Antibody response in patients with autoimmune inflammatory rheumatic disease after pneumococcal polysaccharide prime vaccination or revaccination

OBJECTIVE

The aim of the study was to assess the pneumococcal antibody response in autoimmune inflammatory rheumatic disease (AIIRD) patients receiving 23-valent pneumococcal polysaccharide vaccine (PPV23) as a prime vaccination or revaccination.

METHOD

Antibodies to 12 serotypes occurring in the commonly applied pneumococcal vaccines in Denmark were measured in AIIRD patients receiving biological disease-modifying anti-rheumatic drug (bDMARD) treatment for rheumatoid arthritis, spondyloarthritis, or psoriatic arthritis. Patients with a non-protective level of pneumococcal antibodies (geometric mean pneumococcal antibody level < 1 μg/mL) were invited to receive vaccination with PPV23 followed by control of antibody titre 3 months later.

RESULTS

In total, 224 (74%) of 301 patients were included in the analyses, of whom 126 patients had previously received PPV23 vaccination. Post-vaccination antibody measurement revealed that only 80 patients (36%) achieved a protective level of antibodies. In a multivariable logistic regression analysis, significantly more patients without a previous PPV23 vaccination history achieved a protective antibody level compared with patients with a history of PPV23 vaccination less than 5 years ago (p = 0.005). This difference was not seen when comparing the former group with patients vaccinated 5 years ago or more. Methotrexate (MTX) treatment at the time of vaccination was associated with a non-protective antibody level (p < 0.001).

CONCLUSION

Only 36% of patients with a non-protective antibody level achieved a protective level in response to pneumococcal vaccination. Pneumococcal vaccination within the last 5 years and MTX treatment at the time of vaccination were independently associated with a poor antibody response.

Dissociation between two-dimensional and three-dimensional echocardiography – clinical implications

Objectives

To investigate the agreement between two-dimensional (2DE) and three-dimensional echocardiography (3DE) in a general population, along with clinical impact of the differences.

Background

Left ventricular ejection fraction (LVEF) has prognostic value and is used to guide cardiac treatment. The preferred technique is two-dimensional (2D) echo, although three-dimensional (3D) echo is more accurate when compared to MRI. Our study evaluates the agreement between 2D and 3D LVEF and the potential clinical impact of disagreements.

Methods

Study population ware participants from the Copenhagen City Heart Study, who underwent 2DE and 3DE between 2011–2014. Means of difference (MD) were assessed in participant groups with a LVEF below 40%, 40–50%, and above 50%. Age-adjusted Cox proportional hazard ratios (HR) were calculated for all-cause mortality, major adverse cardiovascular event (MACE) and cardiac event of any kind.

Results

In total 2554 participants from the Copenhagen City Heart Study were included. Median age was 58.3 (IQR: 44.2–69.8) years and 1137 (44.5%) were male. Mean LVEF in 2D was 56.6% (95% CI: 56.4–56.9%) and 52.0% (95% CI: 51.7–52.4%) in 3D, p&lt;0.05. MD increased the further LVEF deteriorated: −14.9% (95% CI: −16.0 to −13.9%) (LVEF &lt;40%), −9.3% (95% CI: −9.8 to −8.9%) (LVEF 40–50%) and −1.2% (95% CI: −1.6 to −0.9%) (LVEF ≥50%). 2DE overestimated the LVEF relative to 3D in 1824 (71.4%) instances.

3D LVEF &lt;40% was associated with a HR for all-cause mortality of 2.58 (95% CI: 1.55–4.31, p&lt;0.05), MACE: 1.90 (95% CI: 1.22–2.98, p&lt;0.05) and cardiovascular event: 1.61 (95% CI: 1.04–2.48, p&lt;0.05).

HR for 2D LVEF &lt;40% 0.84 (95% CI: 0.21–3.41, p=0.80) (all-cause), 3.12 (95% CI: 1.64–5.94, p&lt;0.05) (MACE) and 2.68 (95% CI: 1.42–5.09, p&lt;0.05) (cardiovascular event).

