The Incidence of Severe Radiation-Induced Lymphopenia during Chemoradiotherapy for Stage Ⅲ Non-Small Cell Lung Cancer: A Comparative Study of Proton Versus Photon-Based Radiotherapy

PURPOSE/OBJECTIVE(S)

To investigate the incidence of severe radiation-induced lymphopenia (SRL) and the survival in patients with stage Ⅲ non-small cell lung cancer treated with concurrent chemoradiotherapy with passive scattering proton beam (PSPT) or photon-based radiotherapy (XRT) including 3D-CRT and IMRT.

MATERIALS/METHODS

We conducted a retrospective cohort study including 355 patients who received definitive concurrent chemoradiotherapy with PSPT (n = 38) or XRT (n = 317) at our institution between January 2010 and December 2020. SRL during concurrent chemoradiotherapy was defined as absolute lymphocyte counts (ALCs) of <500 cells/mm3. Propensity score matching (PSM) analysis was performed to adjust for the patient characteristics between the PSPT and XRT groups. Propensity scores were calculated using age, sex, PS (0-1 vs. 2), primary tumor location (upper/middle vs. lower lobe), pathology (Adeno vs. Others), PTV volume, ALCs at pretreatment, year of treatment (before vs. after July 2018, when durvalumab approved in Japan), and platinum-based chemotherapy regimen (CDDP based vs. CBDCA based). After PSM, the incidence of SRL and the overall survival (OS) were analyzed.

RESULTS

The GTV and PTV volumes were significantly lower in the PSPT group than in the XRT group (median, 57 vs. 103 mm3; p < 0.05, 322 vs. 399 mm3; p < 0.05, respectively). ALCs at pretreatment were significantly lower in the PSPT group than in the XRT group (median, 1531 vs. 1718 cells/mm3; p < 0.05). SRL was observed in 275 patients (87%) in the XRT group and 27 patients (71%) in the PSPT group (p < 0.05). After PSM, PSPT significantly reduced the incidence of SRL compared to XRT (68.6 % vs. 88.6 %, p < 0.05), and the patients without SRL may have better 3-year OS than those with SRL (71.1 % vs. 55.3 %; p = 0.062).

CONCLUSION

Compared with XRT, PSPT significantly reduced the incidence of SRL, and the patients without SRL had a good prognosis.

Incidence and Prognostic Factors of Painful Vertebral Compression Fracture Caused by Spine Stereotactic Body Radiotherapy

PURPOSE/OBJECTIVE(S)

Most studies of vertebral compression fracture (VCF) caused by stereotactic body radiotherapy (SBRT) do not mention the symptoms. We aimed herein to determine the rate and prognostic factors of painful VCF caused by SBRT for spinal metastasis.

MATERIALS/METHODS

Between August 2013 and December 2021, spinal segments with VCF were retrospectively identified in patients treated with spine SBRT. Iatrogenic VCFs, excluding pathological fractures, were classified into a modified group and graded using CTCAE v5.0 as grade 1 (painless), grade 2 (mildly painful), or grade 3 (intensely painful, requiring hospitalization or surgery). The primary endpoint was the rate of painful VCF (grades 2-3). Moreover, various factors specific to the patient, tumor, and treatment were evaluated to determine their value in predicting the rate of painful VCF.

RESULTS

In total, 934 spinal segments in 387 patients were analyzed. The median follow-up after SBRT was 14 (range: 0-107) months. Sixty iatrogenic fractures (6.4%) comprising 31 de novo fractures and 29 existing VCF progressions were identified. The patients' median age was 68 (range: 38-79) years, and 31 (52%) spinal segments had a history of radiotherapy. Grade 1, 2, and 3 VCFs were confirmed in 41, four, and 15 segments, respectively. The rate of grade 3 VCF was 2.0% (19 / 934) of the spinal segments treated with SBRT. Eight (0.9%) VCFs required surgery for stabilization or decompression of spinal canal stenosis. None of the 17 VCFs treated with posterior decompression and fixation before SBRT developed into a painful VCF. On univariate analysis, the painful VCF rate was significantly higher in patients with no posterolateral tumor involvement than in those with bilateral or unilateral involvement (56.3% vs 22.7%; p = 0.026). Other spinal instability neoplastic score (SINS) components (Location, Pain, Bone lesion, Alignment, Vertebral body collapse), SINS (Stable/ Potentially unstable vs Unstable), age, number of spinal levels, radiation history, existing VCF, and interval between SBRT and VCF showed no significant correlation with painful VCF.

CONCLUSION

Although VCF is a known adverse effect of spine SBRT, 68% of the cases examined were painless (grade 1). Intensely painful VCFs (grade 3) were confirmed in only 1.6% of all the treated spinal segments. The absence of posterolateral tumor involvement was significantly associated with painful VCF.

Dosimetric Evaluation of Targets and Organs at Risk in Dose Escalation Study for Total Marrow and Lymphoid Irradiation

PURPOSE/OBJECTIVE(S)

Total marrow and lymphoid irradiation (TMLI) delivers radiation dose to the bone marrow and lymph nodal region while reducing the dose to non-target organs. We conducted a dose-escalation study of TMLI to improve treatment outcomes while reducing OAR doses using intensity-modulated radiation therapy. However, this dose escalation strategy may cause increasing risk of recurrence and adverse events because of dose uniformity compromises of the target. We hypothesized that the homogeneity index (HI) could become worse with increased target's dose while maintaining reduced OAR doses for the nine patients enrolled in the TMLI phase Ⅰ clinical trial.

MATERIALS/METHODS

Nine patients treated with TMLI using a treatment delivery system from September 2019 to August 2021 were included. The prescribed doses were 14 Gy/6 fr, 16 Gy/6 fr, and 18 Gy/6 fr twice daily for 3 days, with three patients allocated each prescription. Bone marrow, lymph nodal region, spleen, testis, brain, and liver were designated as targets. The bone marrow was divided into eight parts (see Table); an individual PTV margin was added to each structure. We intended to deliver the D80% prescription dose for PTV. For the brain and liver, the prescribed dose was 12 Gy in consideration of function preservation. Lenses, oral cavity, parotid glands, lungs, heart, esophagus, stomach, kidneys, intestines, and breasts were defined as OAR. Targets were evaluated with HI that was calculated using the formula HI = (D2%-D98%)/D50%, based on ICRU report 83. For OARs, Dmax, D2%, D10%, and mean dose constraint were evaluated.

RESULTS

The table lists HI for the PTV_ALL and each target. The HI of PTV_ALL rose with increasing prescription dose and was highest at 18 Gy. The highest HI was 0.632 for PTV_Rib at 18 Gy, and the lowest HI was 0.045 for PTV_testis at 14 Gy. OAR Dose constraints were achieved in all patients. The average OAR doses in all cases for lenses, oral cavity, parotid glands, lungs, heart, esophagus, intestines, kidneys, and breast were 4.7±0.80, 4.4±0.51, 6.7±0.48, 7.6±0.22, 7.8±0.19, 6.7±0.18, 7.4±1.12, 6.9±0.96, and 14.7 Gy, respectively. The Dmax of the lenes, D2% of the esophagus, and D10% of the stomach were 7.2 ± 1.09, 11.5 ± 0.47, and 10.9 ± 0.98 Gy, respectively.

CONCLUSION

In the TMLI phase I clinical trial, we evaluated the dose uniformity to the targets and the OAR dose constraints. Although the HI for PTV_ALL worsened with increasing prescription dose, compliance with OAR dose constraints was achieved in all patients.

Antithrombotic monotherapy for stable coronary artery disease and atrial fibrillation patients with and without prior coronary artery revascularization: Insights from the AFIRE trial

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): The Japan Cardiovascular Research Foundation under a contract with Bayer Yakuhin

Background

The AFIRE (Atrial Fibrillation and Ischemic Events With Rivaroxaban in Patients With Stable Coronary Artery Disease) trial demonstrated that rivaroxaban monotherapy was noninferior to combination therapy with rivaroxaban plus a single antiplatelet therapy regarding efficacy and superior for safety endpoints in patients with atrial fibrillation and stable coronary artery disease including patients not requiring revascularization [prior percutaneous coronary intervention (PCI) or bypass grafting (CABG)].

Purpose

The aim of this post-hoc subgroup analysis was to investigate the efficacy and safety of rivaroxaban monotherapy compared to combination therapy in patients with and without prior revascularization.

Methods

Among 2,215 patients included in the modified intention-to-treat analysis in the AFIRE trial, 1445 patients (65.2%) had undergone previous PCI alone, and 252 (11.4%) had undergone previous CABG. The remaining 518 patients (23.4%) was categorized as a group without prior revascularization and then compared with a group with prior revascularization (PCI or CABG). The primary efficacy end point was a composite of stroke, systemic embolism, myocardial infarction, unstable angina requiring revascularization, or death from any cause. The primary safety end point was major bleeding, according to the criteria of the International Society on Thrombosis and Hemostasis.

Results

In 1697 patients with prior revascularization, efficacy and safety endpoints of rivaroxaban monotherapy were superior to combination therapy (efficacy: HR 0.62, 95%CI 0.45-0.85, p=0.003; safety: HR 0.62, 95%CI 0.39-0.98, p=0.040), whereas there were no significant differences in efficacy and safety endpoints among 518 patients without prior revascularization (efficacy: HR 1.19, 95%CI 0.67-2.11, p=0.553; safety: HR 0.47, 95%CI 0.18-1.26, p=0.125). There was a borderline interaction of efficacy endpoint (P for interaction=0.055) by randomized treatment assignment (Figure 1 and Figure 2). Compared with combination therapy, the safety benefit of rivaroxaban monotherapy on any bleeding was significant in patients without prior revascularization (HR 0.59, 95%CI 0.38-0.93, p=0.022).

Conclusions

In patients with prior PCI or CABG, rivaroxaban monotherapy resulted in more favorable safety and efficacy outcomes than combination therapy. There was a borderline interaction for primary efficacy outcome between prior revascularization and anti-thrombotic therapy.

Temporal Profiles of Symptom Scores After Palliative Radiotherapy for Bleeding Gastric Cancer With Adjustment for the Palliative Prognostic Index: An Exploratory Analysis of a Multicentre Prospective Observational Study (JROSG 17-3)

AIMS

Although palliative radiotherapy for gastric cancer may improve some symptoms, it may also have a negative impact due to its toxicity. We investigated whether symptoms improved after radiotherapy with adjustment for the Palliative Prognostic Index (PPI) considering that patients with limited survival tend to experience deterioration of symptoms.

