Metixene is an incomplete autophagy inducer in preclinical models of metastatic cancer and brain metastases

A paucity of chemotherapeutic options for metastatic brain cancer limits patient survival and portends poor clinical outcomes. Using a CNS small-molecule inhibitor library of 320 agents known to be blood-brain barrier permeable and approved by the FDA, we interrogated breast cancer brain metastasis vulnerabilities to identify an effective agent. Metixene, an antiparkinsonian drug, was identified as a top therapeutic agent that was capable of decreasing cellular viability and inducing cell death across different metastatic breast cancer subtypes. This agent significantly reduced mammary tumor size in orthotopic xenograft assays and improved survival in an intracardiac model of multiorgan site metastases. Metixene further extended survival in mice bearing intracranial xenografts and in an intracarotid mouse model of multiple brain metastases. Functional analysis revealed that metixene induced incomplete autophagy through N-Myc downstream regulated 1 (NDRG1) phosphorylation, thereby leading to caspase-mediated apoptosis in both primary and brain-metastatic cells, regardless of cancer subtype or origin. CRISPR/Cas9 KO of NDRG1 led to autophagy completion and reversal of the metixene apoptotic effect. Metixene is a promising therapeutic agent against metastatic brain cancer, with minimal reported side effects in humans, which merits consideration for clinical translation.

Luminal Rank loss decreases cell fitness leading to basal cell bipotency in parous mammary glands

Rank signaling pathway regulates mammary gland homeostasis and epithelial cell differentiation. Although Rank receptor is expressed by basal cells and luminal progenitors, its role in each individual cell lineage remains unclear. By combining temporal/lineage specific Rank genetic deletion with lineage tracing techniques, we found that loss of luminal Rank reduces the luminal progenitor pool and leads to aberrant alveolar-like differentiation with high protein translation capacity in virgin mammary glands. These Rank-deleted luminal cells are unable to expand during the first pregnancy, leading to lactation failure and impairment of protein synthesis potential in the parous stage. The unfit parous Rank-deleted luminal cells in the alveoli are progressively replaced by Rank-proficient cells early during the second pregnancy, thereby restoring lactation. Transcriptomic analysis and functional assays point to the awakening of basal bipotency after pregnancy by the induction of Rank/NF-κB signaling in basal parous cell to restore lactation and tissue homeostasis.

STING agonist-loaded, CD47/PD-L1-targeting nanoparticles potentiate antitumor immunity and radiotherapy for glioblastoma

As a key component of the standard of care for glioblastoma, radiotherapy induces several immune resistance mechanisms, such as upregulation of CD47 and PD-L1. Here, leveraging these radiotherapy-elicited processes, we generate a bridging-lipid nanoparticle (B-LNP) that engages tumor-associated myeloid cells (TAMCs) to glioblastoma cells via anti-CD47/PD-L1 dual ligation. We show that the engager B-LNPs block CD47 and PD-L1 and promote TAMC phagocytic activity. To enhance subsequent T cell recruitment and antitumor responses after tumor engulfment, the B-LNP was encapsulated with diABZI, a non-nucleotidyl agonist for stimulator of interferon genes. In vivo treatment with diABZI-loaded B-LNPs induced a transcriptomic and metabolic switch in TAMCs, turning these immunosuppressive cells into antitumor effectors, which induced T cell infiltration and activation in brain tumors. In preclinical murine models, B-LNP/diABZI administration synergized with radiotherapy to promote brain tumor regression and induce immunological memory against glioma. In summary, our study describes a nanotechnology-based approach that hijacks irradiation-triggered immune checkpoint molecules to boost potent and long-lasting antitumor immunity against glioblastoma.

Rank ectopic expression in the presence of Neu and MMTV oncogenes alters mammary epithelial cell populations and their tumorigenic potential

Determination of the mammary epithelial cell that serves as the cell of origin for breast cancer is key to understand tumor heterogeneity and clinical management. In this study, we aimed to decipher whether Rank expression in the presence of PyMT and Neu oncogenes might affect the cell of origin of mammary gland tumors. We observed that Rank expression in PyMT^+/- and Neu^+/- mammary glands alters the basal and luminal mammary cell populations already in preneoplasic tissue, which may interfere with the tumor cell of origin restricting their tumorigenesis ability upon transplantation assays. In spite of this, Rank expression eventually promotes tumor aggressiveness once tumorigenesis is established.

Abstract B36: Nano-engineering of immunosuppressive myeloid cells for immunostimulation in glioblastoma

As a hallmark of glioblastoma (GBM), the myeloid-rich tumor microenvironment is one of the major causes of GBM immunosuppression and therapy resistance. Therefore, tumor-associated myeloid cells (TAMCs) have been identified as a promising therapeutic target for remodeling the immunologically “cold” brain tumors and overcoming the therapy resistance of GBM. Emerging research findings have uncovered the interplay between TAMCs and radiotherapy, a key component of the standard of care for GBM. While radiotherapy is known to induce antitumor immune response, in which the functionality of the myeloid compartment, including phagocytosis of tumor and subsequent activation of effector T cells, plays a key role, irradiation also triggers immune resistance mechanisms, such as the overexpression of anti-phagocytic molecule CD47 in gliomas and immune checkpoint molecule PD-L1 in TAMCs. To tackle this, a bispecific-lipid nanoparticle (B-LNP) was designed to hijack the irradiation-induced upregulation of immunosuppressive molecules for harnessing TAMCs to elicit antitumor immune response. The B-LNP was surface functionalized with anti-CD47/PD-L1 ligands to enable a simultaneous targeting of TAMCs and glioma cells through dual ligation. The engineered B-LNP effectively bound to and blocked CD47 and PD-L1 molecules, and served as a bridge to engage TAMCs for enhanced phagocytosis of glioma cells when combined with radiotherapy. To promote the TAMC-mediated activation of adaptive antitumor immunity post-phagocytosis, diABZI, a synthetic non-nucleotidyl agonist for stimulator of interferon genes (STING), was physically encapsulated into B-LNP as a payload therapeutic. Our results indicate that B-LNP/diABZI complex enabled a TAMC-specific STING activation in preclinical murine glioma model CT-2A, which transformed the immunosuppressive TAMCs into tumor-eradicating cells in the glioma microenvironment, as evidenced by immune profiling, single-cell RNA sequencing analysis, and bulk metabolomics. As a result, the nano-engineered TAMCs dramatically promoted tumor infiltration and anti-glioma activity of T cells, which improved the therapeutic outcome of radiotherapy, eradicating tumors from about 70% of the glioma-bearing mice, and generated a long-lasting immunological memory against gliomas. The translational potential of our nano-engineering approach was further validated using a glioma model that recapitulates the genetic, histological, and immunological features of human GBM, and using the clinical tumor specimens of GBM patients. In conclusion, our work demonstrates a nanotechnology-mediated immunomodulatory approach that targets and modulates the myeloid-rich GBM microenvironment as a combinatorial treatment for improving the existing standard of care for GBM.

Citation Format: Peng Zhang, Aida Rashidi, Junfei Zhao, Brandyn Castro, Abby Ellingwood, Yu Han, Aurora Lopez-Rosas, Markella Zannikou, Crismita Dmello, Rebecca Levine, Ting Xiao, Alex Cordero, Adam M Sonabend, Irina V Balyasnikova, Catalina Lee-Chang, Jason Miska, Maciej S Lesniak. Nano-engineering of immunosuppressive myeloid cells for immunostimulation in glioblastoma [abstract]. In: Proceedings of the AACR Special Conference: Tumor Immunology and Immunotherapy; 2022 Oct 21-24; Boston, MA. Philadelphia (PA): AACR; Cancer Immunol Res 2022;10(12 Suppl):Abstract nr B36.

Cholesterol remnants distribution in patients admitted for acute coronary syndrome

Background

Cholesterol remnants have been identified as one of leading lipid measurements associated with the incidence of coronary heart diseases. Nonetheless, there is scarce evidence on cholesterol remnants distribution in patients with acute coronary syndrome (ACS).

Methods

We included all consecutive patients admitted for ACS in two different centers. Cholesterol remnants were calculated by the equation: total cholesterol minus low-density lipoprotein cholesterol (LDLc) minus high-density lipoprotein cholesterol (HDLc) and values ≥30 were considered high. Premature ACS was defined in patients presenting with age <55 for men or <65 for women. Correlation weres assessed by linear regression and predictive models were obtained after logistic binary regression.

Results

We included 7,479 patients, mean age 66.68 (13.02), 2,062 (27.57%) women, mean body mass index (BMI) 28.60 (4.64) kg/m2, 2088 (27,92%) with diabetes and 2,726 (36.45%) admitted for ST-elevation ACS. Median (interquartile range) remnants level was 28 mg/dl (21–39) and 3,429 (45.85%) patients had levels ≥30 mg/dl. Significantly higher levels of remnants were observed in patients with diabetes, current smokers, BMI >30 kg/m2, absence of previous cardiovascular disease or premature ACS. No gender differences were observed in remnants level. Age (r: −0.29) and BMI (r: 0.44) were the variables more strongly correlated. As shown in the figures, at any given age, the risk of having cholesterol remnants ≥30 increased with higher BMI.

In-hospital mortality was 3.75% (280 patients). After adjustment by age, gender, previous cardiovascular disease and GRACE score, cholesterol remnants were not associated to higher mortality risk (OR: 0.89 95% CI 0.64–1.10; p=0.21)

Conclusions

Elevated cholesterol remnants is highly prevalent in patients admitted for ACS and their levels inversely correlate with age and positively with body mass index. We propose a risk matrix for estimating the probability of having cholesterol remnants ≥30. Elevated cholesterol remnants were not associated to higher in-hospital mortality risk.

Funding Acknowledgement

Type of funding sources: None.

Differential prognosis of patients candidates for standard, short or prolonged dual antiplatelet treatment discharged after an acute coronary syndrome

Background

Current evidence supports the efficacy of prolonged dual antiplatelet treatment prolonged (DAPT) patients at high-ischemic risk and low bleeding risk. In contrast, several trials have demonstrated the efficacy and safety of short DAPT (1,3 o6 months) in high-bleeding risk (HBR) patients. Nonetheless, 12 months of DAPT is the most commonly strategy recommended in patients discharged after an ACS.