Conclusion

With declining LVEF, 2D echo is prone to significantly overestimate LVEF and a 3D LVEF less than 40% is associated with excess all-cause mortality but less with MACE and cardiovascular events when compared to 2D LVEF.

Funding Acknowledgement

Type of funding sources: None.

Serial high-sensitivity troponin T concentrations and long-term outcomes in patients with suspected acute coronary syndrome

Background

High-sensitivity troponin assays allow for accurate and rapid rule-in or rule-out of myocardial infarction (MI) among patients with acute-onset chest pain. However, prognostic implications of serial high-sensitivity troponin concentrations are unknown.

Purpose

To determine short- and long-term prognostic implications of high-sensitivity troponin T (hsTnT) concentrations and their changes from baseline, in patients with suspected acute coronary syndrome.

Methods

Retrospective cohort study based on Danish national registries. We identified all patients discharged from the hospital with either MI, unstable angina, suspected MI, or chest pain from January 2012 through December 2019 and merged these individuals with all records of two serial hsTnT measurements obtained ≤7 hours apart during the same hospitalization. The primary outcome was death at days 0–30 and 31–365. Prognostic implications of serial hsTnT were examined in accordance with the 2012 ESC algorithm stratifying patients for normal baseline concentrations and relative changes of 20% and 50% from baseline. In case of a normal baseline concentration, 20% and 50% of the upper reference level (14 ng/l) were used as thresholds instead, i.e., 3 ng/l and 7 ng/l, respectively. Absolute risks were calculated through multivariable logistic regression with average treatment effect modeling (G-formula).

Results

Complete data were available in 28,902 individuals (median age [25th-75th percentile] 65.2 [53.4–75.4] years, 11,632 [40.2%] women). Of these, 11,116 (38.5%) had a final diagnosis of MI, 1518 (5.3%) of unstable angina, and 16,268 (56.3%) of either suspected MI or chest pain. Median baseline hsTnT was 18 ng/l (25th-75th percentile, 10–69), second hsTnT 21 ng/l (25th-75th percentile, 10–248), relative hsTnT change 3.6% (25th-75th percentile, 0–66.7), and time between samples 4.0 hours (25th-75th percentile, 3.2–5.4). Most patients had either two normal hsTnT concentrations (9483, 32.8%) or two elevated hsTnT concentrations (18,235, 63.1%). At 30 days, 796 (2.8%) individuals had died, while an additional 1287 (4.6% of 30-day survivors) died between days 31–365. Baseline hsTnT and the relative hsTnT change both displayed a significant, non-linear association with death and interacted with each other (P&lt;0.001). Tables 1 and 2 show the standardized, absolute risks of death (with 95% confidence intervals) from days 0–30 and from days 31–365, respectively. Patients with two normal hsTnT concentrations had very low mortality rates, irrespective of the magnitude of relative change. Conversely, patients with two elevated hsTnT concentrations consistently had high mortality rates.

Conclusions

This is the first study to assess both short- and long-term outcomes as a function of both baseline hsTnT and its change from first to second measurement. In general, patients with two normal hsTnT concentrations have an excellent prognosis while those with two elevated concentrations require scrutiny.

Funding Acknowledgement

Type of funding sources: None.

Marital status, cardiovascular events, and intensive blood pressure lowering among men and women in the Systolic Blood Pressure Intervention Trial

Background

Married persons may have lower rates of mortality and cardiovascular disease (CV) than unmarried persons although data regarding potential differences between men and women are conflicting. The Systolic Blood Pressure Intervention Trial (SPRINT) found that intensive versus standard blood pressure (BP) control reduced CV morbidity and mortality in high-risk patients. We hypothesized that marital status would influence CV event risk and the impact of intensive BP control, and that these effects would vary according to sex.

Purpose

To assess the risks of CV events and mortality according to marital status in a high-risk population, and to assess if marital status modified the effect of intensive versus standard BP control.