MATERIALS AND METHODS

This study was an exploratory analysis of the Japanese Radiation Oncology Study Group study (JROSG 17-3). We assessed six symptom scores (nausea, anorexia, fatigue, shortness of breath, pain at the irradiated area and distress) at registration and 2, 4 and 8 weeks thereafter. We tested whether symptoms linearly improved after adjusting for the baseline PPI. Shared parameter models were used to adjust for potential bias in missing data.

RESULTS

The present study analysed all 55 patients enrolled in JROSG 17-3. With time from registration as the only explanatory variable in the model, a significant linear decrease was observed in shortness of breath, pain and distress (slopes, -0.26, -0.22 and -0.19, respectively). Given that the interaction terms (i.e. PPI × time) were not significantly associated with symptom scores in any of the six symptoms, only PPI was included as the main effect in the final multivariable models. After adjusting for the PPI, shortness of breath, pain and distress significantly improved (slope, -0.25, -0.19 and -0.17; P < 0.001, 0.002 and 0.047, respectively). An improvement in fatigue and distress was observed only in patients treated with a biologically effective dose ≤14.4 Gy.

CONCLUSION

Shortness of breath, pain and distress improved after radiotherapy. Moreover, a higher PPI was significantly associated with higher symptom scores at all time points, including baseline. In contrast, PPI did not seem to influence the improvement of these symptoms. Regardless of the expected survival, patients receiving radiotherapy for gastric cancer can expect an improvement in shortness of breath, pain and distress over 8 weeks. Multiple-fraction radiotherapy might hamper the improvement in fatigue and distress by its toxicity or treatment burden.

Association of beta blocker use with new-onset heart failure and mortality in atrial fibrillation without pre-existing heart failure: the Fushimi AF registry

Background

Heart failure (HF) is one of the major complications in atrial fibrillation (AF). We previously reported that not a few AF patients without pre-existing HF (defined as prior HF hospitalization, New York Heart Association functional class≥2, or left ventricular ejection fraction (LVEF)&lt;40%) subsequently developed new-onset HF. Beta blockers are the established therapy for HF, but it remains unclear whether beta blockers prevent new-onset HF and improve outcomes in AF patients without preexisting HF.

Methods

In the Fushimi AF registry, 778 of 3,262 patients without pre-existing HF were receiving beta blockers at baseline. We investigated the incidence of new-onset HF defined as cardiac death or HF hospitalization, and all-cause death in a propensity-matched cohort (N=1,198; mean age, 71 years; 39% female; mean LVEF, 66%). Additionally, annual follow-up prescription data before the onset of events were collected in 294 of patients with beta blockers and 395 of those without beta blockers. We also investigated the association of starting or stopping beta blockers with the incidence of new-onset HF and all-cause death.

Results

During the median follow-up of 5.8 years, new-onset HF and all-cause death occurred in 77 (12.9%) and 118 (19.7%) of patients with beta blockers, and 70 (11.7%) and 131 (21.9%) of those without beta blockers, respectively. Incidence of new-onset HF was comparable between patients with and without beta blockers (Figure 1), and incidence of all-cause death was also comparable between the two groups (Figure 2). In exploratory subgroup analyses, there was no interaction in the association of beta blockers with the incidence of events, except for pulse rate for new-onset HF and left atrial size for all-cause death. Hazard ratio of beta blockers for new-onset HF tended to be lower in patients with higher pulse rates (&gt;84 bpm) (Figure 1), and that for all-cause death was lower in those without left atrial enlargement (Figure 2). Of patients with follow-up prescription data, beta blockers were stopped in 55 (18.7%) and started in 97 (24.6%) patients, respectively. Patients with starting beta blockers had higher pulse rate (78.5±17.3 vs 74.9±13.9 bpm; p=0.03) and more symptomatic AF (58.8% vs 46.0%; p=0.03) compared to those without starting beta blockers, while there was no difference in baseline characteristics between those with and without stopping beta blockers. During the follow-up, the incidences of new-onset HF and all-cause death were also comparable between the patients with and without stopping beta blockers and those with and without starting beta blockers.

Conclusion

Beta blockers were not associated with the incidence of new-onset HF and all-cause death in AF patients without pre-existing HF. However, the exploratory subgroup analyses suggested the existence of subjects who may benefit from beta blockers.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Boehringer Ingelheim, Bayer Healthcare, Pfizer, Bristol-Myers Squibb, Astellas Pharma, AstraZeneca, Daiichi Sankyo, Novartis Pharma, MSD, Sanofi-Aventis, and Takeda Pharmaceutical.

Clinical characteristics and outcomes of atrial fibrillation patients with peripheral artery disease: the Fushimi AF Registry

Background

Atrial fibrillation (AF) represents the common arrhythmia and increases the risk of thromboembolism. Risk assessment for thromboembolism is important for the management of AF patients. Peripheral artery disease (PAD) is identified as a risk factor for thromboembolism in CHA2DS2-VASc score. However, there are little data on clinical characteristics and cardiovascular events of AF patients with PAD.

Purpose

In this study, we investigated the clinical characteristics and outcomes of AF patients with PAD.

Methods

The Fushimi AF Registry, a community-based prospective survey, was designed to enroll all of the AF patients who visited the participating medical institutions in Fushimi-ku, Kyoto, Japan. The inclusion criterion of the registry is the documentation of AF at 12-lead electrocardiogram or Holter monitoring at any time, and there are no exclusion criteria. We started to enroll patients from March 2011 and follow up data including prescription status were available in 4,464 patients from March 2011 to August 2021. Median follow-up period was 1,848 days.

Results

Of 4,464 patients, 183 patients had PAD (4.1%; PAD group). The mean age was higher in PAD group than no-PAD group (PAD group vs. no-PAD group: 76.7 vs. 73.5; p&lt;0.01). Patients with PAD had more co-morbidities such as stroke, systemic embolism, congestive heart failure, hypertension, diabetes mellitus, dyslipidemia coronary artery disease and chronic kidney disease than those without PAD. Thus, CHADS2 score, CHA2DS2-VASc score and HAS-BLED score were higher in PAD group than no-PAD group (2.81 vs. 2.00; p&lt;0.01, 5.17 vs. 3.30; p&lt;0.01, 2.42 vs. 1.71; p&lt;0.01, respectively). The proportion of patients with oral anticoagulant was similar between the two groups and the proportion of patients with antiplatelet drug was higher in PAD group than no-PAD group (59.0% vs. 55.6%; p=0.36, 62.9% vs. 24.7%; p&lt;0.01, respectively). The incidences of all-cause death, cardiac death and myocardial infarction were higher in PAD group than no-PAD group (11.4 vs. 4.6 per 100 person-years; log-rank p&lt;0.01, 1.7 vs. 0.8 per 100 person-years; log-rank p&lt;0.01, 1.2 vs. 0.2 per 100 person-years; log-rank p&lt;0.01). However, the incidence of stroke or systemic embolism was similar between the two groups (2.9 vs. 2.2 per 100 person-years, log-rank p=0.19). Finally, the incidence of composite of cardiac death, stroke, systemic embolism or myocardial infarction was higher in PAD group than no-PAD group (6.0 vs. 3.0 per 100 person-years; log-rank p&lt;0.01).

Conclusion

AF patients with PAD had significantly higher risk for death and cardiac events, whereas the incidence of thromboembolism was similar between AF patients with and without PAD.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Japan Agency for Medical Research and Development

Association of cardiothoracic ratio with heart failure hospitalization in patients with atrial fibrillation: the Fushimi AF Registry

Background

Chest radiography is the most common diagnostic imaging test in clinical medicine, and the cardiothoracic ratio (CTR) is a readily available and non-invasive tool with which to assess the volume status and cardiomegaly. However, it remains unknown whether CTR on chest radiography is associated with the incidence of HF hospitalization in AF patients remains unclear.

Methods

The Fushimi AF Registry is a community-based prospective survey of AF patients in Fushimi-ku, Kyoto, Japan. The inclusion criterion of the registry is the documentation of AF at 12-lead electrocardiogram or Holter monitoring at any time, and there are no exclusion criteria. We started to enroll patients from March 2011, and follow-up data were available for 4,489 patients by the end of August 2021. In the present study, 3,727 patients with available data of CTR were examined. We divided the patients into two groups according to their CTR at baseline; Higher group (CTR ≥50.0%, n=2,696) and Lower group (CTR &lt;50.0%, n=1,031), and compared the clinical background and outcomes between the two groups.

Results

The proportion of female was grater in Higher group, and the patients in Higher group were older. The patients in Higher group had higher prevalence of HF, hypertension and chronic kidney disease. During the median follow-up of 3,033 days, in Kaplan-Meier analysis, the incidence rates of HF hospitalization were higher in Higher group (Higher group: 2.5% per person-year vs. Lower group: 1.1%; p&lt;0.01). Multivariate Cox proportional hazards regression analysis revealed that higher CTR (≥50.0%) was an independent determinant of the incidence of HF hospitalization. Furthermore, when we divided the patients into four groups based on the quartile of CTR; Q1 (CTR&lt;49.0%), Q2 (49.0≤CTR&lt;53.8%), Q3 (53.8≤CTR&lt;59.0%), Q4 (59.0%≤CTR), the incidence of HF hospitalization was more frequent in patients with higher CTR, regardless of the presence or absence of prior hospitalization for HF (Figure).

Conclusion

In Japanese AF patients, patients with higher CTR had significantly higher incidence of HF hospitalization, regardless of the prevalence of prior hospitalization for HF.

Funding Acknowledgement

Type of funding sources: None.

Effect of rivaroxaban monotherapy vs. combination with anti-platelet therapy in patients with atrial fibrillation and stable coronary artery disease across different body mass index categories

Background

The AFIRE (Atrial Fibrillation and Ischemic Events With Rivaroxaban in Patients With Stable Coronary Artery Disease) trial showed both noninferiority for efficacy and superiority for safety endpoints of rivaroxaban monotherapy compared to rivaroxaban plus antiplatelet therapy (combination therapy) in patients with atrial fibrillation (AF) and stable coronary artery disease (CAD). However, no accumulating evidence regarding efficacy and safety of these fixed-dose direct oral anticoagulant therapy was available in underweight and obese patients.

Purpose

The aim of this post-hoc analysis of the AFIRE trial was to evaluate outcomes of rivaroxaban monotherapy (vs. combination therapy) in patients with AF and stable CAD across body mass index (BMI) categories.

