4098Reduced skeletal muscle mass is associated to worsened long-term clinical outcomes in patients with coronary artery disease: a quantitative analysis by computed tomography

Background

Sarcopenia is closely associated to poor clinical outcomes in patients with atherosclerotic cardiovascular disease (ASCVD). However, it is unclear whether the skeletal muscle mass at baseline has quantitative effect on future cardiovascular outcomes.

Purpose

We investigated the quantitative effect of skeletal muscle mass on future cardiovascular outcomes in patients with coronary artery disease (CAD).

Methods

Total 475 patients those who underwent successful percutaneous coronary intervention (PCI) for CAD and performed computed tomography (CT) scan within 30 days of PCI were enrolled. The cross-sectional area of skeletal muscle at the first lumbar vertebra (L1) level was measured. Whole study population was divided into 4 groups according to the sex-specific quartiles of skeletal muscle index (SMI). Primary outcome was all-cause mortality and secondary outcome was major adverse cardiovascular event (MACE) within 3 years of follow-up.

Results

Mean follow-up duration was 4.11±3.02 years and average time period from the date of PCI to CT scan was −3.33±11.72 days. The incidence of 3-year all-cause mortality (23.2% vs. 9.9% vs. 6.6% vs. 4.4%, p<0.001) and MACE (42.9% vs. 24.0% vs. 14.3% vs. 6.2%, p<0.001) was significantly higher in the group of lower quartiles of L1-SMI. In the fully adjusted multivariable analysis, lower quartiles of L1-SMI was an independent predictor of higher risk of all-cause mortality and MACE (lowest vs. highest quartile; OR: 4.90, 95% CI: 1.54 to 15.5, p=0.007; and OR: 12.3, 95% CI: 4.99 to 30.4, p<0.001, respectively).

Results of 3-year clinical outcomes SMI Q1 (n=124) SMI Q2 (n=116) SMI Q3 (n=112) SMI Q4 (n=123) Log-rank p-value All-cause mortality 27 (23.2) 11 (9.9) 7 (6.6) 5 (4.4) <0.001 Non-fatal MI 9 (8.7) 3 (3.0) 2 (2.0) 3 (2.6) 0.038 Repeat revascularization 20 (24.9) 15 (15.2) 7 (7.1) 4 (3.8) <0.001 Total MACEs 47 (42.9) 26 (24.0) 15 (14.3) 7 (6.2) <0.001 Data are expressed as n (%). MACE = major adverse cardiovascular event; MI = myocardial infarction; SMI = skeletal muscle index; Q = quartile.

Impact of reduced skeletal muscle on CAD

Conclusion

Skeletal muscle mass at baseline is a powerful predictor of future adverse clinical outcomes in patients with CAD undergoing successful PCI. Quantitative assessment of skeletal muscle mass at L1 level by CT scan provides prognostic implication for future cardiovascular risk stratification.

Acknowledgement/Funding

National Research Foundation of Korea (NRF-2016R1A2B3013825), Ministry of Future Creation and Science of Korea (2018K000255)

P2523Hand grip strength as a predictor of exercise capacity in coronary heart disease

A recent study has shown that quadriceps strength can be used to predict the level of exercise capacity in patients with coronary heart disease (CHD). We investigated whether the relationship between muscular strength and exercise capacity is also observed with hand grip strength (HGS). We studied 443 participants (age, 61.8±11.2 y; 77.7% male) who underwent coronary intervention and participated in cardiac rehabilitation between 2015 and 2018. Participants were assessed for grip strength, measured using a Jamar dynamometer. Logistic regression was used to assess the relationship between various clinical measures (HGS, age, sex, etc) with the distance walked on a 6-minute walk test (6MWT) and maximal oxygen uptake (VO2max). HGS was significantly related to distance walked on the 6MWT (r=0.435, p<0.001). It was the only predictor of all exercise capacity categories, and one of the strongest predictors of each exercise capacity category. A HGS of 25.5% of body weight predicted an achievement of a 200 m walk on the 6MWT (positive predictive value = 0.95). However, HGS less than 35.5% of body weight predicted that 500m could not be done in 6 minutes (negative predictive value = 0.97). This trend was also observed in the subgroups in which VO2max was measured. This study demonstrates that HGS is associated with exercise capacity in CHD and can be used to predict the level of exercise capacity. These findings may contribute to setting the recommended level of daily activity as well as the level of cardiac rehabilitation in CHD.