Methods

SPRINT was a randomized, controlled, open-label trial of 9361 individuals at high CV risk, at least 50 years of age, without diabetes, and with a systolic BP 130–180 mmHg. Participants were randomized to either intensive or standard BP control and followed for median 3.2 years (range 0–4.8 years). The primary efficacy endpoint was the composite of acute coronary syndromes, stroke, heart failure, or CV death. Secondary efficacy endpoints included the individual components of the primary endpoint and all-cause death. Event risk according to marital status, including variation of the effects of intensive BP control, was evaluated using multivariable Cox proportional-hazards regression with interaction analyses. The group of subjects who were married or living in a marriage-like relationship served as baseline.

Results

Information on marital status was available for 8762 (93.6%) individuals. A total of 4863 (55.5%) were married or in a marriage-like relationship, 3149 (35.9%) were widowed, divorced, or separated, and 750 (8.6%) were never married. Marital status did not differ between patients randomized to intensive versus standard BP control (P=0.51). The risk of the primary endpoint was not significantly affected by marital status (P&gt;0.05), in neither men nor women (P-interaction&gt;0.05). The same was true for its individual components except the risk of CV death which was higher among never married men (adjusted hazard ratio [aHR], 3.29, 95% confidence interval [CI]: 1.34–8.09; P=0.009; P-sex-interaction=0.99). The risk of all-cause death was higher among widowed, divorced, or separated men (aHR, 1.90, 95% CI: 1.35–2.67; P&lt;0.001) and among never married men (aHR, 2.53, 95% CI: 1.51–4.26; P&lt;0.001), but not women belong to these groups (P&gt;0.05; P-sex-interaction=0.24) (Figure). Associations were not modified by age (P-interaction&gt;0.05). Marital status did not modify the effect of intensive BP control for any of the endpoints (P-interaction&gt;0.05).

Conclusions

In SPRINT, never married men had higher risks of both CV death and all-cause death while widowed, divorced, or separated men had a higher risk of all-cause death. The risks and benefits of intensive BP control were not affected by marital status.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Greater event rates in high-risk patients with a history of heart disease: from the Systolic Blood Pressure Intervention Trial (SPRINT)

Background

The Systolic Blood Pressure Intervention Trial (SPRINT) found that intensive versus standard blood pressure (BP) control reduced cardiovascular (CV) morbidity and mortality in patients at high CV risk. Effects were consistent among patients with and without prevalent CV disease. However, it is unknown whether the benefits and risks of intensive BP control are affected by the specific type of heart disease.

Purpose

To assess the risks of incident CV events and safety events in patients with individual types of heart disease, and to assess if the presence of heart disease modified the effect of intensive versus standard BP control.

Methods

SPRINT was a randomized, controlled trial comprising 9,361 individuals ≥50 years of age at high CV risk, without diabetes, and with a systolic BP 130–180 mmHg. Participants were randomized to intensive or standard BP control. The primary efficacy endpoint was the composite of myocardial infarction, other acute coronary syndromes, stroke, heart failure, or death from CV causes. The primary safety endpoint was the composite of serious adverse events. We assessed event risk in patients with self-reported heart disease versus those without and further assessed the safety and efficacy of intensive BP control, including relevant interactions, in these individuals, using multivariable Cox proportional-hazards regression.

Results

Of 9361 participants, 326 (3.5%) reported a history of congestive heart failure, 760 (8.1%) of myocardial infarction, 1206 (12.9%) of angina, and 1830 (19.6%) of atrial fibrillation, atrial flutter, or irregular heartbeat. The prevalence of these conditions did not significantly differ between patients randomized to intensive versus standard BP control (P&gt;0.05 for all). At median 3.2 years (range 0–4.8 years), congestive heart failure (adjusted hazard ratio [aHR], 1.94, 95% confidence interval [CI], 1.45–2.61; P&lt;0.001), myocardial infarction (aHR, 1.73, 95% CI, 1.33–2.25; P&lt;0.001), angina (aHR, 1.41, 95% CI, 1.09–1.84; P=0.01), and atrial fibrillation, atrial flutter, or irregular heartbeat (aHR, 1.36, 95% CI, 1.12–1.64; P=0.002) were all independently associated with the primary endpoint (Figure). All conditions except prior myocardial infarction were also associated with composite serious adverse events (P=0.24 for myocardial infarction, P&lt;0.05 for all others). A history of angina modified the efficacy of intensive versus standard BP control, i.e., patients without angina appeared to benefit from intensive BP control (aHR, 0.66, 95% CI, 0.54–0.80; P&lt;0.001) while those with angina did not (aHR, 1.04, 95% CI, 0.76–1.44; P=0.80) (P=0.02 for interaction). No significant interactions were detected for the primary safety endpoint.

