A MAP1B-cortactin-Tks5 axis regulates TNBC invasion and tumorigenesis

The microtubule-associated protein MAP1B has been implicated in axonal growth and brain development. We found that MAP1B is highly expressed in the most aggressive and deadliest breast cancer subtype, triple-negative breast cancer (TNBC), but not in other subtypes. Expression of MAP1B was found to be highly correlated with poor prognosis. Depletion of MAP1B in TNBC cells impairs cell migration and invasion concomitant with a defect in tumorigenesis. We found that MAP1B interacts with key components for invadopodia formation, cortactin, and Tks5, the latter of which is a PtdIns(3,4)P2-binding and scaffold protein that localizes to invadopodia. We also found that Tks5 associates with microtubules and supports the association between MAP1B and α-tubulin. In accordance with their interaction, depletion of MAP1B leads to Tks5 destabilization, leading to its degradation via the autophagic pathway. Collectively, these findings suggest that MAP1B is a convergence point of the cytoskeleton to promote malignancy in TNBC and thereby a potential diagnostic and therapeutic target for TNBC.

Mass, Spectroscopy, and Two-Neutron Decay of ^{16}Be

The structure and decay of the most neutron-rich beryllium isotope, ^{16}Be, has been investigated following proton knockout from a high-energy ^{17}B beam. Two relatively narrow resonances were observed for the first time, with energies of 0.84(3) and 2.15(5) MeV above the two-neutron decay threshold and widths of 0.32(8) and 0.95(15) MeV, respectively. These were assigned to be the ground (J^{π}=0^{+}) and first excited (2^{+}) state, with E_{x}=1.31(6)  MeV. The mass excess of ^{16}Be was thus deduced to be 56.93(13) MeV, some 0.5 MeV more bound than the only previous measurement. Both states were observed to decay by direct two-neutron emission. Calculations incorporating the evolution of the wave function during the decay as a genuine three-body process reproduced the principal characteristics of the neutron-neutron energy spectra for both levels, indicating that the ground state exhibits a strong spatially compact dineutron component, while the 2^{+} level presents a far more diffuse neutron-neutron distribution.

Wnt/β-catenin-C-kit axis may play a role in adenoid cystic carcinoma prognostication

Adenoid cystic carcinoma (ACC) is one of the most common malignant salivary gland tumors. ACC is composed of myoepithelial and epithelial neoplastic cells which grow slowly and have a tendency for neural invasion. The long term prognosis is still relatively poor. Although several gene abnormalities, such as fusions involving MYB or MYBL1 oncogenes and the transcription factor gene NFIB, and overexpression of KIT have been reported in ACC, their precise functions in the pathogenesis of ACC remain unclear. We recently demonstrated that the elevated expression of Semaphorin 3A (SEMA3A), specifically expressed in myoepithelial neoplastic cells, might function as a novel oncogene-related molecule to enhance cell proliferation through activated AKT signaling in 9/10 (90%) ACC cases. In the current study, the patient with ACC whose tumor was negative for SEMA3A in the previous study, revisited our hospital with late metastasis of ACC to the cervical lymph node eight years after surgical resection of the primary tumor. We characterized this recurrent ACC, and compared it with the primary ACC using immunohistochemical methods. In the recurrent ACC, the duct lining epithelial cells, not myoepithelial neoplastic cells, showed an elevated Ki-67 index and increased cell membrane expression of C-kit, along with the expression of phosphorylated ERK. Late metastasis ACC specimens were not positive for β-catenin and lymphocyte enhancer binding factor 1 (LEF1), which were detected in the nuclei of perineural infiltrating cells in primary ACC cells. In addition, experiments with the GSK-3 inhibitor revealed that β-catenin pathway suppressed not only KIT expression but also proliferation of ACC cells. Moreover, stem cell factor (SCF; also known as KIT ligand, KITL) induced ERK activation in ACC cells. These results suggest that inactivation of Wnt/β-catenin signaling may promote C-kit-ERK signaling and cell proliferation of in metastatic ACC.