Logistic regression models for different levels of exercise capacity Level of exercise capacity B±S.E p-value Odd ratio 95% CI Distance of 6MWT   200 m Grip strength 0.054±0.014 <0.001 1.056 1.027–1.086   300 m Grip strength 0.042±0.009 <0.001 1.042 1.024–1.062   400 m Grip strength 0.047±0.011 <0.001 1.048 1.026–1.070   500 m Grip strength 0.051±0.016 0.001 1.053 1.021–1.086 VO2max level   4 METs Grip strength 0.054±0.010 <0.001 1.056 1.036–1.076   6 METs Grip strength 0.059±0.011 <0.001 1.061 1.039–1.083   8 METs Grip strength 0.081±0.015 <0.001 1.085 1.053–1.117   10 METs Grip strength 0.113±0.049 0.019 1.12 1.019–3.232 Data are presented as mean ± standard deviation (SD). 6MWT, 6-minute walk test; STEMI, ST-Elevation Myocardial Infarction; SE, standard error; CI, confidence interval; VO2max, Maximal Oxygen uptake; METs, Metabolic equivalents.

Estrogen Selectively Enhances TMJ Disc but Not Knee Meniscus Matrix Loss

The preponderance of temporomandibular joint (TMJ) degenerative disorders in women and their early onset during reproductive years have implicated female sex hormones, particularly 17-β estradiol (E2), in the pathogenesis of these disorders. Nevertheless, the mechanisms by which E2 contributes to TMJ degenerative disorders and the reasons for its targeted effects on the TMJ but not other joints remain poorly understood. Here, we developed an ovariectomized mouse model in which systemic E2 concentrations mimicked those in cycling women, and we determined the effect of E2 on the targeted turnover of TMJ fibrocartilage matrix via E2-induced matrix metalloproteinases MMP9 and MMP13. Infusion of E2 and progesterone (P4; hormone control) over 7 d resulted in 5- and 8-fold greater serum E2 and P4 levels relative to controls, respectively, achieving systemic hormone levels similar to high baseline levels in cycling women. Administration of E2 but not P4 caused a significant loss of TMJ collagen and glycosaminoglycans, which was accompanied by amplification of ERα and specific increases in MMP9 and MMP13 expression. This dose of E2 had no effect on knee meniscus fibrocartilage, demonstrating the specificity of the degradative effect of E2. Dose-response experiments showed a greater sensitivity and a higher peak induction of MMP9 and MMP13 in TMJ fibrocartilaginous cells than knee meniscus cells to E2, providing an explanation for the differential responses of these tissues to E2. Using MMP9- and MMP13-null mice, we observed no discernible effects of each proteinase individually to E2-mediated TMJ matrix loss but noted a significant compensatory reciprocal induction of each MMP by E2 in the absence of the other. The redundancy in E2's induction of MMP9 and MMP13 suggests that the proteinases may together contribute to E2-mediated TMJ fibrocartilage loss. These results advance our understanding of E2-mediated upregulation of MMP9 and MMP13 on fibrocartilage matrix turnover targeted to the TMJ.

Compressive stress effect on the loss mechanism in a soft piezoelectric Pb(Zr,Ti)O3

High power piezoelectric devices are often subjected to external mechanical biases, in applications such as underwater transducers. While the performance of these devices under external pressure has been rather extensively studied, there is a lack of study on the loss mechanism in terms of three dielectric, elastic, and piezoelectric losses. Thus, in this paper, we study the mechanical bias stress dependence of the loss mechanism in a soft piezoelectric Pb(Zr,Ti)O₃ (PZT) from a scientific viewpoint, using an equivalent circuit methodology based on the fundamental longitudinal mode. In order to measure the loss behavior, a modified bolt-clamped Langevin transducer was designed and optimized using finite element analysis in order to facilitate the analysis easier. We present the preliminary experimental part of our project on the design of the proposed structure/methodology, material creep behavior, stress relaxation, and uniform stress distribution, in order to minimize the experimental errors. We also introduce a six terminal equivalent circuit analysis in order to determine three losses in the PZT specimen. The resonance/antiresonance frequencies and quality factors showed monotonous increase under compressive stress. Loss factors for one PZT composition are reported in this paper to show the feasibility of our methodology for measuring the uniaxial compressive stress dependence.

