were not significantly different between patients who had future coronary events and those who underwent coronary revascularization at initial CAG (P<0.33). Multivariate analysis revealed that the frequency of CD14⁺CD16⁺monocytes was an independent predictor for future coronary events (P<0.01).

CONCLUSIONS

An increase in the abundance of human peripheral pro-inflammatory monocytes is related to the development of future coronary events.

Feasibility and Clinical Significance of In Vivo Cholesterol Crystal Detection Using Optical Coherence Tomography

OBJECTIVE

Cholesterol crystals (CCs) are frequently found at the site of acute myocardial infarctions (AMIs), but the role of CCs in the onset of AMI remains unclear due to the lack of validated in vivo imaging tools. The aim of this study was to validate the ability of optical coherence tomography (OCT) to detect CCs and to compare the prevalence and distribution of CCs in patients with AMIs and stable angina pectoris. Approach and Results: CC assessment using OCT were compared with histopathology results in 45 coronary samples. We investigated 152 consecutive patients with AMIs and 41 patients with single vessel-diseased stable angina pectoris. Based on the presence of plaque ruptures (PR), AMI patients were divided into 2 groups: those with PR (n=112) and those without PR (n=40). CCs invading fibrous caps were defined as superficial-type CCs. A multivariable logistic regression analysis was performed to determine PR predictors. The sensitivity and specificity of OCT for detecting CCs were 68% and 92%, respectively. The prevalence of plaques with CCs was higher in the AMI with PR group (AMI with PR 81%, AMI without PR 48%, stable angina pectoris 39%, P<0.01). A multivariable logistic model showed that superficial-type CCs and thin-cap fibroatheromas were positive predictors for PR.

CONCLUSIONS

OCT has a high specificity and modest sensitivity for the detection of CCs. The combination of CCs invading fibrous cap and thin-cap fibroatheromas detected by OCT may better identify rupture-prone plaques.

Comparison of quantitative flow ratio value of left anterior descending and circumflex coronary artery in patients with Takotsubo syndrome

Takotsubo syndrome (TTS) is an acute cardiac event without epicardial coronary obstruction but often with reversible ventricular motion abnormalities. Quantitative flow ratio (QFR) is a novel approach to evaluate the coronary stenosis significance on the basis of 3-dimensional quantitative coronary angiography (3D-QCA) and contrast flow by Thrombolysis in Myocardial Infarction frame count. This study aimed to evaluate and compare the QFR value in the left anterior descending artery (LAD) and the left circumflex artery (LCx) in patients with TTS. This retrospective and observational study enrolled 30 patients with TTS who underwent coronary angiography. We evaluated the QFR data using the 3D-QCA analysis and compared the QFR data in the LAD and the LCx. No significant differences were observed in terms of flow velocity, percent diameter stenosis, minimum lumen diameter, and reference diameter between LAD and LCx. However, vessel QFR in the LAD was significantly reduced compared with that in the LCx (0.98 [0.94 to 0.99] vs. 1.00 [0.99 to 1.00], P < 0.001). Ejection fraction at baseline and initial troponin-I levels were not correlated with the vessel QFR both in the LAD and the LCx. The QFR value in the LAD was significantly reduced compared to that in the LCx in patients with TTS.

P832LDL-C levels on statins and cardiovascular event risk in stable coronary artery disease: An observation from the REAL-CAD study

Background

The relation between very low on-treatment low-density lipoprotein cholesterol (LDL-C) level and the cardiovascular event risk is still unclear in patients receiving the same doses of statins.

Methods

From the REAL-CAD study comparing high-dose with low-dose pitavastatin therapy in Japanese patients with stable coronary artery disease, 11105 patients without reported non-adherence for the study drug were divided into 3 groups according to the on-treatment LDL-C level at 6-month (<70 mg/dL, 70–100 mg/dL, and ≥100 mg/dL; N=1016, N=3078, and N=1665 in the pitavastatin 1 mg/day stratum; N=2431, N=2524, and N=391 in the pitavastatin 4 mg/day stratum). Primary outcome measure was a composite of cardiovascular death, non-fatal myocardial infarction, non-fatal ischemic stroke, or unstable angina requiring emergent admission.