Arl4c is involved in tooth germ development through osteoblastic/ameloblastic differentiation

Murine tooth germ development proceeds in continuous sequential steps with reciprocal interactions between the odontogenic epithelium and the adjacent mesenchyme, and several growth factor signaling pathways and their activation are required for tooth germ development. The expression of ADP-ribosylation factor (Arf)-like 4c (Arl4c) has been shown to induce cell proliferation, and is thereby involved in epithelial morphogenesis and tumorigenesis. In contrast, the other functions of Arl4c (in addition to cellular growth) are largely unknown. Although we recently demonstrated the involvement of the upregulated expression of Arl4c in the proliferation of ameloblastomas, which have the same origin as odontogenic epithelium, its effect on tooth germ development remains unclear. In the present study, single-cell RNA sequencing (scRNA-seq) analysis revealed that the expression of Arl4c, among 17 members of the Arf-family, was specifically detected in odontogenic epithelial cells, such as those of the stratum intermedium, stellate reticulum and outer enamel epithelium, of postnatal day 1 (P1) mouse molars. scRNA-seq analysis also demonstrated the higher expression of Arl4c in non-ameloblast and inner enamel epithelium, which include immature cells, of P7 mouse incisors. In the mouse tooth germ rudiment culture, treatment with SecinH3 (an inhibitor of the ARNO/Arf6 pathway) reduced the size, width and cusp height of the tooth germ and the thickness of the eosinophilic layer, which would involve the synthesis of dentin and enamel matrix organization. In addition, loss-of-function experiments using siRNAs and shRNA revealed that the expression of Arl4c was involved in cell proliferation and osteoblastic cytodifferentiation in odontogenic epithelial cells. Finally, RNA-seq analysis with a gene set enrichment analysis (GSEA) and Gene Ontology (GO) analysis showed that osteoblastic differentiation-related gene sets and/or GO terms were downregulated in shArl4c-expressing odontogenic epithelial cells. These results suggest that the Arl4c-ARNO/Arf6 pathway axis contributes to tooth germ development through osteoblastic/ameloblastic differentiation.

Stepwise activation of p63 and the MEK/ERK pathway induces the expression of ARL4C to promote oral squamous cell carcinoma cell proliferation

Carcinogenesis is a multistep process wherein cells accumulate multiple genetic alterations and progress to a more malignant phenotype. It has been proposed that sequential accumulation of gene abnormalities in specific genes drives the transition from non-tumorous epithelia through a preneoplastic lesion/benign tumor to cancer. Histologically, oral squamous cell carcinoma (OSCC) progresses in multiple ordered steps that begin with mucosal epithelial cell hyperplasia, which is followed by dysplasia, carcinoma in situ and invasive carcinoma. It is therefore hypothesized that genetic alteration-mediated multistep carcinogenesis would be involved in the development of OSCC; however, the detailed molecular mechanisms are unknown. We clarified the comprehensive gene expression patterns and carried out an enrichment analysis using DNA microarray data from a pathological specimen of OSCC (including a non-tumor region, carcinoma in situ lesion and invasive carcinoma lesion). The expression of numerous genes and signal activation were altered in the development of OSCC. Among these, the p63 expression was increased and the MEK/ERK-MAPK pathway was activated in carcinoma in situ lesion and in invasive carcinoma lesion. Immunohistochemical analyses revealed that p63 was initially upregulated in carcinoma in situ and ERK was sequentially activated in invasive carcinoma lesions in OSCC specimens. ADP-ribosylation factor (ARF)-like 4c (ARL4C), the expression of which is reportedly induced by p63 and/or the MEK/ERK-MAPK pathway in OSCC cells, has been shown to promote tumorigenesis. Immunohistochemically, in OSCC specimens, ARL4C was more frequently detected in tumor lesions, especially in invasive carcinoma lesions, than in carcinoma in situ lesions. Additionally, ARL4C and phosphorylated ERK were frequently merged in invasive carcinoma lesions. Loss-of-function experiments using inhibitors and siRNAs revealed that p63 and MEK/ERK-MAPK cooperatively induce the expression of ARL4C and cell growth in OSCC cells. These results suggest that the stepwise activation of p63 and MEK/ERK-MAPK contributes to OSCC tumor cell growth through regulation of ARL4C expression.