Abstract P1-14-07: Randomized phase 3 study of anthracycline-containing regimens versus S-1 as first-line treatment for metastatic breast cancer (SELECT BC-CONFIRM)–A combined analysis of two randomized phase 3 studies (SELECT BC-CONFIRM and SELECT BC)–

Background: Anthracycline-containing regimens and taxane have been standard as the first-line chemotherapy for metastatic breast cancer (MBC). We conducted SELECT BC (randomized phase 3 study of taxane versus S-1 as first-line treatment for MBC) for evaluating the efficacy of S-1 for patients with HER2-negative MBC from 2006 to 2010 in Japan. This study demonstrated non-inferiority of S-1 in overall survival (OS) (median OS was 37.2 months in taxes group and 35.0 months in S-1 group (HR 1.05, 95% CI 0.86–1.27, p=0.015)), and superiority in health-related quality of life (HRQOL) to taxanes. S-1 was also shown as less toxic than taxane (Lancet Oncol 2016; 17: 90-98). S-1 might provide clinical benefit as first-line treatment for patients with HER2-negative MBC. To confirm this suggestion, we have conducted further study (randomized phase 3 study of anthracycline-containing regimens versus S-1 as first-line treatment for HER2-negative MBC: SELECT BC-CONFIRM) from 2011 to present, and a combined analysis of two randomized studies (SELECT-BC CONFIRM and SELECT-BC).

Methods: In SELECT BC-CONFIRM, 230 patients receiving first-line treatment for MBC were randomly assigned to either anthracycline group (n=115) or S-1 group (n=115). Anthracycline group patients received anthracycline-containing regimens (AC, EC, FAC, FEC, q3w) at the discretion of the treating physician. S-1 group patients received S-1 40–60 mg twice daily based on the patient's body surface area for 28 days on, 14-day off. The primary endpoint was OS, and secondary endpoints were progression-free survival (PFS), time to treatment failure (TTF), adverse events, HRQOL, and cost-effectiveness. The results were combined with SELECT-BC, to confirm the hypothesis that S-1 treatment is not inferior to the standard therapy (taxanes / anthracycline) for HER2-negative MBC.

Results: A combined analysis of the two studies showed that HR was 1.06, 95%CI 0.90-1.253, and p=0.0071 between the standard therapy group and S-1 group. In addition, the Bayesian posterior probability for which HR would be less than 1.333 was about 99.6%.

Conclusions: A combined analysis of SELECT BC-CONFIRM and SELECT BC clearly demonstrated that OS with S-1 was not inferior to that with the standard therapy in patients receiving first-line treatment for HER2-negative MBC. S-1 could become a standard therapy for this patient population.

Citation Format: Park Y, Akabane H, Watanabe T, Takahashi M, Sagara Y, Nishimura R, Tsurutani J, Takashima T, Fujisawa T, Hozumi Y, Uemura Y, Mukai H. Randomized phase 3 study of anthracycline-containing regimens versus S-1 as first-line treatment for metastatic breast cancer (SELECT BC-CONFIRM)–A combined analysis of two randomized phase 3 studies (SELECT BC-CONFIRM and SELECT BC)– [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-14-07.

Abstract P4-14-09: A nationwide data on the cardiovascular protective effect of tamoxifen and aromatase inhibitor in postmenopausal women with breast cancer

A large proportion of breast cancer patients receive hormonal therapy as their adjuvant treatment options. For postmenopausal women, the initial choice for the hormonal therapy is aromatase inhibitor (AI), and tamoxifen (TM) is reserved for women experiencing severe side effects against AI or having low bone density. An important but unresolved clinical question regarding the use of AI in postmenopausal women is the safety of AI regarding the risk cardiovascular events. Studies have shown inconsistent results over the cardiovascular safety of AI and TM. In this study, we investigated the risk of developing cardiovascular and cerebrovascular events in women with breast cancer who receive hormonal therapy using AI, TM, or both.

To this end, we used the National Health Insurance Sharing Service in Korea which is provided by National Health Insurance Service. The database provides anonymized insurance data for research purposes after the approval of the review committee. In the database, we identified 47,569 women with the age older than 55 who were diagnosed with breast cancer. Patients were classified as no hormonal treatment group (n=18,807), AI group (n=19,584), TM group (n=7,081), or Switch group (n=2,097). The Switch group was defined as the women with history of both AI and TM prescriptions. During the studied period, a total of 2,032 cardiovascular or cerebrovascular events (CVE) were recorded.