Methods

Patients were categorized into groups 1 (underweight: BMI of &lt;18.5 kg/m2), 2 (normal: BMI of 18.5 to &lt;25 kg/m2), 3 (overweight: BMI of 25 to &lt;30 kg/m2), and 4 (obesity: BMI of ≥30 kg/m2). Efficacy (a composite of all-cause death, myocardial infarction, unstable angina requiring revascularization, stroke, or systemic embolism) and safety (major bleeding defined according to International Society on Thrombosis and Haemostasis criteria) were compared between rivaroxaban monotherapy and combination therapy across BMI categories.

Results

We analyzed 2,054 patients with a median age of 75.0 (interquartile range [IQR], 69 to 80)) years old and CHA2DS2-VASc of 4 (IQR, 3 to 5). Group 1 through 4 included 72 (3.5%), 1,158 (56.4%), 680 (33.1%), 144 (7.0%) patients and 62.3%, 52.3%, 36.2%, and 30.3% were received reduced dose of rivaroxaban, respectively. Although the sample sizes for group 1 and 4 were limited, monotherapy was superior to combination therapy for efficacy in group 2 (hazard ratio [HR], 0.64; 95% CI, 0.44 to 0.95) and safety in group 3 (HR, 0.25; 95% CI, 0.10 to 0.62), whereas a significant difference in the endpoints was not observed in the other BMI categories. Impact of monotherapy on endpoints did not have a significant interaction in BMI.

Conclusions

Rivaroxaban monotherapy had similar effect on prognosis across all BMI categories in patients with AF and stable CAD.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The Japan Cardiovascular Research Foundation based on a contract with Bayer Yakuhin, Ltd

The association of left ventricular ejection fraction with incident heart failure in patients with atrial fibrillation

Background

Atrial fibrillation (AF) increases the risk of incident heart failure (HF). Left ventricular ejection fraction (LVEF) is an important prognostic parameter in patients with HF. However, little is known regarding the association of LVEF with incident HF in patients with AF.

Purpose

The aim of this study is to investigate the relationship between LVEF at enrollment and incidence of HF hospitalization during follow-up period in patients with AF.

Methods

The Fushimi AF Registry is a community-based prospective survey of patients with AF in Fushimi-ku, Kyoto, Japan. The inclusion criterion of the registry is the documentation of AF at 12-lead electrocardiogram or Holter monitoring at any time, and there are no exclusion criteria. We started to enroll patients from March 2011, and follow-up data were available for 4,489 patients by the end of August 2021. In the present study, we investigated 3,544 patients with the data of LVEF at enrollment. We divided the patients into 4 groups stratified by LVEF (reduced LVEF [LVEF &lt;40%], mildly reduced LVEF [LVEF: 40–49%], slightly reduced LVEF [LVEF: 50–59%], and normal LVEF [LVEF ≥60%]), and compared the backgrounds and outcomes between these 4 groups.

Results

Of 3,544 patients, the mean age was 73.6±10.7 years, 1,420 (40%) were female, 1,781 (50%) were paroxysmal AF, and 1,085 (30%) had pre-existing HF. The mean CHADS2 and CHA2DS2-VASc scores were 2.1±1.3 and 3.4±1.7, respectively. The mean LVEF at enrollment was 63±12% (reduced LVEF: 197 [6%], mildly reduced LVEF: 250 [7%], slightly reduced LVEF: 532 [15%] and normal LVEF: 2,565 [72%], respectively). Patients with lower LVEF demonstrated lower prevalence of female and paroxysmal AF, and had a higher CHADS2 and CHA2DS2-VASc scores (all P&lt;0.01). A total of 605 patients were hospitalized for HF during the median follow-up period of 5.5 years, corresponding to an annual incidence of 3.4% per person-year. Kaplan-Meier curves demonstrated that LVEF at enrollment could stratify the incidence of HF hospitalization during follow-up in patients with AF (Picture 1). Multivariable Cox regression analysis revealed that lower LVEF strata were significantly associated with the increased risk of HF hospitalization even after adjustment by age, sex, type of AF and CHA2DS2-VASc score (Picture 1). An increased risk of HF hospitalization was observed even in patients with mildly reduced LVEF (adjusted hazard ratio: 2.56, 95% CI: 1.99–3.29) as well as in those with slightly reduced LVEF (adjusted hazard ratio: 1.79, 95% CI: 1.45–2.22) compared with those with normal LVEF. These results were also the case in AF patients without pre-existing HF (Picture 2).

Conclusion

LVEF at enrollment could stratify the incidence of HF hospitalization in patients with AF, suggesting the importance of measuring LVEF in all patients with AF. Even mildly (LVEF: 40–49%) or slightly (LVEF: 50–59%) reduced LVEF was independently associated with the risk of incident HF in patients with AF.

Funding Acknowledgement

Type of funding sources: None.

Surface nanostructures on Nb-doped SrTiO3irradiated with swift heavy ions at grazing incidence

A single crystal of SrTiO₃doped with 0.5 wt% niobium (Nb-STO) was irradiated with 200 MeV Au³²⁺ions at grazing incidence to characterize the irradiation-induced hillock chains. Exactly the same hillock chains are observed by using atomic force microscopy (AFM) and scanning electron microscopy (SEM) to study the relation between irradiation-induced change of surface topography and corresponding material property changes. As expected, multiple hillocks as high as 5-6 nm are imaged by AFM observation in tapping mode. It is also found that the regions in between the adjacent hillocks are not depressed, and in many cases they are slightly elevated. Line-like contrasts along the ion paths are found in both AFM phase images and SEM images, indicating the formation of continuous ion tracks in addition to multiple hillocks. Validity of preexisting models for explaining the hillock chain formation is discussed based on the present results. In order to obtain new insights related to the ion track formation, cross-sectional transmission electron microscopy (TEM) observation was performed. The ion tracks in the near-surface region are found to be relatively large, whereas buried ion tracks in the deeper region are relatively small. The results suggest that recrystallization plays an important role in the formation of small ion tracks in the deep region, whereas formation of large ion tracks in the near-surface region is likely due to the absence of recrystallization. TEM images also show shape deformation of ion tracks in the near-surface region, suggesting that material transport towards the surface is the reason for the absence of recrystallization.

Colchicine protects against cartilage degeneration by inhibiting MMP13 expression via PLC-γ1 phosphorylation

OBJECTIVE

Low molecular weight compounds that reduce the expression of MMP13 at the mRNA level might serve as disease-modifying osteoarthritis (OA) drugs (DMOADs). The objective of this study was to identify a candidate DMOAD that targets MMP13 expression.

DESIGN

High-throughput screening was performed to identify compounds that suppress inflammatory cytokine-induced MMP13 expression. Ingenuity pathway analysis (IPA) using isobaric tags for relative and absolute quantification (iTRAQ)-based proteomic analysis was conducted to identify signaling pathways related to cytokines. MMP13 expression in chondrocytes was evaluated through RT-qPCR and western blotting analyses. Additionally, 10-week-old mice were subjected to destabilization of the medial meniscus (DMM) surgery to induce OA and were sacrificed 12 weeks post-surgery for pathological examination. OA was evaluated using the OARSI scoring system.

RESULTS

Colchicine was identified as a DMOAD candidate as it inhibited inflammatory cytokine-induced MMP13 expression in vitro, and the colchicine-administered mice with DMM presented significantly lower OARSI scores (adjusted P: 0.0242, mean difference: 1.6, 95% confidence interval (CI) of difference: 0.1651-3.035) and significantly lower synovial membrane inflammation scores (adjusted P: 0.0243, mean difference: 0.6, 95% CI of difference: 0.06158-1.138) than mice with DMM. IPA further revealed that components of the Rho signaling pathways are regulated by cytokines and colchicine. IL-1β and TNF-α activate RAC1 and SRC signals, respectively, leading to the phosphorylation of PLC-γ1 and synergistic induction of MMP13 expression. Most notably, colchicine abrogates inflammatory cytokine-induced phosphorylation of PLC-γ1, leading to the induction of MMP13 expression.

CONCLUSIONS

Colchicine is a potential DMOAD candidate that inhibits MMP13 expression and consequent cartilage degradation by disrupting the SRC/RAC1-phospho-PLCγ1-Ca2+ signaling pathway.

Association of low total cholesterol level with clinical outcomes in patients with atrial fibrillation: the Fushimi AF registry

Background

Hyperlipidemia is a well-established risk factor for cardiovascular disease. However, low cholesterol is also reported to be associated with poor outcome in patients with chronic disease, which is called “cholesterol paradox”, and the association of cholesterol level with the incidence of clinical outcomes in patients with atrial fibrillation (AF) remains unclear.

Methods

In the Fushimi AF Registry, a community-based prospective survey of the AF patients in Fushimi-ku, Kyoto, Japan, follow-up data and baseline total cholesterol levels were available in 3,054 patients. We excluded 767 patients who were taking statins, and 2,267 patients were included in the analyses. We defined low cholesterol as total cholesterol &lt;150 mg/dl, and examined the incidence of all-cause death, stroke/systemic embolism (SE), heart failure (HF) hospitalization, and major bleeding.

Results

Patients with low cholesterol (N=464 (20.4%)) were older, more often male, and had higher prevalence of low body weight (&lt;50 kg), permanent/persistent AF, prior stroke/SE, HF, chronic kidney disease, and anemia (hemoglobin &lt;11 g/dl). CHA2DS2-VASc score was higher in patients with low cholesterol (low cholesterol vs others; 3.6±1.6 vs 3.2±1.7: P&lt;0.001). Prescription of oral anti-coagulants was comparable between the groups (50.0% vs 54.5%: P=0.09). During the median follow-up of 1,805 days, the incidence of all-cause death, stroke/SE, HF hospitalization, and major bleeding was significantly higher in patients with low cholesterol (all-cause death, 10.9 vs 3.8 /100 person-years; stroke/SE, 3.4 vs 1.9 /100 person-years; HF hospitalization, 4.7 vs 2.5 /100 person-years; major bleeding, 2.7 vs 1.4 /100 person-years) (Figure 1). After adjustment for the components of CHA2DS2-VASc score, low body weight, permanent/persistent AF, chronic kidney disease, anemia, and prescription of oral anti-coagulants, low cholesterol was significantly associated with the incidence of all-cause death and stroke/SE, but not with that of HF hospitalization or major bleeding (Figure 2, model 3). Total cholesterol levels were still significantly and inversely associated with the incidence of all-cause death (hazard ratio, 0.94; 95% confidence interval, 0.92–0.96 for 10 mg/dl increase) and stroke/SE (hazard ratio, 0.96; 95% confidence interval, 0.92–0.999 for 10 mg/dl increase), when analyzed as continuous variables. Subgroup analysis revealed that the risk of low cholesterol for all-cause death was more pronounced in female (interaction P, 0.049), patient without prior stroke/SE (interaction P, 0.01), those without HF (interaction P, 0.01), and those without vascular disease (interaction P, 0.001). The risk for stroke/SE was more pronounced in patients without vascular disease (interaction P, 0.01).