High Plasma tPAPAI-1C Levels May Be Related to a Poor Prognosis in Patients with Severe or Critical COVID-19: A Single-Center Retrospective Study

Severe novel coronavirus disease 2019 (COVID-19) patients have a high incidence of thrombotic complications and mortality. The pathophysiology of coagulopathy involves fibrinolytic system impairment and vascular endothelial damage. This study examined coagulation and fibrinolytic markers as outcome predictors. In an observational study of 164 COVID-19 patients admitted to our emergency intensive care unit, hematological parameters on days 1, 3, 5, and 7 were retrospectively compared between survivors and nonsurvivors. Nonsurvivors had a higher APACHE II score, SOFA score, and age than survivors. Nonsurvivors also had a significantly lower platelet count and significantly higher plasmin/α2plasmin inhibitor complex (PIC), tissue plasminogen activator/plasminogen activator inhibitor-1 complex (tPAPAI-1C), D-dimer, and fibrin/fibrinogen degradation product (FDP) levels than survivors throughout the measurement period. The 7-day maximum or minimum values of the tPAPAI-1C, FDP, and D-dimer levels were significantly higher in nonsurvivors. A multivariate logistic regression analysis showed that the maximum tPAPAI-1C (OR = 1.034; 95% CI,1.014-1.061; p = 0.0041) was an independent factor affecting mortality, with an area under the curve (AUC) of 0.713 (optimum cut-off of 51 ng/mL; sensitivity, 69.2%; and specificity, 68.4%). COVID-19 patients with poor outcomes exhibit exacerbated coagulopathy with fibrinolysis inhibition and endothelial damage. Consequently, plasma tPAPAI-1C might be a useful predictor of the prognosis in patients with severe or critical COVID-19.

WT1 Trio Peptide-Based Cancer Vaccine for Rare Cancers Expressing Shared Target WT1

No standard treatment has been established for most rare cancers. Here, we report a clinical trial of a biweekly WT1 tri-peptide-based vaccine for recurrent or advanced rare cancers. Due to the insufficient number of patients available for a traditional clinical trial, the trial was designed for rare cancers expressing shared target molecule WT1. The recruitment criteria included WT1-expressing tumors as well as HLA-A*24:02 or 02:01. The primary endpoints were immunoglobulin G (IgG) antibody (Ab) production against the WT1-235 cytotoxic T lymphocyte (CTL) epitope and delayed-type hypersensitivity (DTH) skin reactions to targeted WT1 CTL epitopes. The secondary endpoints were safety and clinical efficacy. Forty-five patients received WT1 Trio, and 25 (55.6%) completed the 3-month protocol treatment. WT1-235 IgG Ab was positive in 88.0% of patients treated with WT1 Trio at 3 months, significantly higher than 62.5% of the weekly WT1-235 CTL peptide vaccine. The DTH positivity rate in WT1 Trio was 62.9%, which was not significantly different from 60.7% in the WT1-235 CTL peptide vaccine. The WT1 Trio safety was confirmed without severe treatment-related adverse events, except grade 3 myasthenia gravis-like symptoms observed in a patient with thymic cancer. Fifteen (33.3%) patients achieved stable disease after 3 months of treatment. In conclusion, the biweekly WT1 Trio vaccine containing the WT1-332 helper T lymphocyte peptide induced more robust immune responses targeting WT1 than the weekly WT1-235 CTL peptide vaccine. Therefore, WT1-targeted immunotherapy may be a potential therapeutic strategy for rare cancers.

Identification of glioblastoma-specific antigens expressed in patient-derived tumor cells as candidate targets for chimeric antigen receptor T cell therapy

Background

New therapies for glioblastoma (GBM) are urgently needed because the disease prognosis is poor. Chimeric antigen receptor (CAR)-T cell therapy that targets GBM-specific cell surface antigens is a promising therapeutic strategy. However, extensive transcriptome analyses have uncovered few GBM-specific target antigens.

Methods

We established a library of monoclonal antibodies (mAbs) against a tumor cell line derived from a patient with GBM. We identified mAbs that reacted with tumor cell lines from patients with GBM but not with nonmalignant human brain cells. We then detected the antigens they recognized using expression cloning. CAR-T cells derived from a candidate mAb were generated and tested in vitro and in vivo.

Results

We detected 507 mAbs that bound to tumor cell lines from patients with GBM. Among them, E61 and A13 reacted with tumor cell lines from most patients with GBM, but not with nonmalignant human brain cells. We found that B7-H3 was the antigen recognized but E61. CAR-T cells were established using the antigen-recognition domain of E61-secreted cytokines and exerted cytotoxicity in co-culture with tumor cells from patients with GBM.