Methods

We evaluated patterns of DAPT candidates in all patients discharged in single center between 2009 and 2019 after an acute coronary syndrome (ACS). Patients categorized in 3 groups: 1) short-DAPT candidates if they met 1 major o 2 minor criteria for HBR, by the 2019 ARC-HBR criteria; 2) prolonged-DAPT candidates if were not HBR and had recurrent ACS, complex percutaneous coronary interventions or diabetes; 3) standard 12 months DAPT if were not include in the previous 2 groups. We evaluated all-cause and cardiovascular mortality, mayor bleeding (MB), and major cardiovascular events (MACE) after discharge.

Results

We assessed 3,155 patients discharged after an ACS, mean age was 68.4 (13.0), 25.9% were women, 32.5% had diabetes, 13.2% received complex percutaneous coronary interventions and 40.5% were categorized as HBR. After categorization, 1,277 (40.48%) were candidates for short DAPT, 1,203 (38.1%) for standard 12m DAPT and 675 (21.39%) for prolonged DAPT.

After a median follow-up was 1032 days (interquartile range 555–1950), all-cause mortality was 15.8%, cardiovascular mortality 10.5%, 35.9% had a first MACE and 6.2% had at least one MB. As shown in figure 1, patients candidates for short or prolonged DAPT had significantly higher rates of all-cause and cardiovascular mortality as well as MACE. In contrast, higher rate of MB was only increased in patients candidates for short-DAPT (figure 2). Multivariate analysis demonstrated higher risk of MB (sHR: 1.60 95% CI 1.10–2.60; p=0.030) only in patients candidates for short-DAPT. In contrast, candidates for short-DAPT has higher risk of all-cause mortality (HR: 2.92 95% CI 1.95–4.37; p<0.01) and cardiovascular mortality (HR: 3.01 95% CI 1.78–5.32; p<0.01) and MACE (HR: 2.22, 95% CI 1.82–2.70; p<0.01). Similarly, patients candidates for prolonged DAPT had higher risk of all-cause mortality (HR: 1.72 95% CI 1.10–2.69; p=0.002), cardiovascular mortality (HR: 2.47 95% CI 1.39–4.40; p=0.017) and MACE (HR: 1.58 95% CI 1.28–1.95; p<0.001).

Conclusions

Almost two thirds of patients discharged after an ACS would be candidates for short or prolonged DAPT and these patients are at higher risk of MACE and mortality. Patients candidates for short-DAPT had higher risk of MB through the follow-up. These results might reinforce the need of individual assessment of most optimal DAPT duration in all patients discharged after an ACS.

Funding Acknowledgement

Type of funding sources: None.

Predictors of no-reflow in patients with myocardial infarction and ST-segment elevation treated with primary angioplasty

Introduction

The no-reflow phenomenon is a serious complication of coronary intervention, especially in primary angioplasty and effective preventive measures are unknown.

Methods

Retrospective study of all patients treated by primary angioplasty in a single center through 4 years. We define no-reflow as the absence of flow immediately after stent angioplasty. The variables associated with this phenomenon were analyzed using binary logistic regression. The delay to primary angioplasty was calculated as the sum of the time to the first medical contact, activation, transfer until arterial puncture.

Results

We included 1453 patients, mean age 64.1 years, 21% women, 16.1% Killip >1. The mean delay to primary angioplasty was 180 minutes (interquartile range 125–323). No-reflow was recorded in 81 (5.57%) patients and these patients had a higher mean age (69.37±12.51 vs. 63.76±13.52; p<0.001), higher delay to primary angioplasty (770.93±2056.91 vs. 348.80±749.73; p<0.001), presentation with Killip grade >1 (29.0% 15.36%; p=0.002), in addition to lower systolic blood pressure (121.18±28.63 vs. 113.37±28.22; p=0.021). Regarding coronary angiography, patients who developed no-reflow presented more frequently TIMI-0 (88.89% vs. 70.32%; p<0.001) and a tendency to being the left anterior descending the culprit vessel (46.91% vs. 36.88, p=0.07). In 59.3% of the patients who presented no-reflow, a final TIMI 3 was achieved, with the measurements carried out, compared to (94.9%) of the patients who did not have no-reflow (p<0.001).

Multivariate analysis identified the following variables associated with no-reflow: age (OR: 1.03 95% CI 1.01–1.05; p=0.008), delay to primary angioplasty >120 min (OR: 2.70, 95% CI 1.21–6.00; p=0.015), initial TIMI-0 (OR: 3.22, 95% CI 1.57–6.58; p=0.001). In fact, patients aged >40 had a very low incidence of no-reflow (1.72%), regardless of delay to primary angioplasty; however, in patients >70 years of age, the incidence was much higher (figure)

Hospital mortality was 9.25% (125 patients) and was almost 4 times higher in patients who presented no-reflow (23.68% vs. 8.39%; p<0.001). Adjusted for age, sex, delay to primary angioplasty diabetes and final TIMI flow, the no-reflow phenomenon was associated with higher hospital mortality (OR: 2.34 95% CI 1.02 4.25; p=0.030)

Conclusions

The no-reflow phenomenon has a low incidence but high mortality in patients with ST-segment elevation myocardial infarction treated with primary angioplasty. Age, delay to primary angioplasty and initial TIMI 0 flow are the main predictors of no-reflow.

Funding Acknowledgement

Type of funding sources: None.

Age as a prognostic modifier in anemic patients discharged after acute coronary syndrome

Introduction

The presence of anemia on admission is a poor long-term prognostic factor in patients diagnosed with acute coronary syndrome (ACS). However, it is unknown whether age is a factor modifying the effect of anemia on mortality.

Objective

To determine the effect of age on anemia in terms of long-term mortality in patients admitted for ACS.

Methods

This is an observational study in which we included all patients discharged from cardiology for ACS in two centers from 2003 to 2020. Patients with anemia were classified by hemoglobin values <13 g/dL in men and <12 g/dL in women in the first blood count performed during hospitalization. The interaction between age and anemia was analyzed using the Cox regression model and the chunk test. We analyzed the effect of anemia on mortality using the Cox regression model adjusted for several confounding variables and the interaction with age.

Results

We included 8872 patients diagnosed with ACS, with a mean age of 66.38 (SD ±12.76) years, 27.1% female and 34.3% diagnosed with ST-segment elevation ACS. The mean hemoglobin value was 13.88 (SD ±1.85) g/dL and 20.5% of patients were anemic on admission.

During follow-up (median 1764 days, IQR 694–2439 days) there was an increased risk of all-cause mortality in patients with anemia adjusted for age and other risk factors (sex, renal function, GRACE score, atrial fibrillation, LVEF and previous revascularization), HR 15.5 (CI 5.77–41.75; p>0.005). We found a significant interaction between age and anemia (p<0.01). As represented in the figure, the adjusted risk of mortality decreased at older ages; in patients whose age was >80 anemia was not associated to higher mortality risk. Similar results were observed for cardiovascular mortality, HR 21.36 (CI 6.13–74.43, p>0.005).

Conclusion

Age modifies the risk of mortality in patients discharged after an ACS being the risk of mortality higher in youngest ages and disappearing in octogenearians. There results should be taken under consideration for the treatment and management of ACS patients.

Funding Acknowledgement

Type of funding sources: None.

Effect on cholesterol remnants and residual lipid risk with PCSK9 inhibitors: the LIPID-REAL Registry

Background

Monoclonal antibodies that inhibit the proprotein convertase subtilisin/kexin type 9 (PCSK9) reduce low-density lipoprotein cholesterol (LDLc) by 55%, regardless of baseline treatments. Nonetheless, the effect of other lipid parameters, as cholesterol remnants or, the so-called residual lipid risk, are unknown.

Methods

Multicenter and retrospective registry of patients treated with PCSK9 inhibitors from 14 different hospitals from Spain. Before and on-treatment lipid parameters were recorded. Cholesterol remnants were calculated by the equation: total cholesterol minus LDLc minus HDLc and values ≥30 were considered high. Residual lipid risk was estimated by 1) the estimation of LDL particle size, by the triglycerides/HDLc ratio (TG/HDL) and values <2 were assumed as low and dense LDL particles; 2) total cholesterol/HDLc (TC/HDL) and values >3 were considered high; and; 3) the triglycerides-to-glucose (TG/Gluc) index, obtained as the natural logarithm of (triglycerides * glucose/2)

Results

A total of 652 patients were analyzed, mean age 60.0 (10.5) years and 161 (24.69%) women. Baseline LDLc was 149.2 (49.9) mg/dl, cholesterol remnants 29.9 (20.3) mg/dl, TG/HDL 3.9 (4.1), TC/HDL 4.9 (1.9) and TG/Gluc index 8.9 (0.7). Most patients (92.3%) were on statins; 54.8% with ezetimibe, 8.5% with fibrates.

Evolocumab was initiated in 318 (56.6%) patients; 229 (40.7%) alirocumab 75 mg and 15 (2.7%) alirocumab 150 mg. Median time to second blood determination were 187.5 (IQR 101–242) days. Mean on-treatment LDLc was 67.46 (45.78) mg/dl what represented a 55% reduction. As shown in the figure, significant reduction in cholesterol remnants (p=0.017), TG/HDL ratio (p=0.020), TC/HDL ratio (p<0.001) and TG/Gluc index (p<0.001). The percentage of patients with remnants >30 mg/dl decreased: 34.62% to 30.07 (p<0.01). Significant reductions were also observed in the percentage of patients with TG/HDL >2 (71.25% to 61.98%; p<0.01) or TC/HDL >3 (94.28% to 38.97%; p<0.01)

Conclusions

This multicenter and retrospective registry of real-world patients treated with PCSK9 inhibitors demonstrates a positive effect on cholesterol remnants and lipid-residual risk beyond LDLc reductions.

Funding Acknowledgement

Type of funding sources: None.

Translocon-associated protein subunit SSR3 determines and predicts susceptibility to paclitaxel in breast cancer and glioblastoma

PURPOSE

Paclitaxel (PTX) is one the most potent and commonly used chemotherapies for breast and pancreatic cancer. Several ongoing clinical trials are investigating means of enhancing delivery of PTX across the blood-brain barrier for glioblastomas (GBMs). Despite the widespread use of PTX for breast cancer, and the initiative to repurpose this drug for gliomas, there are no predictive biomarkers to inform which patients will likely benefit from this therapy.