Results

In the pitavastatin 1 mg/day stratum, cumulative 4-year incidence of the primary outcome measure was not significantly different across the 3 groups (5.0%, 5.7%, and 5.2%, P=0.51), while in the 4 mg/day stratum, it was significantly higher in the LDL-C ≥100 mg/dL group than in other groups (4.5%, 3.4%, and 9.1%, P<0.001). The adjusted risks of the LDL-C <70 mg/dL group relative to the LDL-C 70–100 mg/dL group (reference) remained insignificant for the primary outcome measure in both 1 mg/day and 4 mg/day strata (HR 0.84, 95% CI 0.58–1.18, P=0.32, and HR 1.25, 95% CI 0.88–1.79, P=0.22). The adjusted risk of LDL-C ≥100 mg/dL group relative to the reference group was not significant for the primary outcome measure in the 1 mg/day stratum (HR 0.82, 95% CI 0.60–1.11, P=0.21), while it was highly significant in the 4 mg/day stratum (HR 3.32, 95% CI 2.08–5.17, P<0.001). In the on-treatment LDL-C ≥100 mg/dL group in the 4 mg/day stratum, LDL-C increased by 6.3 mg/dL from baseline to 6-month despite dose escalation of pitavastatin from 1 mg/day to 4 mg/day, suggesting the presence of unreported poor adherence in this small subgroup.

Adjusted Effects of On-treatment LDL-C

Conclusions

Very low on-treatment LDL-C level (<70 mg/dL) was not associated with lower cardiovascular event risk compared with moderately low on-treatment LDL-C level (70–100 mg/dL) in patients receiving the same doses of statins. Too much emphasis on the target LDL-C strategy might mislead the clinical practice.

Acknowledgement/Funding

The Comprehensive Support Project for Clinical Research of Lifestyle-Related Disease of the Public Health Research Foundation.

P1901Use of direct thrombin inhibitor on the day of atrial fibrillation ablation decreases incidence of silent cerebral ischemia detected by magnetic resonance imaging

Background

There is increasing evidence to use direct oral anticoagulants (DOACs) in atrial fibrillation (AF) ablation. Uninterrupted use of DOACs is recommended for peri-procedural anticoagulation; the ways of choosing and/or using DOACs depend on physicians' decisions and preferences. Uninterrupted dabigatran (DAB), a direct thrombin inhibitor, reportedly decreased the risk of major bleeding (MB) in AF ablation, compared to uninterrupted warfarin (NEJM 2017; 376:1627). Among DOACs, only regular-dose of DAB (150 mg b.i.d.), showed superiority to warfarin for preventing ischemic thromboembolism (TE) in patients with non-valvular AF, implicating the powerful anti-thrombotic agent. DAB may decrease the potential risk of procedure-related TE.

Purpose

To evaluate whether use of DAB on the day of AF ablation decreases the prevalence of silent cerebral ischemia (SCI) detected by magnetic resonance imaging (MRI).

Methods

414 AF patients on DOACs were enrolled and admitted on the day before AF ablation. Among 354 patients on factor Xa inhibitors (rivaroxaban, apixaban, and edoxaban), the original DOACs were switched to DAB (150 mg b.i.d.) on the day of the procedure in 172 patients (Group D); the treatment remained unchanged in 182 patients (Group non-D). In both groups, DOACs were continuously used throughout the procedure. After propensity-score matching, procedure-related parameters/events and the incidence of MRI-detected SCI were compared between Group D (n=134) and Group non-D (n=134). These parameters in patients originally taking DAB, used without interruption during the procedure (uninterrupted DAB, n=55), were also compared to Group D (n=55) after propensity-score matching.

Results

Baseline activated clotting time (ACT) before initial heparin injection was increased in Group D vs. Group-non-D (179±25* vs. 146±23 sec, *p<0.05 vs. Group non-D). The time to achieve optimal ACT (>300 sec) was shorter in Group D (34±29* vs. 43±32 min). The amounts of heparin needed to achieve optimal ACT and the total amount of heparin used during the procedure were unchanged between Group D and Group non-D. The incidence of SCI decreased in Group D (13.1%* vs. 21.9%), suggesting the potential anti-thrombotic efficacy of DAB. No MB or symptomatic TE events were observed in either group. Baseline ACT, the time to achieve ACT >300 sec, and the incidence of SCI in Group D were comparable to those in uninterrupted DAB (183±38 vs. 181±32 sec, 39±31 vs. 42±28 min, and 14.5% vs. 16.4%, respectively). No MB or symptomatic TE events were observed either in Group D or uninterrupted DAB.