Conclusions

Cancer-specific targets for CAR-T cells were identified using a mAb library raised against primary GBM tumor cells from a patient. We identified a GBM-specific mAb and its antigen. More mAbs against various GBM samples and novel target antigens are expected to be identified using this strategy.

IMMU-19. IDENTIFICATION OF TARGET ANTIGENS FOR CHIMERIC ANTIGEN RECEPTOR T- CELL THERAPY AGAINST GLIOBLASTOMA USING A MONOCLONAL ANTIBODY LIBRARY RAISED AGAINST PATIENT-DERIVED TUMOR SPHERES

New therapies for GBM are urgently needed due to its poor prognosis and chimeric antigen receptor T (CAR-T) cell therapy is thought to be a promising strategy. To develop CAR-T cell therapy, cell surface targets that is highly specific for GBM cells are needed.Although extensive transcriptome analyses of GBM cells were performed, few transcripts highly specific for GBM cells have been identified. However, GBM cell-specific antigen epitopes formed by post-translational modifications of proteins may have been missed, and could still be discovered by thoroughly searching for cancer-specific monoclonal antibodies and characterizing the antigens they recognize. In this study, we applied this strategy to search for GBM-specific cell surface targets using patient derived tumor spheres. We identified two monoclonal antibodies E61 and A13 as those reacting with GBM cells but not with normal brain parenchymal cells. CAR-T cells derived from both monoclonal antibodies produced IL-2 and IFNɤ and exerted cytotoxicity to GBM cells by chromium 51 release assay. In addition, we identified B7-H3, which is frequently used for a CAR-T cell target against GBM, as the antigen recognized by B7-H3 by the expression cloning method. These results indicate that the strategy shown in this study is useful for identifying antigens that are expressed on patient-derived GBM cells and potentially useful as targets for CAR T cells.

Involvement of growth differentiation factor 15 in paradoxical relationship between body mass index and mortality in patients with suspected or known coronary artery disease; The ANOX Study

Background

Obesity is a well-established risk factor for type 2 diabetes mellitus, hypertension and dyslipidemia, leading to coronary artery disease (CAD). Nevertheless, body mass index (BMI) is inversely associated with cardiovascular (CV) mortality in patients with cardiac disorders, termed “obesity paradox”. However, the underlying mechanism remains unclear.

Purpose

To clarify important factors involved in the pathogenesis of obesity paradox.

Methods

Using data from a multicenter, prospective cohort of 2,418 patients with suspected or known CAD enrolled in the ANOX study, we assessed the relationship between BMI at baseline and the incidence of CV death over 3 years, and investigated the involvement of several endocrine factors which were previously reported to have some roles in obesity and heart diseases, such as adiponectin, N-terminal pro-brain natriuretic peptide (NT-proBNP) and growth differentiation factor 15 (GDF-15), in the relationship between BMI and CV death.

Results

In Kaplan-Meier analyses, the lower quartiles of BMI and the higher quartiles of adiponectin levels were paradoxically associated with the higher cumulative incidence of CV death. To clarify the important factors involved in the paradoxical association between BMI or adiponectin and mortality, we first investigated independent determinants for BMI and adiponectin levels respectively, using multiple stepwise regression analyses among many clinical factors, and then narrow down the prognostic factors commonly associated with BMI and adiponectin, which were age, hemoglobin and NT-proBNP. Interestingly, circulating levels of GDF15 were significantly correlated with NT-proBNP levels, and the presence of anemia raised the gradient of the correlation line in a scatter plot (without anemia, r=0.139, p<0.0001; with anemia, r=0.228, p<0.0001). Moreover, the highest GDF15 quartile showed significantly lower BMI and higher adiponectin levels compared to the lower quartiles (p<0.001 and p<0.001, respectively, by Student t-test). In Cox proportional hazard models, hazard ratios (HRs) of BMI (per 1-unit increase) were 0.90 (95% confidence interval [CI], 0.85–0.96) for CV death. Additional adjustment for hemoglobin, NT-proBNP, adiponectin or GDF15 diminished the statistical significance (HR, 0.92 [95% CI, 0.87–0.99], 0.95 [0.89–1.01], 0.92 [0.87–0.99], or 0.93 [0.87–0.99], respectively).

Conclusions

The lower BMI and the higher adiponectin levels were paradoxically associated with the higher incidence of CV death in patients with CAD. This paradox may be mediated by cardiac endocrine factors induced by cardiac stresses, including GDF-15 in addition to natriuretic peptides.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The ANOX study is supported by a Grant-in-Aid for Clinical Research from the National Hospital Organization.