Conclusion

Low total cholesterol level was significantly associated with the incidence of all-cause and stroke/SE in AF patients not taking statins, suggesting the existence of cholesterol paradox in AF.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Boehringer Ingelheim, Bayer Healthcare, Pfizer, Bristol-Myers Squibb, Astellas Pharma, AstraZeneca, Daiichi-Sankyo, Novartis Pharma, MSD, Sanofi-Avent

The relationship between diastolic blood pressure and the risk of cardiovascular events in patients with atrial fibrillation whose systolic blood pressure was treated to less than 130 mmHg

Background

Hypertension is one of the major risk factors of cardiovascular events in patients with atrial fibrillation (AF). Low diastolic blood pressure (DBP) has been reported to be associated with the incidence of cardiovascular events, but current guidelines recommend an intensive blood pressure target of less than 130/80 mmHg for AF patients taking oral anticoagulants without mentioning the lower limits of DBP.

Methods

The Fushimi AF Registry is a community-based prospective survey of AF patients in a city of Japan. Follow-up data were available in 4,472 patients, and hypertensive patients who received prescription of any antihypertensive agents and whose systolic blood pressure was treated to less than 130 mmHg were available were examined (n=1,319). We divided the patients into four groups according to their DBP at baseline; G1 (DBP&lt;60 mmHg, n=349), G2 (60≤DBP&lt;70, n=434), G3 (70≤DBP&lt;80, n=386) and G4 (80≤DBP, n=150), and compared the clinical background and outcomes among groups.

Results

The proportion of female was grater in G1 group, and the patients in G1 group were older. During the median follow-up of 2,458 days, in Kaplan-Meier analysis, the incidence rates of cardiovascular events (composite of cardiac death, ischemic stroke, systemic embolism, non-fatal myocardial infarction and heart failure hospitalization during follow up) were the highest in G1 group and the lowest in G3 group (G1: 7.2% per person-year vs. G2: 4.9% vs. G3: 2.2% vs. G4: 4.4%; p&lt;0.01). Multivariate Cox proportional hazards regression analysis revealed that DBP was an independent determinant of cardiovascular events (G1 vs. G3; hazard ratio (HR): 1.96, 95% confidence intervals (CI): 1.39–2.76, G2 vs. G3; HR: 1.79, 95% CI: 1.28–2.50, G4 vs. G3; HR: 1.56, 95% CI: 0.99–2.45) (Figure 1). When we examined the association of DBP according to 10 mmHg increment, patients with excessively low DBP (&lt;50 mmHg) had significantly higher incidence of cardiovascular events than patients with DBP of 70–79 mmHg (HR: 2.80, 95% CI: 1.81–4.33), and DBP exhibited J curve association with higher incidence of cardiovascular events (Figure 2).

Conclusion

In Japanese AF patients whose systolic blood pressure was treated to less than 130 mmHg, patients with excessively low DBP had significantly higher incidence of cardiovascular events, and DBP exhibited J curve association with higher incidence of cardiovascular events.

Funding Acknowledgement

Type of funding sources: None.

Previous pacemaker therapy was not associated with the risk of clinical events in patients with atrial fibrillation: the Fushimi AF Registry

Background

Patients with atrial fibrillation (AF) occasionally require pacemaker implantation. Meanwhile, patients with implanted pacemaker are occasionally found to have subclinical AF and develop clinical AF. However, little is known about the clinical outcomes of AF patients with implanted pacemaker.

Purpose

We aimed to investigate the clinical outcomes in AF patients undergoing previous pacemaker therapy.

Methods

The Fushimi AF Registry is a community-based prospective survey of the AF patients in a city of Japan. Follow-up data including prescription status were available for 4,447 patients. After exclusion of patients with implantable cardioverter defibrillator and cardiac resynchronization therapy, we investigated 293 AF patients with pacemaker implantation at baseline. We performed propensity score-matching analysis to assess the impact of pacemaker therapy in AF patients.

Results

Of a total cohort, patients with pacemaker were more often female (51.2% vs. 39.7%; p&lt;0.01) and older (78.0 vs. 73.3 years of age; p&lt;0.01). Patients with pacemaker were more likely to have pre-existing heart failure (33.1% vs. 26.6%; p&lt;0.01), valvular heart disease (22.9% vs. 16.8%; p&lt;0.01), chronic kidney disease (48.8% vs. 34.7%; p&lt;0.01), and history of performing direct current cardioversion (7.2% vs. 3.1%; p&lt;0.01), compared with patients without pacemaker. Mean CHA2DS2-VASc score was higher in patients with pacemaker (3.80 vs. 3.34; p&lt;0.01). Patients with pacemaker were more often prescribed oral anticoagulants (62.1% vs. 55.2%; p=0.02), verapamil (13.3% vs. 9.4%; p=0.03), and loop diuretics (30.7% vs. 21.8%; p&lt;0.01). Using propensity score-matching, 291 patients with pacemaker and 291 without pacemaker were matched and baseline characteristics were comparable. The median follow-up period was 1,819 days. All-cause death occurred in 91 patients with pacemaker (6.0 /100 person-years) and 79 patients without pacemaker (5.9 /100 person-years), with a hazard ratio (HR) for patients with pacemaker of 1.01 (95% confidence interval [CI], 0.75 to 1.37; p=0.93). Furthermore, HR of cardiac death for patients with pacemaker was 1.00 (95% CI, 0.23 to 4.32; p=0.99), that of stroke or systemic embolism was 0.69 (95% CI, 0.44 to 1.07; p=0.10) and that of hospitalization for heart failure was 0.94 (95% CI, 0.65 to 1.37; p=0.76).

Conclusion

We identified that patients undergoing previous pacemaker therapy were not associated with the incidence of various adverse clinical events in Japanese AF patients.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Boehringer Ingelheim, Bayer Healthcare, Pfizer, Bristol-Myers Squibb, Astellas Pharma, AstraZeneca, Daiichi Sankyo, Novartis Pharma, MSD, Sanofi-Aventis, Takeda Pharmaceutical, and the Practical Research Project for Life-Style related Diseases including Cardiovascular Diseases and Diabetes Mellitus from Japan Agency for Medical Research and Development.

Association of the degree of thrombocytopenia with cause of death in patients with atrial fibrillation: the Fushimi AF Registry

Background

Thrombocytopenia is sometimes found in routine blood tests and is associated with an increased risk of mortality in general population. We have previously reported that atrial fibrillation (AF) patients with thrombocytopenia have a higher mortality than those without thrombocytopenia. However, association of the degree of thrombocytopenia with cause of death in AF patients is unknown.

Purpose

We aimed to investigate the association of baseline platelet count with cause of death including cardiac death, intracranial death, malignancy, infection, extracranial bleeding death, renal failure death, respiratory failure death and undetermined death.

Methods

The Fushimi AF Registry was designed to enroll all of the AF patients in Fushimi-ku, Kyoto. Fushimi-ku is densely populated with a total population of 283,000 and is assumed to represent a typical urban community in Japan. We started to enroll patients from March 2011, and follow-up data with baseline platelet counts less than 150,000/μL were available in 853 patients by the end of September 2020. We divided them into 3 groups according to baseline platelet level: Mild thrombocytopenia (100,000–149,999/μL, n=703), Moderate thrombocytopenia (50,000–99,999/μL, n=120), and Severe thrombocytopenia (&lt;50,000/μL, n=30).

Results

In the entire cohort, the mean age was 76 years, 34% were women, the mean body weight and body mass index was 59.3 kg and 22.9 kg/m2, and the median platelet count were 121,000/μL (interquartile range 109,000 to 141,000/μL). Compared to Mild thrombocytopenia, patients with Moderate or Severe thrombocytopenia were more likely to have chronic kidney disease (42.2% vs 54.2% vs 73.3%, p=0.0003), have higher HAS-BLED score (1.90 vs 2.14 vs 2.00, p=0.047) and lower hemoglobin (12.8g/dL vs 11.7g/dL vs 11.2g/dL, p&lt;0.0001) and were less often prescribed anti platelet drugs. Age, sex, body weight, systolic blood pressure, previous stroke, previous major bleeding, hypertension, diabetes mellitus, CHADS2 score and CHA2DS2-VASc score were comparable between three groups. During the median follow-up period, the incidence rate (per 100 person-years) of all-cause death was 6.82 vs 15.27 vs 9.64. (p&lt;0.001) On univariate analysis, the incidence of all-cause death was higher in Moderate group than Mild group. (HR: 2.15; 95% CI 1.61–2.87, p&lt;0.0001), but there was no significant difference between Mild and Severe groups. (HR: 1.44; 95% CI 0.78–2.64, p=0.243). The incidence of cardiac death was comparable between three groups. (Mild vs Moderate: HR 0.65; 95% CI 0.15–2.75, p=0.56, Mild vs Severe: HR 1.11; 95% CI 0.15–8.23, p=0.92) Regarding other causes of death such as intracranial bleeding, extracranial bleeding, malignancy, infection, renal failure, respiratory failure and undetermined cause, there was no significant difference.

Conclusion

Mortality was higher according to the degree of thrombocytopenia in AF patients, but the cause of death was not different among three groups.

Funding Acknowledgement

Type of funding sources: None.

Predictors and risk model for heart failure hospitalization in atrial fibrillation patients without pre-existing heart failure: the Fushimi AF Registry

Background

Atrial fibrillation (AF) increases the risk of hospitalization for heart failure (HF), as well as that of thromboembolism. The strategy for prediction of thromboembolism has been well-established; however, little focus has been placed on the risk stratification for and prevention of HF hospitalization in AF patients.

Purpose

The aim of this study is to investigate the predictors and risk model of HF hospitalization in non-valvular AF patients without pre-existing HF.

Methods

The Fushimi AF Registry is a community-based prospective survey of AF patients in Fushimi-ku, Kyoto, Japan. The inclusion criterion of the registry is the documentation of AF at 12-lead electrocardiogram or Holter monitoring at any time, and there are no exclusion criteria. We started to enroll patients from March 2011, and follow-up data were available for 4,472 patients by the end of October 2020. From the registry, we excluded patients without a pre-existing HF (defined as having one of the following; prior hospitalization for HF, New York Heart Association class ≥2, or left ventricular ejection fraction [LVEF] &lt;40%), and those with valvular AF (mitral stenosis or prosthetic heart valve). Among 3,188 non-valvular AF patients without pre-existing HF, we explored the risk factors for the HF hospitalization during follow-up period. The risk model for predicting HF hospitalization was determined by the cumulative numbers of risk factors which were significant on multivariate analysis.