EXPERIMENTAL DESIGN

To identify predictive biomarkers for susceptibility to PTX, we performed a genome-wide CRISPR knock-out (KO) screen using human glioma cells. The genes whose KO was most enriched in the CRISPR screen underwent further selection based on their correlation with survival in the breast cancer patient cohorts treated with PTX and not in patients treated with other chemotherapies, a finding that was validated on a second independent patient cohort using progression-free survival.

RESULTS

Combination of CRISPR screen results with outcomes from taxane-treated breast cancer patients led to the discovery of endoplasmic reticulum (ER) protein SSR3 as a putative predictive biomarker for PTX. SSR3 protein levels showed positive correlation with susceptibility to PTX in breast cancer cells, glioma cells and in multiple intracranial glioma xenografts models. Knockout of SSR3 turned the cells resistant to PTX while its overexpression sensitized the cells to PTX. Mechanistically, SSR3 confers susceptibility to PTX through regulation of phosphorylation of ER stress sensor IRE1α.

CONCLUSION

Our hypothesis generating study showed SSR3 as a putative biomarker for susceptibility to PTX, warranting its prospective clinical validation.

Repurposing Autophagy Regulators in Brain Tumors

Malignant brain tumors, such as glioblastoma multiforme (GBM) and brain metastases, continue to be an unmet medical challenge. Despite advances in cancer diagnostics and therapeutics, tumor cell colonization in the central nervous system (CNS) renders most treatment options ineffective. This is primarily due to the selective permeability of the blood-brain barrier (BBB), which hinders the crossing of targeting agents into the brain. As such, repositioning medications that demonstrate anti-cancer effects and possess the ability to cross the BBB can be a promising option. Antidepressants, which are BBB-permeable, have been reported to exhibit cytotoxicity against tumor cells. Autophagy, specifically, has been identified as one of the common key mediators of antidepressant's antitumor effects. In this work, we provide a comprehensive overview of US Food and Drug Administration (FDA)-approved antidepressants with reported cytotoxic activities in different tumor models, where autophagy dysregulation was demonstrated to play the main part. As such, imipramine, maprotiline, fluoxetine and escitalopram were shown to induce autophagy, whereas nortriptyline, clomipramine and paroxetine were identified as autophagy inhibitors. Sertraline and desipramine, depending on the neoplastic context, were demonstrated to either induce or inhibit autophagy. Collectively, these medications were associated with favorable therapeutic outcomes in a variety of cancer cell models, including brain tumors. This article is protected by copyright. All rights reserved.

TAMI-25. UPREGULATION OF CREATINE METABOLISM BY MYELOID CELLS RESULTS IN GLIOBLASTOMA PROGRESSION

Malignant brain tumors are uniquely immunosuppressive, with a predominant infiltration of immunosuppressive tumor-associated myeloid cells (TAMCs) and a deficit in T-cells unrivaled to any other tumor. This unique tumor microenvironment (TME) promotes resistance to both conventional and immune therapies for this disease. The underlying mechanisms by which TAMCs promote glioblastoma (GBM) progression are not fully understood. We found that TAMCs specifically upregulate de-novo creatine metabolism within GBM using unbiased genetic and metabolic screening. This metabolic phenotype was confirmed in human GBM patients by comparing peripheral versus tumor-infiltrating myeloid cells. Examination of de-novo creatine generation using Carbon13 arginine flux revealed that TAMCs, but not tumor-infiltrating CD8+ T-cells, can produce creatine. Furthermore, we demonstrate that TAMCs actively secrete de-novo generated creatine into cell cultures. Examination of the single-cell microenvironment of GBM revealed that malignant cells preferentially express the creatine transporter, indicating that TAMC-derived creatine is taken up by GBM. Notably, SLC6A8 is directly upregulated in the context of hypoxia and suggests that creatine uptake is a mechanism to promote survival under hypoxic stress. Indeed, exogenous creatine supplementation promoted both the migration and survival of multiple glioblastoma cell lines in-vitro. Utilizing an established inhibitor of creatine metabolism, β-Guanidinopropionic acid (β -GPA), we found that β -GPA blocks both the migration and survival of glioma cells under hypoxic stress. Lastly, β -GPA also inhibited creatine secretion by TAMCs, showing that creatine blockade can also influence TAMC metabolic phenotype. In the future, we will examine the importance of creatine metabolism on both immune suppression and tumor progression in-vivo. This work provides novel insights into the role of creatine metabolism in GBM and identifies a unique therapeutic avenue for this devastating disease.

BIOM-32. ENDOPLASMIC RETICULUM PROTEIN SSR3 DETERMINES AND PREDICTS RESPONSE TO PACLITAXEL IN BREAST CANCER AND GLIOBLASTOMA

Paclitaxel (PTX) is one the most potent and commonly used chemotherapies for breast and pancreatic cancer. Given the potency of this drug for glioblastomas (GBM) several ongoing clinical trials are investigating means of enhancing delivery of PTX across the blood-brain barrier for this disease. In spite of the efficacy of PTX, individual tumors exhibit variable susceptibility to this drug, with response rate in the range of 30%-60%. To identify predictive biomarkers for response to PTX, we performed a genome-wide CRISPR knock-out screen using human glioma cells. The most enriched genes in the CRISPR screen underwent further selection based on their correlation with survival in the breast cancer patient cohorts treated with PTX and not in patients treated with other chemotherapies, a finding that was validated on a second independent patient cohort. This led to the discovery of endoplasmic reticulum (ER) protein SSR3 as a putative predictive biomarker for PTX. SSR3 protein levels showed positive correlation with response to PTX in breast cancer cells, glioma cells, in multiple intracranial glioma xenografts and in GBM patient derived explant cultures. Knockout of SSR3 turned the cells resistant to PTX while its overexpression sensitized the cells to PTX. In gliomas, SSR3-mediated susceptibility to PTX relates to modulation of phosphorylation of ER stress sensor IRE1α. Thus, by using genome-wide screen combined with patient response data, we discovered a biomarker that demonstrates causal and correlative relationship with response to PTX in breast cancer and GBM. Prospective validation of this biomarker is warranted for its broad implementation for precision oncology.

Reduction of cardiovascular events in patients with cardiovascular disease with the CV-polypill: a retrospective and propensity score matching study

Background

Previous clinical trials suggested that a strategy based on a cardiovascular (CV) polypill improves risk factor control and reduces the incidence of CV events. The CNIC-Polyill (aspirin (ASA) 100mg, atorvastatin 20/40mg (or simvastatin 40mg) and ramipril 2,5–10mg) has shown to improve adherence and risk factors control.

Methods

The NEPTUNO study is a retrospective, non-interventional analysis of an anonymized medical history dataset in the BIG-PAC administrative database in the years 2015–2018. Patients at age ≥18 years with previous CV disease were allocated in four different cohorts according to their therapy: CNIC-polypill containing ASA 100mg, R 2.5/5/10mg and A 20/40mg (1:case cohort), identical mono-components (ASA,R,A) (C2), equipotent medication (ASA 100mg, simvastatin 40/80mg or rosuvastatin 5/10mg, enalapril 5–20mg or valsartan 40–160mg) (C3) and usual care (C4) (control cohorts) and were followed for 2 years. To ensure comparability of the study cohorts, a propensity score matching (PSM) was performed. The primary endpoint was the incidence first major cardiovascular event (MACE) including: myocardial infarction, angina, ischemic stroke, transitory ischemic attack, peripheral artery disease and CV mortality.

Results

8,946 patients were recruited. After the PSM, 4 well-balanced cohorts of 1,614 patients were obtained. The mean age was 63.3 years and 60.4% were men. Cohort 1 (Case cohort, CNIC-polypill) compared with cohorts 2, 3 and 4 showed a significant reduction in MACEs (19.8% vs. 23.3%, 25.5% and 26.8%; p<0.001), respectively although the CV death rate (8.1% vs. 8.1%, 8.9% and 9.2%; p=0.357) did not show differences. The hazard ratio (HR) for a MACE in the CV polypill cohort vs cohort 2 was 0.761 (IC95%; 0.657–0.881), p=0.001; vs Cohort 3 was 0.821 (IC95%; 0.714–0.944), p=0.006 and vs. Cohort 4 was 0.834 (IC95%; 0.716–0,950), p=0.008. Time to the event was also longer in the CV-polypill cohort compared the other 3 cohorts (274.8 days vs 249.2 days; 226.4 days and 217 days; p<0.001). There was a significant greater reduction in the case cohort vs the 3 control cohorts in the absolute levels of all the analyzed lipidic variables (LDL (−19.6 vs. −12.9, −12.3 and −9.1 mg/dL; p<0.001), triglycerides (−67.5 vs. −59.9, −56.1 and −54.4 mg/dL; p<0.001)) and in reduction of blood pressure (PAS (−14.1 vs. −11.7, −10.4 and −10.4 mmHg; p<0.001) and PAD (−4.5 vs −2.5, −2.1, −1.2 mmHg; p<0.001)). Higher persistence to treatment in the CNIC- polypill cohort (72.1% vs. 62. 2%, 60.0% and 54.2%; p<0.001) was also found.

Conclusion

This study shows the reduction of clinical events by the CNIC-polypill in a large population of real-life patients. In spite of the retrospective design of this study, the results of our analysis support the use of a CV-polypill in secondary prevention of cardiovascular events. These results need to be confirmed by prospective randomized clinical trials with major clinical outcomes.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Ferrer International Figure 1

LDLc reduction with fixed-dose combination rosuvastatin-ezetimibe in patients with coronary heart disease that are not candidates for PCSK9 inhibitors treatment

Background

Statin plus ezetimibe combination has a recommendation class IIa, level of evidence B, for low-density lipoprotein cholesterol (LDLc) reduction. Since LDLc treatment target for patients with coronary heart disease (CHD) has been recently reduced to <55 mg/dl most patients might need lipid-lowering drugs combinations and fixed-dose combinations are known to increase adherence. Current indications for PCSK9 inhibitors accepted for reimbursement in Spain in patients with CHD are LDL >100 mg/dl despite maximal dose tolerated of statins or any of previous patients with statin intolerance and LDL >100 mg/dl.