Conclusions

Temporarily switching to DAB from the other DOACs and using it on the day of procedure enable us to achieve optimal ACT quickly and decrease the incidence of SCI, showing similar potential anti-thrombotic efficacy to uninterrupted DAB. Use of DAB on the day of AF ablation also benefits from the availability of its antidote in the case of MB during the procedure.

P6178The optimal point of CT-FFR measurement in comparison with invasive FFR

Background

Currently, invasive fractional flow reserve (FFR), has become a gold standard to select patients requiring revascularization. Coronary computed tomography angiography (CTA) -derived FFR (FFRCT/CT-FFR) can be used for the management of coronary artery disease, which would be a gatekeeper of invasive coronary angiography. In most of the previous report to evaluate the diagnostic performance of FFRCT/CT-FFR, FFRCT/CT-FFR value was measured at the same point as the invasive FFR. Clinically, FFRCT/CT-FFR should be measured without the information of invasive FFR. However, optimal measurement point for CT-FFR has not been established yet.

Purpose

To assess the optimal measurement point of CT-FFR in comparison with invasive FFR as a gold standard.

Methods

CTA images scanned at 70–99% of R-R interval with 320 slice CT were screened. In the de-novo lesions with invasive FFR data were included in this study. Since calcified lesions could affect CT-FFR value, severe calcified lesions on CTA were excluded from the analysis. The CT-FFR analysis was performed by 2 cardiologists blinded to the results of the invasive FFR using a standard desktop computer and dedicated software. CT-FFR values could be provided at any point from ostium of coronary artery to the distal with vessel diameter of 1.8mm. To determine the optimal point for measurement of CT-FFR, CT-FFR values were obtained at 3 points in each coronary artery; 1) at the same point as invasive FFR; 2) lowest CT-FFR at distal point of coronary artery; 3) at 2.0 cm distal to the lesion. The diagnostic performance at each point was compared with invasive FFR.

Results

Fifty vessels of 44 patients (average age 68 years, male were 32) were included. Average Agatston score was 279.4. There was significant correlation between CT-FFR at each point and invasive FFR. CT-FFR at the same point as invasive FFR showed the good correlation with invasive FFR (R=0.641, 95% CI= 0.041–0.127, p<0.0001). Compared to the lowest CT-FFR at distal (R=0.608, 95% CI= 0.069–0.160, p<0.0001), CT-FFR at 2.0 cm distal to the lesion (R=0.604, 95% CI= 0.007–0.061, p<0.0001) revealed better correlation with invasive FFR. Sensitivity, specificity, positive and negative predictive value at each point were 92.8 / 93.3 / 81.8; 75.0 / 57.1 / 94.2; 61.9 / 48.2 / 60.0; and 96.0 / 95.2 / 84.6, respectively. Diagnostic accuracy showed that CT-FFR at 2cm distal to the lesion (0.84) was similar to CT-FFR at the same point as invasive FFR (0.80), and it was better than far distal (0.68) to detect invasive FFR derived ischemia.

Conclusions

CT-FFR was feasible to detect invasive FFR derived ischemia at the same point.

CT-FFR at 2.0 cm distal to the lesion showed higher diagnostic performance compared with CT-FFR measured at the far distal. CT-FFR measurement at 2.0 cm distal to the lesion would be a optimal position clinically.

P5320Reduction in high-sensitivity C-reactive protein by pitavastatin was associated with improved outcomes in Japanese patients with stable coronary artery disease: results from REAL-CAD study

Background

The effect of statins on lowering high sensitivity C-reactive protein (hs-CRP) as well as low density lipoprotein cholesterol (LDL-C) has been associated with reduced risk for cardiovascular events in patients with elevated hs-CRP. However, it remains unclear whether this statin effect applies to low-risk patients with stable coronary artery disease (CAD). In this pre-specified sub-study within the REAL-CAD trial, we explored the association between achieved LDL-C/hs-CRP levels and cardiovascular events in Japanese patients with stable CAD who were treated with pitavastatin 1 mg or 4 mg/day.