Conclusions

In SPRINT, a history of any type of heart disease was associated with a greater risk for both efficacy and safety events. Patients with angina did not appear to derive benefit from intensive BP control.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Primary health insurance and cardiovascular outcomes in the systolic blood pressure intervention trial

Background

The Systolic Blood Pressure Intervention Trial (SPRINT) found that intensive versus standard blood pressure (BP) control reduced cardiovascular (CV) morbidity and mortality in high-risk patients. Although antihypertensive therapies were provided at no cost to trial participants, patients were covered by various entities. Insurance coverage provides a unique dimension of risk assessment and may provide additional prognostic information in this setting.

Purpose

To assess the risks of incident CV events and safety events in a high CV risk population according to type of health insurance, and to assess if insurance type interacted with the effect of intensive versus standard BP control.

Methods

SPRINT was a randomized, controlled trial conducted across 102 US sites of 9,361 high-risk adults ≥50 years, without diabetes, and with a systolic BP 130–180 mmHg at screening. Study participants were randomized to intensive (target systolic BP &lt;120mmHg) or standard BP control (target systolic BP &lt;140mmHg) and followed for median 3.2 years (range 0–4.8 years). The primary efficacy endpoint was the composite of acute coronary syndromes, stroke, heart failure, or CV death. The primary safety endpoint was the composite of serious adverse events. The risk of efficacy and safety events according to type of health insurance, including the effect of intensive BP control in each subgroup, was evaluated using multivariable Cox proportional-hazards regression with interaction analyses. Private/other insurance type served as the reference group.

Results

Of 9361 participants, 3980 (42.5%) were covered by private/other insurance, 1483 (15.8%) by a Veterans Affairs (VA) health plan, 2691 (28.8%) by Medicare, 207 (2.2%) by Medicaid, and 1000 (10.7%) were uninsured. Insurance coverage distribution was well-balanced between the two study arms (P&gt;0.05). Compared with patients who had private/other insurance, the risk of the primary endpoint was significantly higher among Medicaid beneficiaries (adj. hazard ratio [HR], 1.81, 95% confidence interval [CI], 1.09–3.00; P=0.02). The risk of death was similarly highest among Medicaid patients (adj. HR, 2.08, 95% CI, 1.08–4.02; P=0.03) and was also significantly higher among VA patients (adj. HR, 1.49, 95% CI, 1.11–2.99; P=0.008) (Figure). Serious adverse events were more common in the VA population (HR, 1.12, 95% CI, 1.01–1.23; P=0.03). Insurance type did not modify the efficacy and safety of intensive BP control (P&gt;0.05 for all interactions).

Conclusions

In SPRINT, Medicaid beneficiaries were at significantly greater risk for experiencing a primary CV event. Medicaid patients and VA patients both had higher mortality than those covered by private/other insurance. The risks and benefits of intensive BP control were not affected by insurance type.

Funding Acknowledgement

Type of funding sources: None. Risk of death and health insurace type

Long-term outcomes after in-hospital cardiac arrest: 30-day survival and 1-year follow-up of mortality, anoxic brain damage, nursing home admission and in-home care

AIMS

Long-term functional outcomes after in-hospital cardiac arrest (IHCA) are scarcely studied. However, survivors are at risk of neurological impairment from anoxic brain damage which could affect quality of life and lead to need of care at home or in a nursing home.

METHODS

We linked data on ICHAs in Denmark with nationwide registries to report 30-day survival as well as factors associated with survival. Furthermore, among 30-day survivors we reported the one-year cumulative risk of anoxic brain damage or nursing home admission with mortality as the competing risk.