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)<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 (>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.

Prediction of new-onset atrial fibrillation in patients with hypertrophic cardiomyopathy using proteomics profiling

Background

Hypertrophic cardiomyopathy (HCM) is one of the most common genetic cardiac disorders and affects 1 in 200–500 individuals. HCM is known to be heterogeneous. Approximately 20–30% of patients with HCM develop atrial fibrillation (AF), which can lead to stroke and worsening of heart failure symptoms. As AF increases the risk of stroke by 8-fold, AF in HCM is a Class 1 indication for anticoagulation. Despite its high prevalence and clinical importance of early AF detection, there are no risk stratification tools available to predict new-onset AF in patients with HCM. Furthermore, it is still unknown which signaling pathways mediate AF in HCM. Proteomics profiling can determine concentrations of thousands of proteins and potentially reveal underlying molecular mechanisms of disease progression.

Purpose

To develop plasma proteomics-based model to predict new-onset AF in patients with HCM and to determine signaling pathways dysregulated in those who subsequently develop AF.

Methods

In this prospective, multi-center cohort study, we conducted plasma proteomics profiling of 5,032 proteins on 397 patients with HCM. We developed a proteomics-based random forest machine learning model to predict new-onset AF using samples from one institution (training set, n=278). We tested the predictive ability of the model using independent samples from the other institution (test set, n=119). We estimated the hazard ratio for new-onset AF using a Cox proportional hazards model comparing high- and low-risk groups as determined by the proteomics-based model. We also performed pathway analysis of proteins significantly (i.e., univariable P<0.05) associated with new-onset AF using a false discovery rate (FDR) threshold of 0.05.

Results

A total of 15 patients in the training set (5.4%) and 7 in the test set (5.9%) developed new-onset AF. Using the proteomics-based model developed in the training set, the area under the receiver-operating characteristic (ROC) curve to predict new-onset AF was 0.87 (95% confidence interval [CI] 0.77–0.98; Figure) in the test set. The sensitivity was 0.86 (95% CI 0.42–0.99) and the specificity was 0.77 (95% CI 0.68–0.84). In the test set, patients categorized as high-risk based on the proteomics model had a significantly higher rate of developing new-onset AF (hazard ratio 8.18; 95% CI 1.55–43.20; P=0.01). Pathway analysis revealed that the Ras-MAPK pathway was dysregulated in patients who subsequently developed AF (FDR=0.01; Table). Pathways involved in inflammation were also dysregulated.

Conclusions

This study serves as the first to demonstrate the ability of proteomics profiling to predict new-onset AF in patients with HCM, exhibiting dysregulation of both novel (e.g., Ras-MAPK) and known pathways in patients who subsequently experience AF. These results not only exhibit the utility of proteomics profiling for clinical risk stratification but also suggest mechanisms underlying the development of AF in HCM.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): NIH/NHLBI

Vascular endothelial factor C and D in patients with heart failure with preserved, mildly reduced, and reduced ejection fraction: the PREHOSP-CHF study

Background

The lymphatic system has been suggested to play an important role in cardiovascular diseases including heart failure (HF). Vascular endothelial growth factor C (VEGF-C) and D (VEGF-D) are key regulators of lymphangiogenesis, and we recently reported the association of low VEGF-C with the risk of all-cause death and high VEGF-D with the risk of HF hospitalization in patients with HF.

Purpose

To investigate the association of VEGF-C and VEGF-D with prognosis in patients with HF with preserved ejection fraction (EF) (HFpEF: EF≥50%), mildly reduced EF (HFmrEF: EF, 40–49%), and reduced EF (HFrEF: EF<40%).

Methods

The PREHOSP-CHF study is a multicenter prospective cohort study to determine the predictive value of angiogenesis-related biomarkers in HF. A total of 1,024 patients (mean age 75.5±12.6 years; 58.7% male) admitted to acute decompensated HF were included in the analyses. Serum levels of VEGF-C and VEGF-D, as well as N-terminal pro B-type natriuretic peptide (NT-proBNP), high sensitivity cardiac troponin-I (hs-cTnI), high sensitivity C reactive protein, were measured at the time of discharge. Patients were followed-up over two years.