Results

The mean age was 72.4±10.8 years, 1197 were female and 1787 were paroxysmal AF. The mean CHADS2 and CHA2DS2-VASc scores were 1.7±1.2 and 2.9±1.6, respectively. During the median follow-up period of 5.1 years, HF hospitalization occurred in 285 (8.9%), corresponding to an annual incidence of 1.8 events per 100 person-years. In multivariable Cox regression analysis, advanced age (≥75 years), valvular heart disease, coronary artery disease, reduced LVEF (&lt;60%), chronic obstructive pulmonary disease (COPD) and anemia were independently associated with the higher incidence of HF hospitalization (all P&lt;0.001) (Picture 1). A risk model based on these 6 variables could stratify the incidence of HF hospitalization during follow-up period (log-rank; P&lt;0.001) (Picture 2). Patients with ≥3 risk factors had an 11-fold higher incidence of HF hospitalization compared with those not having any of these risk factors (hazard ratio: 11.3, 95% confidence interval: 7.0–18.4; P&lt;0.001).

Conclusions

Advanced age, coronary artery disease, valvular heart disease, reduced LVEF, COPD and anemia were independently associated with the risk of HF hospitalization in AF patients without pre-existing HF. There was good prediction for endpoint of HF hospitalization using these 6 variables, providing the opportunities for the implementation of strategies to reduce the incidence of HF among AF patients.

Funding Acknowledgement

Type of funding sources: None.

Aspirin vs. P2Y12 inhibitors with anticoagulation therapy for atrial fibrillation: insights from the AFIRE trial

Background

Patients with coronary artery disease (CAD) and atrial fibrillation (AF) can be treated with multiple antithrombotic therapies including antiplatelets and oral anticoagulants; however, this has the potential to increase bleeding risk.

Purpose

This sub-analysis aimed to evaluate the efficacy and safety of P2Y12 inhibitors and aspirin in patients also receiving oral anticoagulant therapy.

Methods

We evaluated patients from the Atrial Fibrillation and Ischemic Events with Rivaroxaban in Patients with Stable Coronary Artery Disease (AFIRE) trial who received combination therapy (rivaroxaban plus a single antiplatelet agent). The choice of antiplatelets was left to the physician's discretion. The primary efficacy endpoint was a composite of stroke, systemic embolism, myocardial infarction, unstable angina requiring revascularization, and death from any cause. The primary safety endpoint was major bleeding according to the International Society on Thrombosis and Haemostasis criteria.

Results

A total of 1,075 patients were included (P2Y12 inhibitor group, n=297; aspirin group, n=778). Approximately 60% of patients were administered proton pump inhibitors (PPIs), and there was no significant difference in PPI use in the P2Y12 inhibitor and aspirin groups. Regarding the primary efficacy endpoint, there was no significant difference between the P2Y12 inhibitor and aspirin groups (hazard ratio, 1.31; 95% confidence interval, 0.88–1.94; p=0.178). Likewise, the primary safety endpoint was not different between the groups (hazard ratio, 0.79; 95% confidence interval, 0.43–1.47; p=0.456). In the detailed subgroup analysis, there were no differences in the efficacy and safety endpoints.

Conclusions

There were no significant differences between P2Y12 inhibitors and aspirin in cardiovascular events in patients with AF and stable CAD taking rivaroxaban in the chronic phase.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The Japan Cardiovascular Research Foundation based on a contract with Bayer Yakuhin, Ltd. Summary of this study

Development of a fast response neutron detector for the supersonic FRC collision process

The collisional merging experiments of the field-reversing configuration (FRC) at supersonic/Alfvénic velocities have been performed in the FRC Amplification via Translation-Collisional Merging device only in Japan. This experiment may excite shockwaves and cause particle acceleration. To obtain supporting evidence of particle acceleration by shockwaves, we have proposed to observe neutrons originating from the D-D fusion reaction of accelerated non-thermal particles. A plastic scintillation detector has been developed for the supersonic/Alfvénic collision/merging FRC experiment. The developed neutron detector has sufficient performance of neutron sensitivity and nanosecond response time. In the collisional merging process, we obtained a signal that could be considered a neutron, which is not predicted by the adiabatic compression process in the two-dimensional magnetohydrodynamics simulation.

An analysis of osteoporosis in patients with hereditary multiple exostoses

We analyzed osteoporosis in 20 HME patients. According to the T-score of BMD, 30% and 67.5% of the patients fell in the range of osteopenia in the lumbar spine and femoral neck. Our results indicate HME patients have low bone mass. They do not have abnormal bone metabolism.

INTRODUCTION

There are few reports of osteoporosis in hereditary multiple exostoses (HME) patients. Therefore, the purpose of this study was to analyze osteoporosis in HME patients.

METHODS

This retrospective cohort study included 20 patients diagnosed with HME. Patients underwent bone mineral density (BMD) measurement of the lumbar spine (n = 20) and femoral neck (n = 40). Bone metabolic parameters, including serum osteocalcin and urinary cross-linked N-telopeptide of type 1 collagen (NTx), were analyzed in all subjects. EXT1 and EXT2 genes were sequenced using genomic DNA. We also examined the correlation between genotype and BMD Z-score and T-score.

RESULTS

The mean BMD values of the lumbar spine were 1.085 ± 0.116 g/cm² (n = 11) in male and 1.108 ± 0.088 g/cm² (n = 9) in female. The mean BMD values of the femoral neck area were 0.759 ± 0.125 g/cm² (n = 22) in male and 0.749 ± 0.115 g/cm² (n = 18) in female. Z-score of most HME patients show < 0, indicating that these patients tend to have low bone mass compared with the age-matched population. According to the T-score of BMD, 30% (6 of 20) and 67.5% (27 of 40) of the patients fell in the range of osteopenia in the lumbar spine and femoral neck areas, respectively. Serum osteocalcin and urinary NTx were in the normal range in most patients. There was no significant correlation between genotypes and Z-score.

CONCLUSION

HME patients have low bone mass, especially in the femoral neck area. They do not have abnormal bone metabolism, and there was no correlation between genotypes and Z-score.

Derivation and validation of a novel score to detect heart failure with preserved ejection fraction in patients with atrial fibrillation: the Fushimi AF registry

Background

Heart failure with preserved ejection fraction (HFpEF) is an important comorbidity of atrial fibrillation (AF). However, it is sometimes difficult to detect HFpEF among AF patients with preserved EF, since AF and HF share similar symptoms.

Purpose

The aim of this study was to identify factors associated with having HFpEF in AF patients with preserved EF, and derive a new score for HFpEF in AF patients.

Methods

The Fushimi AF Registry is a community-based prospective survey of the AF patients in Fushimi-ku, Kyoto, Japan. Follow-up data were available for 4,466 patients, and 3,083 patients had preserved EF (≥50%). Of the 3,083 patients, 444 had prior HF hospitalization at baseline and we defined these patients as HFpEF. We examined the factors associated with having HFpEF, and derived a new score for detecting HFpEF in AF patients. Thereafter, we validated this score in patients without prior HF hospitalization.

Result

The mean age of the patients with EF ≥50% was 73.6 years, and 41.3% were female. Compared with the patients without prior HF hospitalization, HFpEF patients were older, more often female, less in body weight, had more heart disease (valvular heart disease, cardiomyopathy, old myocardial infarction, and coronary artery disease), chronic kidney diseases (CKD), anemia (Hb &lt;11 g/dL), sustained AF (persistent or permanent), left atrial enlargement (&gt;45 mm), and dilation of cardio-thoracic ratio (CTR) (&gt;54%) at baseline. In multivariate analysis, heart diseases, CKD, sustained AF, dilatation of CTR, left atrial enlargement, and anemia were significantly associated with HFpEF (Table 1). We derived a new score to diagnose HFpEF in AF patients (2 points for heart diseases, 1 point for CKD, sustained AF, dilatation of CTR, left atrial enlargement, and anemia; range 0 to 7 points). In a receiver-operating characteristic curve, optimal cut-off point for detecting HFpEF was 3 (Figure 1). We validated this score in patients without prior hospitalization for HF (n=2,639). Of these, 298 patients had HF symptoms of NYHA 2–4 (Symptomatic-HF), and 2,341 patients had neither prior HF hospitalization nor HF symptoms (No-HF). Notably, 207 patients (69.5%) in symptomatic-HF group and 748 patients (32.0%) in No-HF group were classified into HFpEF based on this new score. Furthermore, patients diagnosed as HFpEF by this score had higher incidence of new hospitalization for HF during the follow-up in both symptomatic-HF group and No-HF group. (Figure 2).

Conclusion

We derived a new score to diagnose HFpEF in AF patients based on the presence of prior HF hospitalization (2 points for heart diseases, 1 point for CKD, sustained AF, dilatation of CTR, left atrial enlargement, and anemia). In patients without prior HF hospitalization, sizable number of patients had high HFpEF score (≥3), and those patients showed higher incidence of new HF hospitalization.

Funding Acknowledgement

Type of funding source: None

Clinical outcomes of Japanese atrial fibrillation patients with combined valvular heart disease: the Fushimi AF Registry

Background

We previously reported that valvular heart disease (VHD) was not at the significant risk of stroke/systemic embolism (SE), but was associated with an increased risk of hospitalization for heart failure (HF) in Japanese atrial fibrillation patients. However, the impact of combined VHD on clinical outcomes has been little known.

Purpose

The aim of this study is to investigate the prevalence of combined VHD and its clinical characteristics and impact on outcomes such as stroke/SE, all-cause death, cardiac death and hospitalization for HF.

Method

The Fushimi AF Registry is a community-based prospective survey of AF patients in one of the wards of our city which is a typical urban district of Japan. We started to enroll patients from March 2011, and follow-up data were available for 4,466 patients by the end of November 2019. In the entire cohort, echocardiography data were available for 3,574 patients. 68 AF patients with prosthetic heart valves were excluded and we compared clinical characteristics and outcomes between 488 single VHD (103 Aortic valve disease (AVD), 315 mitral valve disease (MVD), 70 tricuspid valve disease (TVD)) and 158 combined VHD (46 AVD and MVD, 11 AVD and TVD, 66 MVD and TVD, 35 AVD and MVD and TVD).