RESULTS

In total, 517 patients (27.3%) survived to day 30 out of 1892 eligible patients; 338 (65.9%) were men and median age was 68 (interquartile range 58-76). Lower age, witnessed arrest by health care personnel, monitored arrest and presumed cardiac cause of arrest were associated with 30-day survival. Among 454 30-day survivors without prior anoxic brain damage or nursing home admission, the risk of anoxic brain damage or nursing home admission within the first-year post-arrest was 4.6% (n = 21; 95% CI 2.7-6.6%) with a competing risk of death of 15.6% (n = 71; 95% CI 12.3-19.0%), leaving 79.7% (n = 362) alive without anoxic brain damage or nursing home admission. When adding the risk of need of in-home care among 343 30-day survivors without prior home care needs, 68.8% (n = 236) were alive without any of the composite events one-year post-arrest.

CONCLUSION

The majority of 30-day survivors of IHCA are alive at one-year follow-up without anoxic brain damage, nursing home admission or need of in-home care.

SAT0600 PNEUMOCOCCAL VACCINATION IN PATIENTS WITH AUTOIMMUNE INFLAMMATORY RHEUMATIC DISEASES, TREATED WITH BIOLOGICAL THERAPY AND WITH A LOW LEVEL OF ANTIBODIES - A COHORT STUDY OF PATIENTS WITH VARYING VACCINATION STATUS

Background:

Risk of infection is increased in patients with autoimmune inflammatory rheumatic diseases (AIRD)1. Furthermore, disease-modifying antirheumatic drug (DMARD) treatment contributes to this risk2. To reduce the risk of serious infections, it is recommended that patients are vaccinated againstStreptococcus pneumoniae3. However, some AIRD patients do not develop or maintain an adequate antibody response after pneumococcal vaccination4.

Objectives:

The aim of the study was to examine the proportion of patients with low antibody levels, who achieved a protective level of pneumococcal antibodies after vaccination.

Methods:

Pneumococcal antibodies were measured by a serological assay in patients treated with biologics in a rheumatology outpatient clinic. Vaccination with 23-valent-pneumococcal polysaccarid vaccine was then offered to patients with a protective antibody level below the defined threshold and pneumococcal antibody level was measured at follow-up 2-3 months later. The patients continued their DMARD treatment without any changes.

Demographic and clinical data were collected, including age, sex, AIRD diagnosis, duration and activity (high/low), in addition to treatment (biologics, prednisolone, methotrexate) and previous vaccination history.

Results:

A total of 248 patients with inadequate antibody level accepted vaccination and among those, 137 patients (55%) had previously been vaccinated, 98 patients had not previously been vaccinated and for 13 patients data on vaccination status could not be obtained.

At follow-up, 84 patients (34%) achieved a protective level of antibodies. Use of methotrexate as part of the DMARD regimen was associated with an unprotected level of pneumococcal antibodies (Figure 1) (p<0,001). There was no similar association with respect to use of biologics.

Figure 1

In the group of patients who had previously been vaccinated, time between vaccinations spanned from 20 to 111 months, median 49 months.

There was an association between previous vaccination, and failure in achieving a protective antibody level (Figure 1) (p=0,02), as well as an association between less than 5 years (60 months) between vaccinations and not achieving a protective level.

Conclusion:

We found that only one-third of patients achieved a protective pneumococcal antibody level after vaccination. Methotrexate treatment was associated with a decreased antibody response, which was not the case for treatment with biologics or prednisolone.

Among patients who had previously been vaccinated, significantly less achieved a protective level of antibodies, compared to patients who had not been vaccinated. All 248 patients had a low antibody level at baseline, despite 137 being previously vaccinated.

Further studies are warranted to show whether or not a short discontinuation of methotrexate, will better the response to vaccination.

References:

[1]Wolfe, F. et al. The mortality of rheumatoid arthritis.Arthritis Rheum1994;37(4):481–494.

[2]Ramiro, S. et al.). Safety of synthetic and biological DMARDs: a systematic literature review informing the 2016 update of the EULAR recommendations for management of rheumatoid arthritis.Ann Rheum Dis2017;76(6):1101–1136.