Overall, the women prescribed with TM had significantly less hazard ratio for developing CVE when compared to the women who did not receive any hormonal treatment (HR 0.809 95% C.I. 0.706-0.928). However, this protective effect of tamoxifen was not observed in either AI or Switch group (HR 0.917 95% C.I. 0.833-1.010, and HR 0.856 95% C.I. 0.695-1.053, respectively). The protective effect of TM was also similar in women older than 60 (HR 0.808 95% C.I. 0.696-0.938). The cardiovascular and cerebrovascular protective effects of tamoxifen was also substantial in high risk women defined by their family history of cardiovascular diseases and the diagnosis of hypertension or diabetes.

Our results suggest that the use of TM is associated with a substantial protective effect against developing cardiovascular or cerebrovascular events in women with breast cancer. However, the protective effect was not observed for women receiving AI. Our data suggest the potential tailored approach in hormonal treatment in breast cancer patients who are at high risk of cardiovascular of cerebrovascular events.

Citation Format: Moon H-G, Choi SH, Park Y, Jung JG, Ju YW, Kim KE, Kim Y, Lee E, Lee H-B, Han W, Noh D-Y, Yoon H-J. A nationwide data on the cardiovascular protective effect of tamoxifen and aromatase inhibitor in postmenopausal women with breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-14-09.

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H, Suomalainen H, Colman P, Healy F, Mesfin S, Redl L, Wentworth J, Willis J, Farley M, Harrison L, Perry C, Williams F, Mayo A, Paxton J, Thompson V, Volin L, Fenton C, Carr L, Lemon E, Swank M, Luidens M, Salgam M, Sharma V, Schade D, King C, Carano R, Heiden J, Means N, Holman L, Thomas I, Madrigal D, Muth T, Martin C, Plunkett C, Ramm C, Auchus R, Lane W, Avots E, Buford M, Hale C, Hoyle J, Lane B, Muir A, Shuler S, Raviele N, Ivie E, Jenkins M, Lindsley K, Hansen I, Fadoju D, Felner E, Bode B, Hosey R, Sax J, Jefferies C, Mannering S, Prentis R, She J, Stachura M, Hopkins D, Williams J, Steed L, Asatapova E, Nunez S, Knight S, Dixon P, Ching J, Donner T, Longnecker S, Abel K, Arcara K, Blackman S, Clark L, Cooke D, Plotnick L, Levin P, Bromberger L, Klein K, Sadurska K, Allen C, Michaud D, Snodgrass H, Burghen G, Chatha S, Clark C, Silverberg J, Wittmer C, Gardner J, LeBoeuf C, Bell P, McGlore O, Tennet H, Alba N, Carroll M, Baert L, Beaton H, Cordell E, Haynes A, Reed C, Lichter K, McCarthy P, McCarthy S, Monchamp T, Roach J, Manies S, Gunville F, Marosok L, Nelson T, Ackerman K, Rudolph J, Stewart M, McCormick K, May S, Falls T, Barrett T, Dale K, Makusha L, McTernana C, Penny-Thomas K, Sullivan K, Narendran P, Robbie J, Smith D, Christensen R, Koehler B, Royal C, Arthur T, Houser H, Renaldi J, Watsen S, Wu P, Lyons L, House B, Yu J, Holt H, Nation M, Vickers C, Watling R, Heptulla R, Trast J, Agarwal C, Newell D, Katikaneni R, Gardner C, Del Rio A, Logan A, Collier H, Rishton C, Whalley G, Ali A, Ramtoola S, Quattrin T, Mastrandea L, House A, Ecker M, Huang C, Gougeon C, Ho J, Pacuad D, Dunger D, May J, O’Brien C, Acerini C, Salgin B, Thankamony A, Williams R, Buse J, Fuller G, Duclos M, Tricome J, Brown H, Pittard D, Bowlby D, Blue A, Headley T, Bendre S, Lewis K, Sutphin K, Soloranzo C, Puskaric J, Madison H, Rincon M, Carlucci M, Shridharani R, Rusk B, Tessman E, Huffman D, Abrams H, Biederman B, Jones M, Leathers V, Brickman W, Petrie P, Zimmerman D, 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Manley L, Nemery R, Charlton W, Smith P, Kerr L, Steindel-Kopp B, Alamaguer M, Tabisola-Nuesca E, Pendersen A, Larson N, Cooper-Olviver H, Chan D, Fitz-Patrick D, Carreira T, Park Y, Ruhaak R, Liljenquist D. A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.