Methods

Investigator-initiated retrospective analysis of patients with coronary heart disease that received fixed-dose combination with rosuvastatin-ezetimibe between 2019 and 2020 in a specialized unit for patients with CHD. Inclusion criteria were: CHD and LDLc <100 mg/dl despite statin treatment or >100 mg/dl without previous lipid-lowering treatments. We also analysed patients in whom treatment was initiated at discharge from and acute coronary syndrome (ACS) or with chronic coronary syndrome (CCS)

Results

We analyzed 137 patients, 79.4% males, mean age 62. (12.3) and 24.1% with ACS. Statin treatment before initiation fixed-dose combination was higher in patients with CCS (71.2% vs. 8.2%; p<0.01). Mean LDLc before treatment was 103.0 (30.5) mg/dl and it was higher in patients with ACS (121.3 (40.2) vs. 97.4 (24.4); p<0.001). Median time to second blood test was 203 days (IQR 122–300); mean post-treatment LDLc was 60.8 (21.2) mg/dl and no difference (p=0.18) was found in patients with ACS vs CCS: 56.0 (26.1) vs. 62.4 (19.2) mg/dl. Mean LDLc reduction was 38.5% and it was higher in was higher in ACS patients (49.9% vs. 34.7%) (figure). LDLc <55 mg/dl was achieved in 42.1% of the patients, more frequently in patients with ACS: 59.3% vs. 36.3% (p=0.036). No increase in transaminases was detected and a reduction in triglycerides was found (149.1 (100.4) to 124.7 (82.3) mg/dl; p=0.041).

Conclusions

Treatment with a fixed-dose combination with rosuvastatin-ezetimibe in patients with CHD not candidate for PCSK9 inhibitors is effective and safe for LDLc reduction especially in patients discharged after an ACS.

Funding Acknowledgement

Type of funding sources: None.

The value of GRACE risk score for predicting mortality in heart failure patients admitted with non-ST elevation acute coronary syndrome

Background

Acute coronary syndrome (ACS) in heart failure (HF) patients has not been well studied yet.

Purpose

The main aims of this study were to compare the characteristics and outcomes of Non-ST elevation ACS (NSTACS) in patients with and without prior HF, and to assess the GRACE risk score performance for risk stratification in both groups.

Methods

All consecutive patients (n=5661) admitted due to a NSTACS from November'2003 to November'2017 in two Spanish hospitals were retrospectively analysed. Patients were divided according to prior HF. As GRACE score predicts mortality in 6 months, logistic regression models were used to predict mortality in both groups. The different aspects of model performance were studied, including calibration and discrimination.

Results

Killip class, GRACE and CRUSADE scores were higher in HF-patients compared to patients without prior HF. Also, HF-patients had more complications (major bleeding, worsening HF, acute kidney injury) and higher mortality. Discrimination capacity of GRACE score to predict mortality at 6 months was slightly higher in non-HF patients (AUC 83.9% [81.6–86.2]) than in HF-patients [AUC 77.0% [70.1–83.8]) (Figure 1). The risk score calibration was acceptable for both groups [Brier scores were 0.139 (c-AUC 0,77) for HF-patients, and 0.046 (c-AUC 0.839) for non-HF patients]. Finally, HF-patients with lower GRACE scores had a higher predicted mortality than non-HF patients (Table 1).

Conclusions

We showed the potential utility of GRACE risk score in HF-patients admitted with NSTACS, expanding the indication of GRACE risk score for HF-patients as well. In fact, GRACE risk score not only keeps its accuracy, but it is even more robust in HF-patients than in non-HF patients.

Funding Acknowledgement

Type of funding sources: None. Figure 1Table 1

Trends in major bleeding events in patients with acute coronary syndrome

Background

Bleeding events incidence has gained a crucial role in acute coronary patients (ACS) due to its independent effect prognostic value.

Methods

We assessed the trend of in-hospital and first-year-after-discharge major bleeding events (MB) in all ACS admitted in a single center between January 2009 and Agoust 2019. MB was defined as those fitting definitions 3 or 5 of the BARC consortium. Patients were categorized as high-bleeding risk (HBR) if according to the 2019 Academic Research Consortium HBR consensus if they met at least one major or two minor criteria. Inclusion period was divided in 3 groups: 2009–2012 (n=884; 27.4%), 2013–2015 (n=1,047; 32.5%); 2016–2019 (n=1,294; 40.1%). Post-discharge MB was assessed by competing events regression models, taking all-cause mortality as a competing event, and results are presented as sub-hazard ratio (sHR).

Results

We included 3225 patients, mean age was 68.4 (29.7), 25.7% females, 1,108 32.1% had diabetes and 44.0% STEMI. Radial access was perfume in 92% of the angiographies in the 3 time-periods. A significant decrease in dual antiplatelet treatment (DAPT) before angiography was noted (69.0%; 56.3%; 53.6%; p=0.001) with a decreasing pattern in clopidogrel and increase in ticagrelor and prasugrel. A total of 1,591 (46.2%) were categorized as HBR patients. A non-significant trend to higher incidence of in-hospital MB was noted through the 3 time periods: 1.39%; 1.43%; 2.55% (p=0.056) and it was mainly driven by the significant increase only in HBR patients: 2.21%; 3.55%; 6.26% (p=0.003). Multivariate analysis identified age (OR: 1.06 95% CI 1.03–1.08, p<0.001) and the time period 2016–2019 (OR: 1.96 95% CI 1.01–3.84; p=0.031) as main variables associated to higher in-hospital MB.

In contrast, postdischarge MB did not change overtime (p=0.155) and trends were the same in HBR and non-HBR patients (figure). The competing risk regression analysis, adjusted by age, gender, previous cardiovascular disease, revascularization and medical treatments, identified that the leading factors for postdischarge MB were diabetes (sHR: 1.37; 95% CI 1.01–2.92), time-period 2016–2019 (sHR: 1.52; 95% CI 1.01–2.30), HBR patient (sHR: 1.91; 95% CI 1.28- 2.87) and and previous heart failure (sHR: 2.26; 95% CI 1.264.40)

Conclusions

This continuous 10-year registry highlights the increasing trend of in-hospital mainly driven by the incidence in HBR patients. In contrast, postdischarge MB increased in all patients.

Funding Acknowledgement

Type of funding sources: None. Post-discharge MB incidence

Clinical benefit of direct oral anticoagulants vs. vitamin-K antagonist in octogenarians with atrial fibrillation

Background

Direct oral anticoagulants (DOACs) have demonstrated to the be more effective and safer than vitamin-K antagonist (VKA) for stroke prevention in patients with atrial fibrillation (AF). AF prevalence increases exponentially with age but octogenarians were underrepresented in clinical trials.

Methods

We performed a metanalysis with currently available studies that assessed the effect of DOACS vs. VKA in patients with age ≥80 and AF after performing a systematic search. The primary endpoints analyzed were stroke and all-cause death. Secondary endpoints were major bleeding, according to each study definitions, intracranial bleeding and gastrointestinal (GI) bleeding. The raw numbers of incident end-points reported in each study were used. A random effects model was selected because significant heterogeneity was observed; sensitivity analyses tested potential sources of heterogeneity, publication bias and the small-study effect.

Results

A total of 147,067 patients from 16 studies were included, 71,913 treated with DOACs and 75,154 with VKA. Inclusion criteria for the study was age ≥80 in 13 studies, ≥85 in two and ≥90 in one. Mean age of patients included all the studies was 86.2 (2.6) years. According to the study drug, 34,448 received rivaroxaban; 20,295 apixaban; 14,641 dabigatran, 492 edoxaban and; 2,037 any DOAC. No difference in mean age was observed according to the study drug.

Stroke incidence was available in the 16 studies. DOACs treatment was associated to 28% reduction of stroke (RR: 0.72 95% CI 0.63–0.82; p<0.001) (figure). All-cause mortality could be assessed in 12 studies and DOACs treatment was associated to 18% in mortality (RR: 0.82, 95% CI 0.70–0.96; p=0.012) (figure). DOACs treatment was not associated to reductions in major bleeding (RR: 0.85, 95% CI 0.69–1.04; p=0.108); in contrast, the highest effect of DOACs treatment was a 43% reduction of intracranial bleeding (RR: 0.47, 95% CI 0.36–0.60; p<0.001) (Figure 4). Finally, DOACs treatment was not associated higher of GI bleeding risk (RR: 1.08, 95% CI 0.76–1.53; p=0.678). Metaregression identified inclusion site in North-America (p<0.001), the ELDERCARE-AF results (p=0.023), control arm different than VKA (p=0.006) and the prevalence of hypertension (p=0.042) were outlined as main sources of heterogeneicity for stroke risk reduction. The type of DOAC was the main source of source of heterogeneicity for all-cause mortality (p<0.001) and major bleeding (p=0.03) risk reduction. No small-study effect was found for any endpoint except for intracranial bleeding (Harbor test p=0.029).

Conclusions

Treatment with DOACs in octogenarians reduces the incidence of stroke, all-cause mortality and intracranial bleeding as compared to VKA.

Funding Acknowledgement

Type of funding sources: None.

Prognostic benefit from an early invasive strategy in patients with non ST elevation acute coronary syndrome (NSTEACS): evaluation of the new risk stratification in the NSTEACS European guidelines

Objectives

The objective of our work is to evaluate the prognostic benefit of an early invasive strategy in patients with high-risk NSTACS according to the recommendations of the 2020 clinical practice guidelines during long-term follow-up.

Methods

This retrospective observational study included 6454 consecutive NSTEACS patients. We analyze the effects of early coronary angiography (<24 h) in patients with: (a) GRACE risk score >140 and (b) patients with “established NSTEMI” (non ST-segment elevation myocardial infarction defined by an increase in troponins) or dynamic ST-T-segment changes with a GRACE risk score <140.

Results

From 2003 to 2017, 6454 patients with “new high-risk NSTEACS” were admitted, and 6031 (93.45%) of these underwent coronary angiography. After inverse probability of treatment weighting, the long-term cumulative probability of being free of all-cause mortality, cardiovascular mortality and MACE differed significantly due to an early coronary interven- tion in patients with NSTEACS and GRACE >140 [HR 0.62 (IC 95% 0.57–0.67), HR 0.62 (IC 95% 0.56–0.68), HR 0.57 (IC 95% 0.53–0.61), respectively]. In patients with NSTEACS and GRACE <140 with established NSTEMI or ST/T-segment changes, the benefit of the early invasive strategy is only observed in the reduction of MACE [HR 0.62 (IC 95% 0.56–0.68)], but not for total mortality [HR 0.96 (IC 95% 0.78–1.2)] and cardiovascular mortality [HR 0.96 (IC 95% 0.75–1.24)].