[3]van Assen S. et al. (). EULAR recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases.Ann Rheum Dis2011;70(3):414–422.

[4]Hua, C. et al. Effect of methotrexate, anti-tumor necrosis factor alpha, and rituximab on the immune response to influenza and pneumococcal vaccines in patients with rheumatoid arthritis: a systematic review and meta-analysis.Arthritis Care Res 2014;66(7):1016–1026.

Disclosure of Interests:

None declared

1180 2D and 3D assessment of the left ventricle volume and ejection fraction in a general population

Conclusion

In our study, we found a significant difference in both LVEF and ventricular volumes when comparing 2D echocardiograms with 3D. 3DE had, in general, lower LVEF, higher EDV and ESV compared to 2D.

Table 1: Summary of results Table 1 - Summary of results n = 2090 Variable Min Max Mean IQR (25-75) p-value LVEF, 2D (%) 18 76 57.3 ± 6.1 54-61 &lt; 0.05 LVEF, 3d (%) 13 77 51.7 ± 7.9 47-57 &lt; 0.05 EDV, 2D (ml) 13 275 106.1 ± 29.6 85-123.8 &lt; 0.05 EDV, 3D (ml) 50 270 128.2 ± 32.3 106-148 &lt; 0.05 ESV, 2D (ml) 15 150 45.7 ± 15.6 35-54 &lt; 0.05 ESV, 3D (ml) 13 185 45.7 ± 20.7 48-74 &lt; 0.05 LVEF: left ventricle ejection fraction, EDV: end-diastolic volume, ESV: end systolic volume, IQR: Inter-quartile range

Abstract 1180 Figure 1: Correlation and BA-plot

5226The majority of 30-day survivors of in-hospital cardiac arrest are alive one-year post-arrest without anoxic brain damage, admission to nursing home or need of in-home care

Background

Survivors of in-hospital cardiac arrest are at risk of anoxic brain damage that can lead to admission to nursing home or need of in-home care. However, studies on long-term outcomes after in-hospital cardiac arrest are scarce with previous research focusing on short term measures such as survival-to-discharge.

Purpose

This study aimed to investigate the composite endpoint of nursing home admission or anoxic brain damage among 30-day survivors of in-hospital cardiac arrest within the first-year post-arrest. As a sub analysis, we also investigated the additional need of in-home care.

Methods

All in-hospital cardiac arrests in 13 Danish hospitals during 2013–2015 were identified from the DANARREST register. Inclusion criteria were indication for a resuscitation attempt and survival to day 30. Patients who, prior to arrest, already lived in a nursing home, and/or had anoxic brain damage were excluded. In the sub analysis patients who received in-home care prior to arrest were also excluded. The DANARREST data was linked to nationwide registries including the National Patient Register and administrative nursing home and home care registries using the Danish Civil Registration Number, a unique personal identification number that is given to every citizen in Denmark.

Results

The primary study population comprised of 454 (26.3%) 30 day-survivors out of 1723 eligible patients. Median age was 67 (Q1-Q3 57–75); 301 (66.9%) were men. In this group, the 1-year risk of anoxic brain damage or nursing home admission was 4.6% (95% CI 2.7%- 6.6%) with a competing risk of death of 15.6% (95% CI 12.3%-19.0%), leaving 79.8% alive without anoxic brain damage or nursing home admission at one-year follow-up (see Figure 1A).

The sub study population comprised of 343 30-day survivors with a 1-year risk of anoxic brain damage, nursing home admission or need of in-home care of 23.6% (95% CI 19.1%-28.1%). The competing risk of death was 7.6% (95% CI 4.8%-10.4%), leaving 68.8% alive without anoxic brain damage, nursing home admission or need of in-home care at one-year follow-up (see Figure 1B).

Figure 1

Conclusion

The majority of 30-day survivors of in-hospital cardiac arrest were alive at one-year follow-up without being diagnosed with anoxic brain damage, admitted to nursing home or without need of in-home care.