Result

Compared with single VHD, patients with combined VHD were older (combined vs. single VHD: 78.5 vs. 76.0 years, respectively; p&lt;0.01), more likely to have persistent/permanent type AF (73.4% vs. 63.9%, p=0.02) and prescription of warfarin (63.1% vs. 53.8%, p=0.04). Combined VHD was less likely to have diabetes mellitus (13.9% vs. 23.6%, p=0.01) and dyslipidemia (26.6% vs. 40.4%, p&lt;0.01). Sex, body weight, hypertension, pre-existing HF were comparable between the two groups.

During the median follow-up of 1,474 days, the incidence rate of stroke/SE was not significantly different between the two groups (1.58 vs. 1.89 per 100 person-years, respectively, log rank p=0.10). The incidence rate of all-cause death (7.35 vs. 5.33, p=0.65), cardiac death (1.20 vs. 0.99, p=0.91) and hospitalization for HF (5.55 vs. 4.43, p=0.53) were also not significantly different. We previously reported AVD had significant impacts on cardiac adverse outcomes in AF patients, and we further analyzed event rates between combined VHD including AVD (AVD and MVD/TVD) and without AVD (MVD and TVD). Combined VHD with AVD group had higher incidence rate of all-cause death (10.7 vs. 5.79, p=0.03) than that without AVD group. However, the incidence rate of stroke/SE (1.98 vs. 1.56, p=0.59), cardiac death (0.98 vs. 1.14, p=0.68), hospitalization for HF (8.03 vs. 5.38, p=0.17) were not significantly different between the two groups.

Conclusion

As compared with single VHD, the risk of stroke/SE, all-cause death, cardiac death and hospitalization for HF in combined VHD was not significantly different. Among patients with combined VHD, those having AVD had higher incidence rate of all-cause death than those without AVD.

Figure 1

Funding Acknowledgement

Type of funding source: None

The relationship between diastolic blood pressure and the risk of cardiovascular events in patients with atrial fibrillation: the Fushimi AF registry

Background

Hypertension is one of the major risk factors of cardiovascular events in patients with atrial fibrillation (AF). However, relationship between diastolic blood pressure (DBP) and cardiovascular events in AF patients remains unclear.

Methods

The Fushimi AF Registry is a community-based prospective survey of AF patients in Japan. Follow-up data were available in 4,466 patients, and 4,429 patients with available data of DBP were examined. We divided the patients into three groups; G1 (DBP&lt;70 mmHg, n=1,946), G2 (70≤DBP&lt;80, n=1,321) and G3 (80≤DBP, n=1,162), and compared the clinical background and outcomes between groups.

Results

The proportion of female was grater in G1 group, and the patients in G1 group were older and had higher prevalence of heart failure (HF), diabetes mellitus (DM), chronic kidney disease (CKD). Prescription of beta blockers was higher in G1 group, but that of renin-angiotensin system-inhibitors and calcium channel blocker was comparable. During the median follow-up of 1,589 days, in Kaplan-Meier analysis, the incidence rates of cardiovascular events (composite of cardiac death, ischemic stroke and systemic embolism, major bleeding and HF hospitalization during follow up) were higher in G1 group and G3 group than G2 group (Figure 1). When we divided the patients based on the systolic blood pressure (SBP) at baseline (≥130 mmHg or &lt;130 mmHg), the incidence of rates of cardiovascular events were comparable among groups. Multivariate Cox proportional hazards regression analysis including female gender, age (≥75 years), higher SBP (≥130 mmHg), DM, pre-existing HF, CKD, low left ventricular ejection fraction (&lt;40%) and DBP (G1, G2, G3) revealed that DBP was an independent determinant of cardiovascular events (G1 group vs. G2 group; hazard ratio (HR): 1.40, 95% confidence intervals (CI): 1.19–1.64, G3 group vs. G2 group; HR: 1.23, 95% CI: 1.01–1.49). When we examined the impact of DBP according to 10 mmHg increment, patients with very low DBP (&lt;60 mmHg) (HR: 1.50,95% CI:1.24–1.80) and very high DBP (≥90 mmHg) (HR: 1.51,95% CI:1.15–1.98) had higher incidence of cardiovascular events than patients with DBP of 70–79 mmHg (Figure 2). However, when we examined the impact of SBP according to 20 mmHg increment, SBP at baseline was not associated with the incidence of cardiovascular events (Figure 3).

Conclusion

In Japanese patients with AF, DBP exhibited J curve association with higher incidence of cardiovascular events.

Funding Acknowledgement

Type of funding source: None

Aggressive lipid lowering therapy with pitavastatin and ezetimibe improve cardiovascular outcomes in patients with ST segment elevation myocardial infarction: insights from the HIJ-PROPER Study

Aims

The purpose of this study was to evaluate the effect of aggressive lipid-lowering therapy with pitavastatin and ezetimibe in patients with ST-segment elevation myocardial infarction (STEMI) as compared with those with other classification of an acute coronary syndrome (ACS) including non-STEMI (NSTEMI) and unstable angina pectoris (UA).

Methods

This is a post hoc sub-analysis of the HIJ-PROPER study. In the original study, ACS patients with dyslipidemia were randomized to either pitavastatin + ezetimibe therapy or pitavastatin monotherapy. In the present analysis, we divided HIJ-PROPER participants into the STEMI group (n=880) and NSTEMI + UA group (n=841). Cardiovascular events were analyzed between the two groups. The primary endpoint was a composite of major advanced cardiovascular events (MACE; all-cause death, non-fatal myocardial infarction, non-fatal stroke, unstable angina pectoris, and ischemia-driven revascularization)

Result

During median follow-up period of 3.4 years, the cumulative incidence of the primary endpoint in STEMI group was 31.9% in the pitavastatin+ezetimibe therapy, compared with 39.7% in the pitavastatin-monotherapy (HR, 0.77; 95% CI, 0.62–0.97; p=0.02). However, there was no effect of pitavastatin+ezetimibe therapy on the primary endpoint in the NSTEMI + UA group. Concerning the individual components of the primary endpoint in STEMI group, the percentage of occurrence of all-cause death was significantly lower in the pitavastatin+ezetimibe therapy compared to pitavastatin mono-therapy (14 patients (3.2%) vs. 31 patients (6.9%), respectively; HR, 0.45; 95% CI, 0.23–1.84, p=0.01). Multivariate analysis revealed that use of ezetimibe and prevalence of diabetes mellitus at baseline were independent predictors of primary endpoints in STEMI group (HR, 0.79; 95% CI, 0.63–0.99; p=0.04 for use of ezetimibe, HR 1.54; 95% CI, 1.22–1.94, p=0.0003 for diabetes mellitus).

Conclusion

Patients with pitavastatin+ezetimibe therapy as compared with pitavastatin-monotherapy had lower cardiovascular event in patients with ST-segment elevation myocardial infarction.

Kaplan-Meier curves for primary endpoint

Funding Acknowledgement

Type of funding source: None

Adverse outcomes after worsening renal function in patients with atrial fibrillation: the Fushimi AF Registry

Background

Patients with atrial fibrillation (AF) commonly coexist with chronic kidney disease (CKD). Non-vitamin K antagonist oral anticoagulants (NOAC) are recommended for stroke prevention in patients with non-valvular atrial fibrillation (AF), and worsening renal function (WRF) as well as CKD is an important issue in using NOAC. However, little is known about the clinical outcomes of patients after WRF.

Purpose

We aimed to investigate outcomes after WRF in AF patients.

Methods

The Fushimi AF Registry is a community-based prospective survey of the AF patients in our city. Follow-up data including prescription status were available for 4,441 patients. Of them, 1,890 patients who have baseline and at least 1 follow-up creatinine clearance (CrCl) measurements, estimated by the Cockcroft-Gault formula, were analyzed in the present study. WRF was defined as a decrease of ≥20% from baseline CrCl measurement at any time point during follow-up. We evaluated demographics and outcomes after WRF in AF patients.

Results

During the median follow-up period of 2,194 days, mean CrCl decrease of 2.2 ml/min/year was observed and WRF occurred in 981 patients (51.9%). Patients with WRF were significantly more often female (with vs. without WRF; 40.3% vs. 35.4%; p=0.03), older (73.4 vs. 71.1 years of age; p&lt;0.01), more often paroxysmal type (49.9% vs. 47.1%; p&lt;0.01), and more likely to have prior stroke (17.9% vs. 12.7%; p&lt;0.01), heart failure (30.8% vs. 24.8%; p&lt;0.01), diabetes (31.7% vs. 27.1%; p=0.03), and coronary artery disease (19.9% vs. 12.1%; p&lt;0.01) than those without WRF. Co-existing of CKD and mean CrCl at baseline were comparable (37.4% vs. 36.9%; p=0.82, 65.3 vs. 63.5 ml/min; p=0.66, respectively). Mean CHA2DS2-VASc score was significantly higher in WRF patients (3.55 vs. 3.03; p&lt;0.01). On landmark analysis, all-cause mortality occurred in 135 patients (8.6 /100 person-years) after WRF and 82 patients (1.7 /100 person-years) without WRF, with an adjusted hazard ratio (HR) of 6.33 (95% confidence interval [CI], 4.33–9.50; p&lt;0.01), adjusted by sex, age, body weight, serum creatinine, type of AF, oral anticoagulant prescription and comorbidities. Stroke or systemic embolism occurred in 45 patients after WRF (3.0 /100 person-years) and 78 (1.7 /100 person-years) patients without WRF (adjusted HR 1.60 [95% CI, 1.04–2.49; p=0.03]) (Figure).

Conclusions

AF patients after WRF had higher incidence of various adverse events.

Incidence of Adverse Outcomes

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): The Practical Research Project for Life-Style related Diseases including Cardiovascular Diseases and Diabetes Mellitus from Japan Agency for Medical Research and Development. Boehringer Ingelheim, Bayer Healthcare, Pfizer, Bristol-Myers Squibb, Astellas Pharma, AstraZeneca, Daiichi-Sankyo, Novartis Pharma, MSD, Sanofi-Aventis, and Takeda Pharmaceutical.

Clinical impact of regression from sustained to paroxysmal atrial fibrillation: the Fushimi AF registry

Background

Atrial fibrillation (AF) commonly progresses from paroxysmal type to sustained type in the natural course of the disease, and we previously demonstrated that the progression of AF was associated with increased risk of clinical adverse events. There are some patients, though less frequently, who regress from sustained to paroxysmal AF, but the clinical impact of the regression of AF remains unknown.