Conclusions

An early invasive management is associated with reduced all-cause mortality, cardiovascular mortality and MACE in NSTEACS with high GRACE risk score. However, this benefit is less evident in the subgroup of patients with a GRACE score <140 with established NSTEMI or ST/T-segment changes.

Funding Acknowledgement

Type of funding sources: None.

Gender differences low-density lipoprotein cholesterol reduction with PCSK9 inhibitors in real world patients

Background

Monoclonal antibodies that inhibit the proprotein convertase subtilisin/kexin type 9 (PCSK9) reduce low-density lipoprotein cholesterol (LDLc) by 55%, regardless of baseline treatments, and are supposed to have a homogenous effect. We tested possible gender differences in a large multicenter registry of real-world patients treated with PCSK9 inhibitors.

Methods

Multicentre and retrospective registry of patients treated with PCSK9 inhibitors from 14 different hospitals from Spain. Before and on-treatment LDLc cholesterol was recorded as well as medical treatments, clinical indication and clinical features.

Results

A total of 562 patients were analysed, mean age 60.2 (9.6) years and 79.2% males. Most frequent indication for PCSK9 inhibitor treatment was established cardiovascular disease (CVD) with LDLc >100 mg/dl (58.1%) followed by familial hypercholesterolemia (23.4%) and statin intolerance (18.5%). Indications other than CVD were more frequent in women (53.3% vs. 39.1%; p=0.03). Women were more frequently ezetimibe (67.5% vs. 50.6%; p=0.001) before PCSK9 treatment; although no gender differences in statin use was observed (78.6% vs. 83.6%; p=0.93) in the whole cohort it was significantly lower in patients with coronary heart disease (91.4% vs. 98.9%; p=0.005). Before treatment LDLc was 148.7 (50.1) mg/dl and it was higher women vs. men (160.3 (59.3) vs. 145.6 (47.0); p=0.005). Evolocumab was initiated in 318 (56.6%) patients; 229 (40.7%) alirocumab 75 mg and 15 (2.7%) alirocumab 150 mg. No gender differences in PCSK9 inhibitors drug or dose were observed.

Median time to second blood determination were 187.5 (IQR 101–242) days. Mean on-treatment LDLc was 66.7 (46.4) mg/dl and it was also higher in women vs. men (84.4 (58.6) vs. 61.9 (41.3); p<0.001). Mean LDLc reduction was 54.7% but it was higher in men as compared to women (57.0% vs. 46.1%; p=0.0003). Higher LDLc reductions were also observed in patients with CVD as compared to the other 2 indications (57.1% vs. 47.3%; p=0.002). Moreover, LDLc reduction with PCSK9 inhibitors treatment was also higher in men vs women among patients with CVD (58.9% vs. 48.0%; p=0.04)

Conclusions

This multicentre and retrospective registry of real-world patients treated with PCSK9 inhibitors highlights significant gender differences in LDLc reduction.

Funding Acknowledgement

Type of funding sources: None.

The real-world cost and health resource utilization associated to the CNIC-polypill compared to usual care

Background

Cardiovascular (CV) polypills have been defined as scalable strategies for CV prevention. Nonetheless, their impact on health systems from an economic perspective has been questioned. The NEPTUNO study has evaluated the effectiveness, the healthcare resources utilization (HRU) and the economic impact of the CNIC-polypill - aspirin (ASA) 100mg, atorvastatin (A) 20/40mg and ramipril (R) 2,5/5/10mg – compared to usual care in a real-life clinical setting in Spain.

Methods

The NEPTUNO study is a retrospective, non-interventional analysis of an anonymized medical history dataset covering patients contained in the BIG-PAC administrative database in the years 2015–2018. Patients at age ≥18 years with medical history of previous CV disease were allocated in 4 different cohorts according to their therapy: (1) CNIC-polypill (case cohort), (2) identical mono-components (ASA,R,A), (3) equipotent medication and (4) usual care (control cohorts) and were followed for 2 years. To ensure comparability the cohorts a propensity score matching was performed. Direct all-cause HRU, including inpatient stay, outpatient visits, emergency room visits, rehabilitation, testing and medical treatment, were registered. Total direct medical costs were computed based on unit costs (€, 2020) assigned to each HRU item and were expressed on a per patient (PP) basis. Indirect costs where estimated based on registered productivity loss and the interprofessional average salary.

Results

8,946 patients were recruited. After PSM, each of the four study cohorts consisted of 1,614 patients. There was acceptable comparability between the study cohorts (balance). The mean age was 63.3 years and 60.4% were men. Cohort 1 compared with the control cohorts 2, 3 and 4 showed a significant reduction in HRU on a per patient average for all items (table), specifically in visits to primary care (16.6 vs. 18.7, 18.9 and 21.0; p<0.001), visits to specialists (5.0 vs. 6.2, 6.5 and 7.3; p<0.001), percentage of patients hospitalized (16.5% vs. 19.8%, 21.9% and 24.0%; p<0.001) and days of hospitalization (2.3 vs. 3.4, 3.7 and 4.0; p<0.001), respectively. The total cost per patient with the CNIC-Polypill compared to monotherapy, equivalents and other treatments, corrected for covariates (ANCOVA), was significantly lower (€4,668 vs. €5,587, €5,682 and €6,016; p<0.001), representing a 16.5%, 17.8% and 22.4% reduction in total costs, respectively. Differences were also observed in healthcare costs, while in non-healthcare costs (loss of labor productivity) the differences were not significative (table).

Conclusion(s)

The results of our analysis demonstrate that the use of the CNIC-polypill results in a significantly lower HRU compared to control cohorts as well as a significantly lower total cost and direct medical costs. This data could support the sustainability and scalability of the polypill strategy.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Unrestricted grant from Ferrer Lab, Spain

Is it justified to remove the intermediate risk group in the latest European guidelines for NSTEACS?

Background

Risk stratification in patients with non-ST elevation acute coronary syndrome (NSTEACS), becomes a priority after its diagnosis, due to the fact that it gives us information about prognosis and has crucial implications. The latest guidelines of European Society of Cardiology (ESC) suggest a new proposal of risk stratification dividing patients in three different groups: “low”, “high” and “very high risk”. Thus, they remove the intermediate risk group that defended the previous guidelines (2015).

Purpose

Our aim was to identify an intermediate risk group following the recommendations of the previous guidelines about risk stratification. We believe that the risk stratification in four groups if more accurate that the latest proposed in 2020 in three groups, because the “intermediate risk group” has a different prognosis that the subgroup nowadays considered “low risk”.

Methods

We included a cohort of 7 597 patients with NSTEACS admitted in two different Cardiology departments between 2003 and 2017 with 4,4±2,7 mean years of follow-up. Subsequently, a classification of the patients in four different risk groups was made following the 2015 guidelines and events during follow-up was assigned in the next categories:first adverse major cardiovascular event (MACE),all-cause mortality and cardiovascular mortality.

Results

Stratified analysis brought up that patients included in the intermediate risk group, had a different prognosis to the categories of “low” and “high risk” patients and we obtained the following results:

Mean incidence rate for total mortality measured in cases per 100 person-year [confidence interval (CI 95%)] was 1.96; for “low risk” patients CI95% 1.30–2.95, “intermediate risk” 3.91; (CI95% 3.28–4.57), “high risk” 4.94; CI95% 4.87–5.21 and “very high risk” 8.74; CI95% 7.75- 9.85.

Incidence rate for cardiovascular mortality for “low”, “intermediate”, “high” and “very high” was 1.02; (CI95% 0.58–1.18); 2.64 (CI95% 2.13–3.26); 3.32 (CI95% 3.11–3.55) and 6.71 (CI95% 4.84–7.69), respectively.

Using Cox analysis, the “intermediate risk group” (refference), still achieved statistical significance. Results expressed in hazard ratio demonstrated that:

Conclusion

These findings suggest that the four categories proposal could have better ability for risk stratification in NSTEACS patients and make us doubt about the new three groups classification displayed in the current ESC guidelines, particularly the “intermediate risk” group exclusion that would be reassessed as “low risk”.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): No funding sources.

Clinical outcomes in percutaneous coronary interventions with polymer-free vs. durable-polymer stents: a metanalysis of randomized clinical trials

Background

Polymer-free (PF) stents were designed as an alternative to durable-polymer (DP) drug-eluting stents to minimize the time on dual antiplatelet treatment for patients at high-risk of bleeding. Nonetheless, the efficacy and safety of PF vs. DP stents in patients undergoing percutaneous coronary intervention (PCI) remain controversial.

Methods

We performed a metanalysis with currently available studies that assessed the effect of PF-stents vs. DP-stents after performing a systematic search. The endpoints analyzed were all-cause death, myocardial infarction, target lesion revascularization (TLR) and probable or definite stent thrombosis. The raw numbers of incident end-points reported in each study were used. We performed analyses in short and long term (<1 or >1 year follow-up) studies.

Results

We included 12464 patients from 8 studies (5 short-term and 3 long-term): 6723 treated with PF-stents and 5741 with DP stents. Females represented 23.3% (n=3284) and 33.7% (n=4202) were included in the setting of acute coronary syndromes. As shown in the figure, PF-stents were associated to lower incidence of all-cause mortality (HR: 0.91 95% CI 0.84–0.98; p=0.016) and TLR (HR: 0.88 95% CI 0.80–0.96; p=0.003). No differences were observed in the risk of cardiovascular death (HR: 0.96 95% CI 0.86–1.06 p=0.415), myocardial infarction (HR: 0.90 95% CI 0.80–1.01; p=0.061) or probable-definite stent thrombosis (HR: 0.92 95% CI 0.74–1.14; p=0.447). Finally, no differences in the primary end-point (HR: 0.92 95% CI 0.83–1.03; p=0.143) were detected with PF-stents vs. DP-stents. No significant heterogenicity was observed in any of the endpoints, except for the incidence of stent thrombosis.

Conclusions

Under current PCI techniques the use of PF-stent might be associated to better outcomes, especially in terms of all-cause mortality and TLR.

Funding Acknowledgement

Type of funding sources: None.