Methods

The REAL-CAD trial randomly allocated 13,054 patients with stable CAD to pitavastatin 1 mg or 4 mg/day. LDL-C and hs-CRP were measured at baseline and at 6 months after randomization. We excluded those patients without 6-month data and those with endpoint events before 6 months (N=1915). The primary endpoint of the study was a composite of cardiovascular death, nonfatal myocardial infarction, nonfatal ischemic stroke, or unstable angina requiring emergency hospitalization. Outcomes were assessed by landmark analysis beyond 6 months among 4 groups that were configured based on LDL-C (median) and hs-CRP (median) targets: achieving neither target, achieving LDL-C target only, achieving hs-CRP target only, and achieving both targets. Data were adjusted for baseline characteristics including age, gender, diabetes and baseline values of LDL-C and hs-CRP.

Results

Median LDL-C and hs-CRP levels were 88 mg/dL and 0.52 mg/L at baseline and 80 mg/dL and 0.48 mg/L after 6 months, respectively. There was no correlation between the change in LDL-C and hs-CRP levels from baseline to 6 months (correlation coefficient: 0.009, P=0.331). Of the 11,677 patients included in the study, 25.1% (N=2799) achieved both LDL-C and hs-CRP targets, 25.3% (N=2282) met neither target, 24.8% (N=2765) met only the hs-CRP target, and 24.7% (N=2753) met only the LDL-C target. Risk of primary endpoint occurrence was significantly lower in those achieving either or both targets than in those meeting neither target (Figure A). In the subgroup analysis stratified by the randomized dose of pitavastatin, the risk for the primary endpoint was significantly lower in patients achieving both targets in both the 1mg and 4 mg arms, and in patients achieving only hs-CRP target in the 1 mg arm (Figure B, C).

Figure 1

Conclusions

In this subanalysis of the REAL-CAD trial, the hs-CRP lowering effect of pitavastatin was independent from LDL-C lowering. Lower achieved hs-CRP was associated with lower risk for cardiovascular events in Japanese patients with stable CAD.

Acknowledgement/Funding

Public Health Research Foundation, The company manufacturing the study drug (Kowa Pharmaceutical Co Ltd) was one of the entities providing financial s

P6171Role of myocardial mass for identifying FFR-verified ischemia and determining therapeutic strategy

Background

Conventional noninvasive approach using coronary CT angiography (CTA) focusing on only coronary artery lesions remains mismatch in identifying functional ischemia and determining indication for coronary revascularization.

Purpose

We aimed to assess the usefulness of CT-verified myocardial mass for identifying FFR-verified myocardial ischemia and determining the indication of coronary revascularization after FFR examination.

Methods

We examined 244 vessels with intermediate stenoses (50 to 90% stenosis visually on CTA) in 216 patients (mean age 69.2±9.2, 166 men) who underwent both coronary CTA and invasive FFR. In addition to coronary stenosis severity and plaque characteristics on visual, minimal lumen diameter (MLD), minimal lumen area (MLA), plaque volume, the entire myocardial volume of the target vessel (MTV) and that exposed to ischemia (FFR ≤0.80) (myocardial volume of ischemia: MVI) were evaluated. Additionally, therapeutic strategy after FFR was recorded.

Results

Of 244 vessels, myocardial ischemia (FFR ≤0.80) was shown in 99 (40.6%). MTV was larger in the patients with FFR-verified ischemia than those without (53.3±19.2 vs. 41.5±21.6, P<0.001); MLA, plaque burden (PB) and percentage of aggregated plaque volume (%APV) were also associated with ischemia. The area under the curves (AUCs) of MLA, PB, %APV, and MTV were 0.69, 0.67, 0.64, and 0.71, respectively. Addition of MTV to a model with coronary stenosis on visual, MLA, PB, and %APV improved C-index (from 0.72 to 0.79, P<0.01), net reclassification improvement (NRI) (0.71, P<0.01), and integrated discrimination improvement (IDI) (0.10, P<0.01). Of 99 vessels with FFR ≤0.80, MVI was larger in the vessels with early revascularization after FFR than those without (38.8 vs. 29.1, P=0.01).

Conclusions

The measurement of myocardial mass improves the diagnostic performance of coronary CTA for the identification of coronary arteries with FFR-verified ischemia. Furthermore, it is associated with therapeutic strategy for the diseased vessels after FFR examination.