Purpose

We sought to investigate whether regression from sustained to paroxysmal AF is associated with better clinical outcomes.

Methods

Using the dataset of the Fushimi AF Registry, patients who were diagnosed as sustained (persistent or permanent) AF at baseline were studied. Conversion of sustained AF to paroxysmal AF during follow-up was defined as regression of AF. Major adverse cardiac events (MACE) were defined as the composite of cardiac death, stroke, and hospitalization for heart failure (HF). Event rates were compared between the patients with and without regression of AF. In patients with sustained AF at baseline, predictors of MACE were identified using Cox proportional hazards model.

Results

Among 2,253 patients who were diagnosed as sustained AF at baseline, regression of AF was observed in 9.0% (202/2,253, 2.0 per 100 patient-years) during a median follow-up of 4.0 years. Of these, 24.3% (49/202, 4.6 per 100 patient-years) of the patients finally recurred to sustained AF during follow-up. The proportion of asymptomatic patients was lower in patients with regression of AF than those without (with vs without regression; 49.0% vs 69.5%, p&lt;0.01). The percentage of beta-blocker use at baseline was similar between the two groups (37.2% vs 33.8%, p=0.34). The prevalence of patients who underwent catheter ablation or electrical cardioversion during follow-up was higher in patients with regression of AF (catheter ablation: 15.8% vs 5.5%; p&lt;0.01, cardioversion: 4.0% vs 1.4%; p&lt;0.01, respectively). The rate of MACE was significantly lower in patients with regression of AF as compared with patients who maintained sustained AF (3.7 vs 6.2 per 100 patient-years, log-rank p&lt;0.01). Figure shows the Kaplan-Meier curves for MACE, cardiac death, hospitalization for heart failure, and stroke. In patients with sustained AF at baseline, multivariable Cox proportional hazards model demonstrated that regression of AF was an independent predictor of lower MACE (adjusted hazard ratio [HR]: 0.50, 95% confidence interval [CI]: 0.28 to 0.88, p=0.02), stroke (HR: 0.51, 95% CI: 0.30 to 0.88, p=0.02), and hospitalization for HF (HR: 0.50, 95% CI: 0.29 to 0.85, p=0.01).

Conclusion

Regression from sustained to paroxysmal AF was associated with a lower incidence of adverse cardiac events.

Funding Acknowledgement

Type of funding source: None

Plasma natriuretic peptide level is an independent determinant of major clinical outcomes in atrial fibrillation patients without heart failure: the Fushimi AF Registry

Background

Atrial fibrillation (AF) increases the risk of death, stroke/systemic embolism and heart failure (HF). Plasma natriuretic peptide (NP) level is an important prognostic marker in HF patients. However, little is known regarding the prognostic significance of plasma NP level in AF patients without HF.

Purpose

The aim of this study is to investigate the relationship between plasma NP level and clinical outcomes such as all-cause death, stroke/systemic embolism and HF hospitalization during follow-up period in AF patients without HF.

Methods

The Fushimi AF Registry is a community-based prospective survey of AF patients in our city. The inclusion criterion of the registry is the documentation of AF at 12-lead electrocardiogram or Holter monitoring at any time, and there are no exclusion criteria. We started to enroll patients from March 2011, and follow-up data were available for 4,466 patients by the end of November 2019. From the registry, we excluded 1,220 patients without a pre-existing HF (defined as having one of the following; prior hospitalization for HF, New York Heart Association class ≥2, or left ventricular ejection fraction &lt;40%). Among 3,246 AF patients without HF, we investigated 1,189 patients with the data of plasma BNP (n=401) or N-terminal pro-BNP (n=788) level at the enrollment. We divided the patients according to the quartile of each plasma BNP or NT-pro BNP level and compared the backgrounds and outcomes between these 4 groups stratified by plasma NP level.

Results

Of 1,189 patients, the mean age was 72.1±10.2 years, 454 (38%) were female and 684 (58%) were paroxysmal AF. The mean CHADS2 and CHA2DS2-VASc score were 1.6±1.1 and 2.9±1.5, respectively. Oral anticoagulants were prescribed in 671 (56%) at baseline. The median (interquartile range) BNP and N-terminal pro-BNP level were 84 (38, 176) and 500 (155, 984) pg/ml, respectively. Patients with high plasma NP level were older, and demonstrated lower prevalence of paroxysmal AF, higher CHADS2 and CHA2DS2-VASc scores and higher prevalence of chronic kidney disease and oral anticoagulants prescription (all P&lt;0.01). A total of 165 all-cause death, 114 stroke/systemic embolism and 103 HF hospitalization occurred during the median follow-up period of 5.0 years. Kaplan-Meier curves demonstrated that higher plasma NP level was significantly associated with the incidences of all-cause death, stroke/systemic embolism and HF hospitalization in AF patients without HF (Figure 1A). Multivariable Cox regression analysis revealed that plasma NP level could stratify the risk of clinical outcomes even after adjustment by type of AF, CHA2DS2-VASc score, chronic kidney disease and oral anticoagulant prescription (Figure 1B).

Conclusion

Plasma NP level is a significant prognostic marker for all-cause death, stroke/systemic embolism and HF hospitalization in AF patients without HF, suggesting the importance of measuring plasma NP level in AF patients even without HF.

Figure 1

Funding Acknowledgement

Type of funding source: None

Impact of comprehensive management on clinical outcomes in hypertensive patients with coronary artery disease: HIJ-CREATE sub-study

Background

There are limited data on the effects of blood pressure (BP) control and lipid lowering in secondary prevention of coronary artery disease (CAD) patients. We report a secondary analysis of the effects of BP control and lipid management in participants of the HIJ-CREATE, a prospective randomized trial.

Methods

HIJ-CREATE was a multicenter, prospective, randomized, controlled trial that compared the effects of candesartan-based therapy with those of non-ARB-based standard therapy on major adverse cardiac events (MACE; a composite of cardiovascular death, non-fatal myocardial infarction, unstable angina, heart failure, stroke, and other cardiovascular events requiring hospitalization) in 2,049 hypertensive patients with angiographically documented CAD. In both groups, titration of antihypertensive agents was performed to reach the target BP of &lt;130/85 mmHg. The primary endpoint was the time to first MACE. Incidence of endpoint events in addition to biochemistry tests and office BP was determined during the scheduled 6, 12, 24, 36, 48, and 60-month visits. Achieved systolic BP and LDL-Cholesterol (LDL-C) level were defined as the mean values of these measurements in patients who did not develop MACEs and as the mean values of them prior to MACEs in those who developed MACEs during follow-up.

Results

During a median follow-up of 4.2 years (follow-up rate of 99.6%), the primary outcome occurred in 304 patients (30.3%). Among HIJ-CREATE participants, 905 (44.2%) were prescribed statins on enrollment. Kaplan–Meier curves for the primary outcome revealed that there was no relationship between statin therapy and MACEs in hypertensive patients with CAD. The original HIJ-CREATE population was divided into 9 groups based on equal tertiles based on mean achieved BP and LDL-C during follow-up. For the analysis of subgroups, estimates of relative risk and the associated 95% CIs were generated with a Cox proportional-hazards model (Figure 1). The relation between LDL cholesterol level and hazard ratios for MACEs was nonlinear, with a significant increase of MACEs only in the patients with inadequate controlled LDL-C level even in the patients with tightly controlled BP.

Conclusions

The results of the post-hoc analysis of the HIJ-CREATE suggest that clinicians should pay careful attention to conduct comprehensive management of lipid lowering even in the contemporary BP lowering for the secondary prevention in hypertensive patients with CAD.

Figure 1

Funding Acknowledgement

Type of funding source: None

Lower levels of high-density lipoprotein cholesterol are associated with increased cardiovascular events in patients with acute coronary syndrome receiving contemporary lipid-lowering therapy

Background

This study aimed to elucidate whether high-density lipoprotein cholesterol (HDL-C) at 3-month follow-up for patients receiving contemporary lipid-lowering therapy after acute coronary syndrome (ACS) could predict cardiac events.

Methods

The HIJ-PROPER study was a multicenter, prospective, randomized trial comparing intensive lipid-lowering therapy (pitavastatin + ezetimibe) and conventional lipid-lowering therapy (pitavastatin monotherapy) after ACS. For the present analysis, the entire cohort was divided into three groups according to HDL-C levels at 3-month follow-up (Group 1, HDL-C ≤43 mg/dL; Group 2, 43–53.6 mg/dL; Group 3; HDL-C ≥53.6 mg/dL). Baseline characteristics and the incidence of the primary endpoint (a composite of all-cause death, non-fatal myocardial infarction, non-fatal stroke, unstable angina pectoris, or ischemia-driven revascularization) were compared among the three groups.

Results

The primary endpoint was reported in 34.8%, 30.1%, and 24.6% of patients in Groups 1, 2, and 3, respectively. The incidence of the primary endpoint was significantly higher in Group 1 than in Group 3 (hazard ratio [HR], 1.5; 95% confidence interval [CI], 1.19–1.9; p=0.001). Irrespective of the treatment regimen, Group 1 had a significantly higher rate of the primary endpoint than Group 3 (pitavastatin + ezetimibe therapy: HR, 1.6; 95% CI, 1.12–2.22; p=0.01 and pitavastatin monotherapy: HR, 1.4; 95% CI, 1.05–1.98; p=0.02). These trends remained even after adjustment for baseline characteristics and lipid profiles.

Conclusions

Lower levels of HDL-C at 3-month follow-up are associated with higher incidence of the cardiovascular events in patients with acute coronary syndrome receiving contemporary lipid-lowering therapy.

HDL-C levels and Cardiovascular events

Funding Acknowledgement

Type of funding source: None

Heparan sulfate deficiency leads to hypertrophic chondrocytes by increasing bone morphogenetic protein signaling

OBJECTIVE

Exostosin-1 (EXT1) and EXT2 are the major genetic etiologies of multiple hereditary exostoses and are essential for heparan sulfate (HS) biosynthesis. Previous studies investigating HS in several mouse models of multiple hereditary exostoses have reported that aberrant bone morphogenetic protein (BMP) signaling promotes osteochondroma formation in Ext1-deficient mice. This study examined the mechanism underlying the effects of HS deficiency on BMP/Smad signaling in articular cartilage in a cartilage-specific Ext^-/- mouse model.