BET inhibition increases βIII-tubulin expression and sensitizes metastatic breast cancer in the brain to vinorelbine

Metastases from primary breast cancer result in poor survival. βIII-tubulin (TUBB3) has been established as a therapeutic target for breast cancer metastases specifically to the brain. In this study, we conducted a systematic analysis to determine the regulation of TUBB3 expression in breast cancer metastases to the brain and strategically target these metastases using vinorelbine (VRB), a drug approved by the U.S. Food and Drug Administration (FDA). We found that human epidermal growth factor receptor 2 (HER2) signaling regulates TUBB3 expression in both trastuzumab-sensitive and trastuzumab-resistant neoplastic cells. We further discovered that bromodomain and extra-terminal domain (BET) inhibition increases TUBB3 expression, rendering neoplastic cells more susceptible to apoptosis by VRB. Orthotopic xenograft assays using two different breast cancer cell models revealed a reduction in tumor volume with BET inhibition and VRB treatment. In addition, in vivo studies using a model of multiple brain metastasis (BM) showed improved survival with the combination of radiation + BET inhibitor (iBET-762) + VRB (75% long-term survivors, P < 0.05). Using in silico analysis and BET inhibition, we found that the transcription factor myeloid zinc finger-1 (MZF-1) protein binds to the TUBB3 promoter. BET inhibition decreases MZF-1 expression and subsequently increases TUBB3 expression. Overexpression of MZF-1 decreases TUBB3 expression and reduces BM in vivo, whereas its knockdown increases TUBB3 expression in breast cancer cells. In summary, this study demonstrates a regulatory mechanism of TUBB3 and provides support for an application of BET inhibition to sensitize breast cancer metastases to VRB-mediated therapy.

RANK links senescence to stemness in the mammary epithelia, delaying tumor onset but increasing tumor aggressiveness

Rank signaling enhances stemness in mouse and human mammary epithelial cells (MECs) and mediates mammary tumor initiation. Mammary tumors initiated by oncogenes or carcinogen exposure display high levels of Rank and Rank pathway inhibitors have emerged as a new strategy for breast cancer prevention and treatment. Here, we show that ectopic Rank expression in the mammary epithelia unexpectedly delays tumor onset and reduces tumor incidence in the oncogene-driven Neu and PyMT models. Mechanistically, we have found that ectopic expression of Rank or exposure to Rankl induces senescence, even in the absence of other oncogenic mutations. Rank leads to DNA damage and senescence through p16/p19. Moreover, RANK-induced senescence is essential for Rank-driven stemness, and although initially translates into delayed tumor growth, eventually promotes tumor progression and metastasis. We uncover a dual role for Rank in the mammary epithelia: Rank induces senescence and stemness, delaying tumor initiation but increasing tumor aggressiveness.

Polyamines drive myeloid cell survival by buffering intracellular pH to promote immunosuppression in glioblastoma

Glioblastoma is characterized by the robust infiltration of immunosuppressive tumor-associated myeloid cells (TAMCs). It is not fully understood how TAMCs survive in the acidic tumor microenvironment to cause immunosuppression in glioblastoma. Metabolic and RNA-seq analysis of TAMCs revealed that the arginine-ornithine-polyamine axis is up-regulated in glioblastoma TAMCs but not in tumor-infiltrating CD8+ T cells. Active de novo synthesis of highly basic polyamines within TAMCs efficiently buffered low intracellular pH to support the survival of these immunosuppressive cells in the harsh acidic environment of solid tumors. Administration of difluoromethylornithine (DFMO), a clinically approved inhibitor of polyamine generation, enhanced animal survival in immunocompetent mice by causing a tumor-specific reduction of polyamines and decreased intracellular pH in TAMCs. DFMO combination with immunotherapy or radiotherapy further enhanced animal survival. These findings indicate that polyamines are used by glioblastoma TAMCs to maintain normal intracellular pH and cell survival and thus promote immunosuppression during tumor evolution.

The Network of Cytokines in Brain Metastases

Brain metastases are the most common of all intracranial tumors and a major cause of death in patients with cancer. Cytokines, including chemokines, interferons, interleukins, lymphokines, and tumor necrosis factors are key regulators in the formation of brain metastases. They regulate the infiltration of different cellular subsets into the tumor microenvironment and affect the therapeutic outcomes in patients. Elucidating the cancer cell-cytokine interactions in the setting of brain metastases is crucial for the development of more accurate diagnostics and efficacious therapies. In this review, we focus on cytokines that are found in the tumor microenvironment of brain metastases and elaborate on their trends of expression, regulation, and roles in cellular recruitment and tumorigenesis. We also explore how cytokines can alter the anti-tumor response in the context of brain metastases and discuss ways through which cytokine networks can be manipulated for diagnosis and treatment.

28 Evaluation invitro of two protocols of vitrification from alpaca (Vicugna pacos) embryos

The reproductive efficiency of South American camelids as the alpaca is low, with a few number of animals having a good genetic characteristic. The transfer of cryopreserved embryos has great potential to disseminate valuable genetic, but the suitable protocol for such cryopreservation still needs to be developed. In this study, two protocols of vitrification of alpaca embryos were tested. Day 6.5 post-mating, embryos (n=66) were recovered from 14 female alpacas through a non-surgical technique and classified according to the characteristics of old world camelids reported by Skidmore et al. 2004 (Reprod. Fertil. Dev. 16, 605–609). Only quality 1 and 2 embryos were used for the study. They were placed together in 50-µL drops of holding medium for 30min and transferred to a 100-µL drop of equilibration solution 1, consisting of 7.5% (v/v) ethylene glycol (EG) + 0.25M sucrose. After 1min, embryos were transferred to equilibration solution 2, consisting of 15% (v/v) EG + 0.5M sucrose. After 2min, embryos were transferred into 2 consecutive drops of vitrification solutions A [SA: 30% (v/v) EG + 1M sucrose] for 20s each, then in 2 other drops of vitrification solution B [SB: 30% (v/v) EG + 3% glycerol + 1M sucrose] for 20s each. Thereafter, embryos were quickly loaded into open pulled straws (OPS) in a volume of 10µL and then plunged into liquid nitrogen. For warming, the OPS were held in air for 5s and subsequently thawed at 37°C for 50s. Straws were emptied into 1mL of prewarmed holding medium solution (HMS1) containing 1M sucrose for wash and the thawed blastocysts were transferred into a second 1mL of prewarmed HMS1. After 5min incubation at 37°C, the blastocysts were transferred into 1mL of warmed Holding medium solution 2 (HMS2) containing 0.5M sucrose maintained at room temperature (∼24°C) for evaluation. Data were analysed by the Chi-squared test. Post-thaw embryo expansion results were 81.3% and 58.8% for SA and SB (P&lt;0.05), respectively. Post-thaw embryo quality (1 and 2) were found at 62.5% and 29.1% with SA and SB, respectively (P&lt;0.05). In conclusion, the vitrification of alpaca embryos with the ethylene glycol:sucrose solution results in better post-thaw outcomes than the ethylene glycol:sucrose:glycerol. Further experiments with embryo transfer are needed. This research was funded by FONDECYT project no. 149-2017.

Sex-related differences in mortality and heart failure after nstacs. the cardio chus-hsuj registry

Introduction and objectives

A sex-specific analysis of cardiovascular outcomes afternon-ST segment elevation acute coronary syndrome (NSTACS) using a large contemporary cohort of patients from two Spanish tertiary hospitals.

Methods

This retrospective observational study included 5686 consecutive NSTACS patients between the years 2003 and 2017. We performed a propensity score matching to obtain a well-balanced subset of patients, resulting in 3120 patients. Cox regression models performed survival analyses once proportional risk test were verified.

Results

Among the study participants, 1572 patients (27.6%) were women. The median follow-up was 60.0 months (standard deviation 32 months). Women had higher risk of cardiovascular mortality compared with men (OR (Odds ratio) 1.27, CI (confidence interval) 95% 1.08–1.49) and heart failure (HF) hospitalization (OR 1.39, CI 95% 1.18–1.63), but a similar risk of all-cause mortality (OR 1.10, CI 95% 1.08–1.49). After a propensity score matching, women were associated with a significant reduction in the risk of total mortality (OR 0.77, CI 95% 0.65–0.90) with a similar risk of cardiovascular mortality (OR 0.86, CI 0.71–1.03) and HF hospitalization (OR 0.92, CI 95% 0.68–1.23). After adjustment for baseline characteristics, the risks of all-cause mortality and cardiovascular mortality were less in women; although the risk of HF was similar among sexes.

Conclusions

Women are at similar risk to develop early and late HF admissions after NSTACS, and have better survival compared with male, with lower risk of all-cause mortality and cardiovascular mortality.

Cumulative risk according to gender

Funding Acknowledgement

Type of funding source: None

Validation of the Zwolle score for selection of very low-risk STEMI patients treated with primary angioplasty

Background

The Zwolle risk score was designed to stratify the actual in-hospital mortality risk of ST-elevation myocardial infarction (STEMI) patients treated with primary percutaneous coronary intervention (p-PCI) but, also, for decision-making related to patients location in an intensive care unit or not. Since the GRACE score continues being the gold-standard for individual risk assessment in STEMI in most institutions we assessed the specificity of both scores for in-hospital mortality.

Methods

We assessed the accuracy of Zwolle risk score for in-hospital mortality estimation as compared to the GRACE score in all patients admitted for STEMI in 3 tertitary hospitals. Patients with Zwolle risk score &lt;3 would qualify as “low risk”, 3–5 as “intermediate risk” and ≥6 as “high risk”. Patients with GRACE score &lt;140 were classified as low-risk. Specificity, sensitivity and classification were assessed by ROC curves and the area under the curve (AUC).

Results

We included 4,446 patients, mean age 64.7 (13.6) years, 24% women and 39% with diabetes. Mean GRACE score was 157.3 (4.9) and Zwolle was 2.8 (3.3). In-hospital mortality was 10.6% (471 patients). Patients who died had higher GRACE score (218.4±4.9 vs. 149.6±37.5; p&lt;0.001) and Zwolle score (7.6±4.3 vs. 2.3±2.18; p&lt;0.001); a statistically significant increase of in-hospital mortality risk, adjusted adjusted by age, gender and revascularization, was observed with both scores (figure). A total of 1,629 patients (40.0%) were classified as low risk by the GRACE score and 2,962 (66.6%) by the Zwolle score; in-hospital mortality was 1.6% and 2.7%, respectively. Moreover, the was a significant increase of in-hospital mortality rate according to Zwolle categories (2.7%; 13.0%; 41.6%)The AUC of both score was the same (p=0.49) but the specificity of GRACE score &lt;140 was 43.1% as compared to 72.6% obtained by Zwolle score &lt;3; patients accurately classified was also lower with the GRACE score threshold (48.8% vs. 73.7%).