Results

The numbers of HFpEF, HFmrEF, and HFrEF were 429 (41.9%), 186 (18.2%), and 409 (39.9%), respectively. HFpEF patients were older, more likely to be female, and had more hypertension, atrial fibrillation, and anemia, but less coronary artery disease. NT-proBNP and hs-cTnI levels increased with decreasing EF. VEGF-C levels decreased with increasing EF (median [interquartile range]: HFpEF, 4508 [3318–5919] pg/ml; HFmrEF, 4719 [3663–6203] pg/ml; HFrEF, 5023 [3804–6382] pg/ml), whereas VEGF-D levels were comparable among the three EF groups (HFpEF, 404.6 [293.1–560.3] pg/ml; HFmrEF, 386.0 [298.5–556.3] pg/ml; HFrEF, 414.2 [296.1–557.3] pg/ml). In multivariate stepwise logistic regression analyses, anemia and high NT-proBNP were independently associated with low VEGF-C levels, and high NT-proBNP was independently associated with high VEGF-D levels, across all the EF groups. During the follow-up, incidences of all-cause death and HF hospitalizations were similar among the three EF groups (log-rank P=0.6 for all-cause death, and log-rank P=0.3 for HF hospitalization). On multivariate Cox proportional hazard analyses including established risk factors and cardiovascular biomarkers, VEGF-C levels tended to be inversely associated with the incidence of all-cause death in patients with HFpEF and HFrEF (Figure). On the contrary, VEGF-D levels were significantly and positively associated with the incidence of HF hospitalization in patients with HFpEF, and tended to be positively associated with it in patients with HFmrEF and HFrEF (Figure).

Conclusions

Low VEGF-C was associated with the risk of all-cause death in patients with HFpEF and HFrEF, while high VEGF-D was associated with the risk of HF hospitalization especially in HFpEF.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Grant-in-Aid for Clinical Research from the National Hospital Organization

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<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<0.01, 5.17 vs. 3.30; p<0.01, 2.42 vs. 1.71; p<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<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<0.01, 1.7 vs. 0.8 per 100 person-years; log-rank p<0.01, 1.2 vs. 0.2 per 100 person-years; log-rank p<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<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

Associations of soluble fms-like tyrosine kinase-1 with cardiovascular events and stroke in patients with atrial fibrillation and suspected or known coronary artery disease: the EXCEED-J study

Background

Atrial fibrillation (AF) increases the risk of stroke. Soluble fms-like tyrosine kinase-1 (sFlt-1), a vascular endothelial growth factor (VEGF) antagonist, has been suggested as a marker of endothelial dysfunction, which are associated with both AF and coronary artery disease (CAD). Recently, we demonstrated that sFlt-1 is independently associated with major adverse cardiovascular (CV) events (MACE) in patients with suspected or known CAD. However, the prognostic utility of sFlt-1 in patients with AF remains unknown.

Methods

Using data from a multicenter, prospective cohort of 3255 patients with suspected or known CAD, we investigated whether AF modifies the prognostic utility of sFlt-1. Heparin-free serum levels of sFlt-1, N-terminal pro-brain natriuretic peptide, high-sensitivity cardiac troponin-I, high-sensitivity C-reactive protein, cystatin C, neutrophil gelatinase-associated lipocalin, VEGF, and placental growth factor were measured in 324 patients with AF and 2931 patients without AF. The primary outcome was MACE defined as a composite of CV death, nonfatal myocardial infarction, and nonfatal stroke. The secondary outcomes were all-cause death, CV death, stroke, heart failure (HF) hospitalization, and coronary/peripheral artery revascularization. The biomarkers were natural log-transformed for use as continuous variables.