METHOD

We generated mice with a conditional Ext1 knockout in cartilage tissue (Ext1-cKO mice) using Prg4-Cre transgenic mice. Structural cartilage alterations were histologically evaluated and phospho-Smad1/5/9 (pSmad1/5/9) expression in mouse chondrocytes was analyzed. The effect of pharmacological intervention of BMP signaling using a specific inhibitor was assessed in the articular cartilage of Ext1-cKO mice.

RESULTS

Hypertrophic chondrocytes were significantly more abundant (P = 0.021) and cartilage thickness was greater in Ext1-cKO mice at 3 months postnatal than in control littermates (P = 0.036 for femur; and P < 0.001 for tibia). However, osteoarthritis did not spontaneously occur before the 1-year follow-up. matrix metalloproteinase (MMP)-13 and adamalysin-like metalloproteinases with thrombospondin motifs(ADAMTS)-5 were upregulated in hypertrophic chondrocytes of transgenic mice. Immunostaining and western blotting revealed that pSmad1/5/9-positive chondrocytes were more abundant in the articular cartilage of Ext1-cKO mice than in control littermates. Furthermore, the BMP inhibitor significantly decreased the number of hypertrophic chondrocytes in Ext1-cKO mice (P = 0.007).

CONCLUSIONS

HS deficiency in articular chondrocytes causes chondrocyte hypertrophy, wherein upregulated BMP/Smad signaling partially contributes to this phenotype. HS might play an important role in maintaining the cartilaginous matrix by regulating BMP signaling.

Long-term prognostic significance of dispersion of ventricular repolarization in patients with cardiac sarcoidosis

Background

Although the presence of cardiac involvement is recognised as a determinant of worse clinical outcomes in sarcoidosis patients, the determinants of adverse outcomes in patients with cardiac sarcoidosis (CS) have not been well understood. T-peak to T-end interval (TpTe) on the surface electrocardiogram (ECG) was proposed as a marker of dispersion of ventricular repolarisation. Prolonged TpTe to QT interval ratio (TpTe/QT) represents a period of potential vulnerability to reentrant ventricular arrhythmias. Notably, prolonged TpTe/QT has been associated with increased risk of mortality in hypertrophic cardiomyopathy, congenital long-QT syndrome, and Brugada syndrome. However, its prognostic implication in patients with CS is unclear.

Purpose

We sought to investigate whether TpTe/QT was associated with long-term clinical outcomes in patients with CS.

Methods

A total of 108 consecutive CS patients between August 1986 and March 2019 in two academic hospitals who had ECG data before initiation of immunosuppressive therapy were examined. We excluded patients who received pacemaker (n=15) or cardiac resynchronization therapy (n=3) at the time of ECG. Ultimately, 90 CS patients were included in this study. All standard 12-lead ECGs were recorded at 25 mm/s with an amplification of 10 mm/mV. TpTe was measured from the peak of T wave to the end of T wave which defined as the intersection of the tangent to the down slope of the T wave and the isoelectric line. Lead V5 was selected for the analyses. If V5 is not suitable for analyses, V4 was selected. The primary outcome was the composite of advanced atrioventricular block (AVB), ventricular tachycardia or ventricular fibrillation (VT/VF), heart failure hospitalisation and all-cause death.

Results

During a median follow-up period of 4.70 (interquartile range [IQR] 2.06–7.23) years, adverse events occurred in 21 patients (23.3%), including 2 advanced AVB, 12 VT/VF, 4 heart failure hospitalisation and 3 all-cause death. Events group had higher TpTe/QT compared to no events group (0.231 [IQR 0.193–0.261] vs. 0.282 [IQR 0.263–0.304] P&lt;0.001). Kaplan-Meier analyses revealed that the primary outcome, especially VT/VF or sudden cardiac death more frequently occurred in patients with higher TpTe/QT (≥0.242, the median) compared to those with lower TpTe/QT (Figure 1). Multivariable Cox regression analysis showed that higher TpTe/QT was independently associated with increased subsequent risk of adverse events (hazard ratio 1.09, 95% confidence interval [CI] 1.02–1.17, P=0.014) even after adjustment for age, sex and left ventricular ejection fraction. Furthermore, the optimal cut-off value of TpTe/QT for the discriminatory of primary outcome was 0.257, and c-index was 0.77 (95% CI 0.64–0.89).

Conclusions

Higher TpTe/QT was associated with worse long-term clinical outcomes in patients with CS. Our findings indicate the importance of assessing TpTe/QT for risk stratification in patients with CS.

Figure 1

Funding Acknowledgement

Type of funding source: None

The relationship between sucrose intake in coffee or tea, and root or coronal caries in an elderly Japanese population

OBJECTIVES

Few studies have examined the effect of sucrose intake in coffee or tea (SCT) on dental caries, especially root caries, in elderly people. The purpose of the present study was to examine the associations between SCT and the prevalence of root or coronal caries in community-dwelling elderly Japanese.

METHODS

Participants were 370 elders aged 75 years from a larger cohort study of elders in Niigata City, Japan. Dietary habits during the preceding month were assessed with a validated brief self-administered diet history questionnaire (BDHQ). The caries examination was conducted using mirror and ball-pointed periodontal probes under artificial light. Poisson regression analysis was performed to analyze the prevalence-rate ratios (PRRs) between SCT and the root or coronal caries. The number of root or coronal caries was selected as the dependent variable for the analysis. Then, SCT (tertiles labeled low, medium and high) and other 4 variables were selected as independent variables.

RESULTS

The PRRs between the number of root caries lesions and SCT were signifi cantly higher in the second (medium intake, 1.38, p ⟨ 0.001) and third tertiles (high intake, 2.07, p ⟨ 0.001). Similar tendencies were seen for the number of coronal caries lesions (PRRs in the second and third tertiles 1.74 and 2.46, respectively, both p ⟨ 0.001).

CONCLUSION

A significant positive relationship was observed between sucrose in coffee and tea and the number of coronal or root caries lesions in community-dwelling elderly Japanese.

P5390Adipolin/C1q/Tnf-related protein 12 attenuates adverse cardiac remodeling in a mouse model of myocardial infarction

Background

Ischemic heart disease is one of leading causes of death worldwide. Obesity is closely linked to the development of cardiovascular diseases including ischemic heart disease. Adipose tissue produces various secretory bioactive proteins called as adipokines, and dysregulation of adipokine production contributes to the pathogenesis of obesity-related complications. Previously we identified adipolin, also referred to as C1q/Tnf-related protein12, as an insulin-sensitizing adipokine that is down-regulated in obesity. Here, we investigated the effects of adipolin on cardiac remodeling in a mouse model of myocardial infarction (MI).

Method

Male adipolin-knockout (APL-KO) and wild-type (WT) mice were subjected to the permanent ligation of the left anterior descending coronary artery to create MI. Echocardiographic and histological analyses were performed to evaluate cardiac function and myocardial remodeling at 4 weeks after MI. Apoptosis was detected by terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assay. Cardiomyocyte cross sectional area was evaluated by Wheat Germ Agglutinin staining. Perivascular fibrosis was assessed by Masson's trichrome staining. Neonatal rat ventricular myocytes were used as cultured cardiac myocytes for in vitro study.

Results

APL-KO mice exhibited increased ratios of the heart weight/body weight and lung weight/body weight after MI compared with WT mice. APL-KO mice showed increased left ventricular diastolic diameter and decreased fractional shortening after MI compared with WT mice. APL-KO mice had increases in myocardial apoptosis, cardiomyocyte hypertrophy and perivascular fibrosis at the remote zone of infarct hearts as compared with WT mice. Treatment of cultured cardiomyocytes with adipolin protein reduced apoptosis in response to 24 hours of hypoxia. Treatment with adipolin protein also increased the phosphorylation of Akt in cardiomyocytes. Inhibition of PI3 kinase/Akt signaling by LY294002 reversed the anti-apoptotic effects of adipolin in cultured cardiomyocytes.

Conclusion

Our data indicate that adipolin prevents pathological myocardial remodeling after chronic ischemia, at least in part, by suppressing myocardial apoptosis through an Akt-dependent mechanism.

P3771Validation of risk scoring system predicting for progression of atrial fibrillation: the Fushimi AF Registry

Background

Atrial fibrillation (AF) increases the risks of thromboembolism and death. Progression from paroxysmal to sustained types (persistent or permanent) of AF is sometimes seen in clinical practice. We recently reported that progression of AF was associated with increased risk of clinical adverse events in Japanese AF patients. However, risk stratification schemes of predicting the progression of AF has not been fully established.

Methods

The Fushimi AF Registry, a community-based prospective survey, was designed to enroll all of the AF patients in Fushimi-ku, Kyoto, which is a typical urban district of Japan with a population of 283,000. Follow-up data were available for 4,454 patients. We investigated the risk factors of AF progression and validated the performance of various risk scoring systems predicting for progression of AF, such as APPLE, BASE-AF2, HATCH, and MB-LATER score, using data from 995 paroxysmal AF patients (mean age; 72.6±11.4 years, female; 42.2%, mean CHA2DS2-VASc score; 3.26±1.67) whose echocardiogram data were obtained at baseline.

Results

Of 995 AF patients, during the median follow-up of 1,477 days, progression from paroxysmal to sustained AF occurred in 160 patients (16.1%; 4.0 per 100 person-years). On a multivariate model, we indicated that history of AF ≥2 years (odds ratio [OR] 1.83; 95% confidence interval [CI] 1.28–2.61), left atrial diameter ≥40 mm (OR 1.45; 95% CI 1.02–2.08), daily drinker (OR 1.56; 95% CI 1.24–2.81), and cardiomyopathy (OR 2.58; 95% CI 1.17–5.69) were significantly associated with higher incidence of AF progression. Our model had better predictive potential for AF progression (area under curve [AUC] 0.612; 95% CI 0.566–0.658) than the APPLE (AUC 0.553; 95% CI 0.508–0.598; p=0.06), BASE-AF2 (AUC 0.571; 95% CI 0.526–0.617; p=0.04), CHADS2 (AUC 0.508; 95% CI 0.462–0.554; p<0.01), CHA2DS2-VASc (AUC 0.501; 95% CI 0.453–0.548; p<0.01), HATCH (AUC 0.502; 95% CI 0.456–0.548; p<0.01), and MB-LATER (AUC 0.528; 95% CI 0.483–0.572; p<0.01) score.

Conclusion

We identified 4 risk factors which may be useful to predict for progression of AF in Japanese patients. External validation of our model in other cohorts is needed.

Acknowledgement/Funding

Boehringer, Bayer, Pfizer, Bristol-Myers, Astellas, AstraZeneca, Daiichi Sankyo, Novartis, MSD, Sanofi and Takeda. Japan Agency for Medical Research