Conclusions

Selection of low-risk STEMI patients treated with p-PCI based on the Zwolle risk score has higher specificity than the GRACE score and might be useful for the care organization in clinical practice.

Funding Acknowledgement

Type of funding source: None

Stroke and myocardial infarction prevention with GLP1 analogues in high or very-high cardiovascular risk diabetic patients

Background

Patients with established cardiovascular disease have an increased risk of stroke, even in the absence of atrial fibrillation. Several trials have analysed the effect of glucagon-like peptide-1 receptor (GLP1) analogues on cardiovascular events in patients with high cardiovascular disease.

Methods

We performed a metanalysis with all randomized clinical trial that compared a GLP1 analogue vs. placebo. Primary endpoint was stroke incidence, including ischemic and haemorrhagic aetiology, assessed by fixed-effect model.

Results

We identified 7 trials that compared a GLP analogue (albiglutide, dulaglutide, exenatide, liraglutide, lixinatide or semaglutide). A total of 56,004 patients were included in the analysis, 27977 treated with a GLP1 analogue. Mean age of the patients was 63.9 (2.1) years, 25,398 (45.4%) patients had cardiovascular disease.

A total of 1,568 strokes were reported, 711 in patients receiving a GLP analogue and 857 in control arm; treatment with a GLP1 analogue reduced the incidence of stroke by 147% (RR: 0.83, 95% CI 0.75–0.92; p&lt;0.001). No heterogeneity between trials was observed (p=0.835). Globally, treatment with GPL1 analogues reduced the incidence of stroke or myocardial infarction by 11% (RR: 0.89, 95% CI 0.84–0.94; p&lt;0.01)

A total of 3,192 cases of myocardial infarction were reported: 1,524 in patients treated with GLP1 analogues and 1,668 with placebo. Treatment with GLP1 analogues reduce the incidence of myocardial infarction by 8% (RR: 0.92, 95% CI 0.86–0.98; p=0.010)

Conclusions

Treatment with a GLP1 analogue reduced the incidence of stroke by 17% and myocardial infarction by 8%, in different trials involving high or very-high risk patients with diabetes.

Forest plot: stroke and MI

Funding Acknowledgement

Type of funding source: None

Acute coronary syndrome patients with two minor high-bleeding risk criteria have the same bleeding rate that patients with one major criteria

Background

In 2019 the Academic Research Consortium of high-bleeding risk (ARC-HBR) proposed a new and binary definition of high-bleeding risk (HBR) patients based on the presence of 1 major or 2 minor criteria.

Methods

Prospective study of all consecutive patients admitted for ACS in two different centers. We analyzed bleeding incidence in patients with 1 major criteria (1MC) vs. 2 minor criteria (2mC) using the 2019 ARC-HBR consensus. Bleeding events were collected according those fitting definitions 3 or 5 of the BARC consortium.

Results

We included 8,724 patients included and 40.9% we classified as HBR; 20.9% for 1MC and 20.0% for 2mC. In-hospital mayor bleeding rate was 8.6%; no-HBR patients had 0.3%, 2mC 15.1% and 1MC 29.7% (p&lt;0.001 for the comparison). In contrast, the statistically highest in-hospital mortality was observed in patients with 2mC (11.4%), followed by patients with 1MC (8.0%) and no-HBR patients (2.0%).

During follow-up (median time 57.8 months) all-cause mortality rate was 21.0% and cardiovascular dead 14.2%. The incidence of post-discharge major bleeding was 10.5%. No-HBR patients had the lowest bleeding rate (7.4%) and no difference was observed in patients with 1MC (14.6%) or 2mC (15.8%) (figure). The multivariate analysis, adjusted by age, gender, medical treatment, atrial fibrillation and revascularization and considering all-cause mortality as competing risk, showed independent association of 1MC (sHR: 1.46, 95% 1.22–1.75) and 2mC (sHR: 1.31, 95% CI 1.05–1.63) with post-discharge major bleeding.

Conclusions

HBR patients according to the 2019 ARC-HBR containing 2mC or 1MC are at similar and higher risk of in-hospital or post-discharge bleeding events

Funding Acknowledgement

Type of funding source: None

HIF-1α Is a Metabolic Switch between Glycolytic-Driven Migration and Oxidative Phosphorylation-Driven Immunosuppression of Tregs in Glioblastoma

The mechanisms by which regulatory T cells (Tregs) migrate to and function within the hypoxic tumor microenvironment are unclear. Our studies indicate that specific ablation of hypoxia-inducible factor 1α (HIF-1α) in Tregs results in enhanced CD8⁺ T cell suppression versus wild-type Tregs under hypoxia, due to increased pyruvate import into the mitochondria. Importantly, HIF-1α-deficient Tregs are minimally affected by the inhibition of lipid oxidation, a fuel that is critical for Treg metabolism in tumors. Under hypoxia, HIF-1α directs glucose away from mitochondria, leaving Tregs dependent on fatty acids for mitochondrial metabolism within the hypoxic tumor. Indeed, inhibition of lipid oxidation enhances the survival of mice with glioma. Interestingly, HIF-1α-deficient-Treg mice exhibit significantly enhanced animal survival in a murine model of glioma, due to their stymied migratory capacity, explaining their reduced abundance in tumor-bearing mice. Thus HIF-1α acts as a metabolic switch for Tregs between glycolytic-driven migration and oxidative phosphorylation-driven immunosuppression.

Miska et al. demonstrate that regulatory T cell (Treg)-specific depletion of HIF-1α promotes enhanced immune suppression at the cost of migration under hypoxic conditions. Within the hypoxic brain-tumor environment, Tregs are uniquely able to metabolize extracellular free fatty acids to promote their immunosuppressive functionality, which can be targeted in vivo.

108 Use of seminal plasma as ovulation inductor in alpacas (Vicugna pacos) embryo recipient and its effect on pregnancy rate

Alpacas, like other camelids, are classified as induced ovulators because an external stimulus is required for the occurrence of ovulation. Recent studies have identified the β-nerve growth factor (β-NGF), a protein present in the seminal plasma (SP), as responsible for inducing ovulation in this species and having potent luteotropic function. We speculate that SP can be used in reproductive biotechnologies, such as embryo transfer (ET), to increase the number of genetically superior animals produced in breeding programs. The objective of this study was to evaluate the effect of inducing ovulation with SP or a gonadotrophin-releasing hormone (GnRH) analogue on pregnancy rate in recipients of an alpaca ET program. Semen from 5 adult male alpacas was collected with an artificial vagina and diluted 1:1 (v/v) with phosphate-buffered saline (PBS; Gibco-BRL). The diluted semen was centrifuged for 30min at 1200g, and the supernatant or SP was decanted and examined for absence of sperm. Then, the SP was centrifuged again for 20min at 1200×g. The SP was stored at −80°C until the use. Female alpacas (n=38; 6-8 years) with a body condition score of 2.5-3.5 (scale 1-5) were used for the experiment. Animals were evaluated daily by transrectal ultrasonography to determine the presence of a dominant follicle ≥7mm and randomly assigned to one of two groups: (1) GnRH (n=20), 0.04mg of Buserelin acetate IM, or (2) SP (n=18): 1.0mL of seminal plasma IM. Seven days after GnRH or SP treatment (Day 0) the recipients received a fresh embryo. Alpaca donors (n=18) were given GnRH (0.04mg IM) and treated 36h later with 700IU of equine chorionic gonadotropin (ECG). Donors were mated with fertile males 5 days after ECG (Day 0 of recipients), and embryos were recovered 7 days later. Embryos of similar quality were assigned to both groups and transferred nonsurgically to the uterine horn ipsilateral to the corpus luteum. Ultrasonography examinations were performed on Day 2 to confirm ovulation and Day 25 to determine pregnancy in all of the recipients. Data was analysed by chi-squared test. Ovulation rate was not different between groups (100% each). Pregnancy rate was 45% (9 out of 20) and 44% (8 of 18) in GnRH and SP groups, respectively (P=0.77). In conclusion, SP was effective to induce ovulation in alpacas and was able to produce a pregnancy rate similar to that of GnRH as an ovulation-inducing treatment. Thus, SP can be used as an alternative for ET programs in alpacas. Research was funded by the project Role of Seminal Plasma in Reproductive Physiology and Application of Biotechnologies in Camelids (149-2017-CIENCIACTIVA).

P1223Attributable risk proportion of uncontrolled low-density lipoprotein cholesterol in recurrent acute coronary syndromes

Background

Coronary heart disease is chronic condition that usually has recurrent events. Risk factors for incident coronary heart disease are well known conditions related to recurrences have not been clearly outlined. Attributable risk proportion (ARP) refers to the proportion of incident cases in subjects exposed to risk factors that are attributable to that risk factor so we analysed ARP in wide cohort of patients admitted for an acute coronary syndrome (ACS).

Methods

Cross-sectional analysis of all patients admitted in two hospitals between January 2006 and December 2016. ARP was calculated by the equation: prevalence in exposed – (prevalence in exposed/odds ratio). LDL uncontrolled was codified as >70 mg/dl in patients with previous cardiovascular disease; >100 mg/dl in patients with diabetes without previous cardiovascular disease or; >155 mg/dl in patients without cardiovascular disease.

Results

We included 7,518 patients, mean age 66.9 (12.9) years, 72.5% males, median GRACE score 143.2 (40.3) and 35.3% STEMI. Previous coronary heart disease total was present in 2,032 (23.2%) patients and they had statistically higher mean age (70.6±11.11 vs. 65.8±13.3), prevalence of diabetes (37.9% vs. 25.3%) and hypertension (72.9% vs. 53.3%) and lower smoking habit (15.5% vs. 30.9%). LDLc was lower in patients with previous coronary heart disease (90.3±33.8 vs. 111.7±38.1; p<0.01), as well as HDLc (33.5±14.29 vs. 35.9±35.5; p<0.01) and haemoglobin (13.5±3.7 vs. 14.0±2.4; p<0.01). Uncontrolled LDLc was present in 83.4% of the patients with previous coronary heart disease, in contrast to the 28.7% of patients without previous coronary heart disease; this resulted in an ARP of 13.8%. The ARP for diabetes and hypertension were 1.6% and 1.4%, respectively.

Conclusions

The proportion of attributable risk of uncontrolled LDL on recurrent ACS is 13.8% and, therefore, 1 out of every 7 recurrent ACS could be prevented by an accurate LDLc control.

P5503Long term prosnoctic benefit of complete revascularizaction in elderly non ST elevation myocardial infarction patients

Background

The benefit of complete or culprit vessel revascularization in elderly patients (>75 years) with Acute Coronary Syndrome without ST-segment elevation (NSTEMI), and multivessel disease (MVD) remains debated.

Purpose

We aimed to study the current long-term prognostic benefit of complete revascularization in an elderly population with NSTEMI and MVD.

Methods

We performed a retrospective cohort study of 1722 consecutive elderly NSTEMI patients. Baseline patient characteristics were examined and a follow-up period was established for the registry of death and first major cardiovascular event (MACE). We performed a propensity-matching analysis to draw up two groups of patients paired according to whether or not they had been completely revascularized. The prognostic value of the revascularization to predict events during follow-up was analyzed using Cox regression.

Results

Among the study participants, 30.4% (n=524) underwent complete revascularization and 69.6% (n=1198) had culprit vessel revascularization performed. Patients in these groups have different clinical and pharmacological profiles. After the propensity score analysis, the population was divided into two groups: complete revascularization (n=353) and culprit vessel revascularization (n=353).The median follow-up was 45.7 months. All cause mortality (52.1% vs 28.6%, p<0.001), cardiovascular mortality (39.1% vs 18.4%, p<0.001) and MACE rates were significantly higher in patients with incomplete revascularization compared with those with complete revascularization.

Kaplan-Meyer curves for main endpoints

Conclusion

In our study, the long-term benefit of complete revascularization in an elderly population with NSTEMI and MVD was observed.

P1759Elevated NT-pro BNP predicts Heart Failure re-hospitalizations after an acute coronary syndrome

Background

NT pro-BNP is a well-established biomarker of tissue congestion and has prognostic value in patients with heart failure (HF) and, also, with acute coronary syndrome (ACS). Nonetheless, there is scarce evidence on the predictive capacity of NT pro-BNP for HF re-admission after an ACS.

Objective

To test whether elevated values of NT pro-BNP can predict subsequent hospitalizations for HF in patients discharged after an ACS.

Methods

We performed a prospective study of all patients discharged after an ACS in a single center. HF re-admission was analysed by competing risk regression, taking all-cause mortality as a competing event, and results are presented as sub-Hazard Ratio (sHR); recurrent hospitalizations were tested by negative binomial regression and results are presented as incidence risk ratio (IRR).

Results

We included 1,679 patients, mean age 70.1 (29.7) year, 71.9% males, 41.4% STEMI and mean GRACE score 151.7 (44.4). Median NT pro-BNP was 948.2 pg/ml (IQ range 274.5–2923) and patients were divided in <300U (27.0%), 300–600 pg/ml (13.4%), 600–1000 pg/ml (10.8%) and >1000 pg/ml (46.7%) A total of 132 (5.9%) died within hospitalization and follow-up was available 98% of the patients, with a median follow-up of 33 months (IQ range 16–59). A total of 220 patients (13.1%) had at least one hospital re-admission of HF and 126 (7.5%) had more than one re-hospitalization for HF. Patients with NT pro-BNP had higher un-adjusted HF re-admissions (22.2% vs. 4.4%; p<0.01). Cardiovascular mortality increased significantly in each category of NT pro-BNP (3.8%; 8.0%; 7.7%; 18.5%) as well as all-cause mortality (0.1%; 12.4%; 11.6%; 25.3%), first HF readmission (2.7%; 7.1%; 5.5%; 23.5%); patients with NT pro-BNP had higher rates of recurrent HF readmissions: 11.6/1000 vs. 2.4/1000 patients/years (p<0.01). Multivariate analyses, adjusted by age, gender, GRACE score, left ventricle ejection fraction, revascularization and medical treatments at discharge, identified that NT pro-BNP >1000 pg/ml was associated to HF re-hospitalization (sHR: 2.60 95% CI 1.12–5.95) and recurrent hospitalizations (IRR: 1.10 95% CI 1.04–1.14).

Conclusions

NT pro-BNP >1000 pg/ml is an accurate risk factor for first and recurrent HF rehospitalisations after an ACS.

5132Effect of PCSK9 inhibitors treatment on acute coronary syndrome and stroke incidence: a metanalysis of currently available clinical trials

Background

Proprotein convertase subtilisin–kexin type 9 (PCSK9) inhibitors have demonstrated to induce large reductions in low-density lipoprotein cholesterol (LDLc) and major cardiovascular events but none of the studies was statistically powered to demonstrate reductions in specific endpoints rather than a combined end-point of major cardiovascular events.

Methods

We performed an intention-to-treat meta-analysis in line with recommendations from the Cochrane Collaboration and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement using currently available studies involving PCSK9 inhibitors. The endpoint assessed were acute coronary syndrome (ACS) and stroke.

Results

We included 81,544 patients, 41,147 treated with a PSCK9 inhibitors: 17,179 with evolocumab; 13,718 with bococizumab and 10,250 with alirocumab (table 1). A total of 1,316 ACS were registered in the treatment group vs. 1,608 in controls, resulting in 18.0% reduction associated with PCSK9 treatment (figure 1). This result was reproduced exactly in the EBCT althougt a non-significant heterogeneity was detected (p=0.052). Metaregression analyses did not demonstrate the implication of the study (p=0.45), study drugs (p=0.26), age (p=0.89), hypertension (p=0.81) or diabetes (p=0.81) on such result.

Results on stroke incidence are presented in figure 2. PCSK9 inhibitors treatment resulted in a 24% reduction of stroke when all studies were analyzed together; heterogeneity was statistically significant (p=0.021) but it was not observed in the EBCT analysis where PCSK9 inhibitors were associated with 24% stroke incidence reduction.

Conclusions

The meta-analysis of currently available studies demonstrates that PCSK9 inhibitors treatment reduces the incidence of ACS by 18% and stroke by 24%.

FABP7 is a key metabolic regulator in HER2+ breast cancer brain metastasis

Overexpression of human epidermal growth factor receptor 2 (HER2) in breast cancer patients is associated with increased incidence of breast cancer brain metastases (BCBM), but the mechanisms underlying this phenomenon remain unclear. Here, to identify brain-predominant genes critical for the establishment of BCBM, we conducted an in silico screening analysis and identified that increased levels of fatty acid-binding protein 7 (FABP7) correlate with a lower survival and higher incidence of brain metastases in breast cancer patients. We validated these findings using HER2+ BCBM cells compared with parental breast cancer cells. Importantly, through knockdown and overexpression assays, we characterized the role of FABP7 in the BCBM process in vitro and in vivo. Our results uncover a key role of FABP7 in metabolic reprogramming of HER2 + breast cancer cells, supporting a glycolytic phenotype and storage of lipid droplets that enable their adaptation and survival in the brain microenvironment. In addition, FABP7 is shown to be required for upregulation of key metastatic genes and pathways, such as integrins-Src and VEGFA, and for the growth of HER2+ breast cancer cells in the brain microenvironment in vivo. Together, our results support FABP7 as a potential target for the treatment of HER2+ BCBM.

Current state of clinical trials in breast cancer brain metastases

Background

Breast cancer brain metastases (BCBM) are the final frontier in neuro-oncology for which more efficacious therapies are required. In this work, we explore clinical trials in BCBM, and determine the shortcomings in the development of new BCBM therapies to shed light on potential areas for enhancement.

Methods

On July 9, 2018, we searched ClinicalTrials.gov for all interventional and therapeutic clinical trials involving BCBM, without limiting for date or location. Information on trial characteristics, including phase, status, start and end dates, study design, primary endpoints, selection criteria, sample size, experimental interventions, results, and publications were collected and analyzed.

Results

Fifty-three trials fulfilled the selection criteria. Median trial duration across phases ranged between 3 and 6 years. More than half of the trials were conducted in the United States. Although 94% of the trials were in early phases (I-II), 20% of patients were in phase III trials. Two phase III trials were anteceded by phase II trials that were non-randomized; one reported positive results. Approximately one-third of the trials were completed, whereas 23% of trials were terminated early; mostly due to inadequate enrollment. Only 13% of all trials and 22% of completed trials had published results directly linked to their primary outcomes.

Conclusions

The low number of trials and accrual numbers, the lack of diversity, and the scarcity of published results represent the main troubles in clinical BCBM research. Optimization of BCBM trials is necessary to achieve effective therapies.

Local Application of Autologous Platelet-Rich Fibrin Patch (PRF-P) Suppresses Regulatory T Cell Recruitment in a Murine Glioma Model

The immunosuppressive microenvironment is one of the major factors promoting the growth of glioblastoma multiforme (GBM). Infiltration of CD4⁺CD25⁺Foxp3⁺ regulatory T cells (Tregs) into the tumor microenvironment plays a significant role in the suppression of the anti-tumor immunity and portends a dismal prognosis for patients. Glioma-mediated secretion of chemo-attractant C-C motif ligand 2 and 22 (CCL2/22) has previously been shown by our group to promote Treg migration in vitro. In this study, we show that a local implantation of platelet-rich fibrin patch (PRF-P) into the brain of GL261 glioma-bearing mice prolonged the survival of affected animals by 42.85% (p = 0.0011). Analysis performed on brain tumor tissue harvested from PRF-P-treated mice revealed a specific decrease in intra-tumoral lymphocytes with a preferential depletion of immunosuppressive Tregs. Importantly, co-culture of GL261 or chemo-attractants (CCL2/22) with PRF-P abrogated Treg migration. Pharmacological blockade of the CCL2/22 interaction with their receptors potentiated the inhibitory effect of PRF-P on Tregs recruitment in culture. Moreover, our findings revealed the soluble CD40 ligand (sCD40L) as a major Treg inhibitory player produced by activated platelets entrapped within the fibrin matrix of the PRF-P. Blockade of sCD40L restored the migratory capacity of Tregs, emphasizing the role of PRF-P in preventing the Treg migration to glioma tissue. Our findings highlight autologous PRF-P as a personalized, Treg-selective suppression platform that can potentially supplement and enhance the efficacy of glioma therapies.