Results

After adjustment for potential clinical confounders including anticoagulant drug use, sFlt-1 was significantly associated with MACE (hazard ratio for 1 standard deviation increase [HR], 1.55; 95% confidence interval [CI], 1.14–2.08), CV death (HR, 1.68; 95% CI, 1.10–2.48), and stroke (HR, 1.89; 95% CI, 1.16–3.10), but not with all-cause death (HR, 1.32; 95% CI, 0.99–1.73), HF hospitalization (HR, 0.97; 95% CI, 0.73–1.25), or revascularization (HR, 0.99; 95% CI, 0.74–1.28) in patients with AF, whereas sFlt-1 was significantly associated with MACE (HR, 1.19; 95% CI, 1.02–1.37), all-cause death (HR, 1.19; 95% CI, 1.05–1.34), CV death (HR, 1.26; 95% CI, 1.03–1.48), and HF hospitalization (HR, 1.26; 95% CI, 1.11–1.42), but not with stroke (HR, 1.06; 95% CI, 0.81–1.33) or revascularization (HR, 1.01; 95% CI, 0.95–1.07) in patients without AF. Among other biomarkers, only VEGF was significantly associated with MACE (HR, 1.55; 95% CI, 1.02–2.44), and no biomarkers were significantly associated with CV death or stroke in patients with AF. sFlt-1 added incremental prognostic information for MACE (P=0.005 for net reclassification improvement [NRI], P=0.026 for integrated discrimination improvement [IDI]) and stroke (P=0.034 for NRI, P=0.018 for IDI), but not for CV death (P=0.021 for NRI, P=0.134 for IDI), to the model with potential clinical confounders in patients with AF.

Conclusions

sFlt-1 independently predicted MACE and stroke in patients with AF and suspected or known CAD. sFlt-1 may serve as a novel prognostic biomarker to stratify the risk of MACE and stroke in patients with AF.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Health Labour Sciences Research Grant (2013-2014), AMED (2015-2017, Grant Number JP17ek0210008)

Prediction of worsening heart failure in patients with hypertrophic cardiomyopathy using plasma proteomics profiling

Background

While hypertrophic cardiomyopathy (HCM) is the most common genetic cardiovascular disease affecting 1 in 200–500 people, it is a heterogeneous disease. Only a subset of patients with HCM develop heart failure (HF; prevalence 35–50%). Prediction of worsening HF using clinical measures alone (e.g., cardiac imaging, genetic testing) remains limited. Furthermore, the underlying mechanism by which patients with HCM develop worsening HF has not been fully investigated. Proteomics profiling measures concentrations of thousands of proteins simultaneously and has been used to predict worsening of HF and to highlight which signaling pathways mediate worsening HF in non-HCM populations.

Purpose

In patients with HCM, we aimed to develop a plasma proteomics-based model to predict which patients with HCM would develop worsening HF and to identify signaling pathways that are differentially regulated in those who subsequently develop worsening HF.

Methods

We conducted a prospective cohort study in our multi-center biorepository of patients with HCM. We performed plasma proteomics profiling of 5032 proteins. We then developed a random forest model to predict worsening HF using proteomics profiling data from patients enrolled through one institution (training set). The outcome of worsening HF was defined as an increase in New York Heart Association functional class by at least 1 class. We externally validated this model in independent samples from patients enrolled through a different institution (test set). Further, we executed pathway analysis of proteins significantly dysregulated (i.e., univariable p<0.05) in patients who developed worsening HF compared to those who did not. Pathways with false discovery rate [FDR]<0.05 were considered to be dysregulated.

Results

There were 398 patients included in the study, with 278 in the training set and 120 in the test set. During a median follow-up of 1.8 years [interquartile range, 1.2–2.6], 60 (15%) patients developed worsening HF symptoms (45 patients in the training set and 15 patients in the test set). Using the proteomics-based model derived from the training set, the area under the receiver-operating-characteristic curve to predict worsening HF was 0.85 (95% confidence interval: 0.75–0.95) in the test set (Figure 1). Pathway analysis revealed that the Ras-MAPK pathway (FDR<0.00001) and its upstream PI3K-Akt pathway (FDR<0.00001) were dysregulated in patients who subsequently developed worsening HF (Figure 2).

Conclusions

Our study is the first to apply proteomics profiling to the prediction of worsening HF symptoms in patients with HCM, identifying patients who are at high risk of worsening HF and elucidating that the Ras-MAPK and related signaling pathways as potential underlying mechanisms. These findings support the potential application of proteomics profiling to clinical risk stratification and the investigation of signaling pathways underlying disease progression in HCM.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): NIH/NHLBI R01 grant

Serum amyloid A-low-density-lipoprotein complex and mortality in patients with suspected or known coronary artery disease: the ANOX study

Background

Serum amyloid A-low-density-lipoprotein (SAA-LDL) is a complex formed from the oxidative interaction between SAA and LDLs. A relatively small-scale study has shown that circulating SAA-LDL levels may serve as a prognostic marker in patients with stable coronary artery disease (CAD). However, the prognostic value of SAA-LDL should be confirmed in a larger-scale cohort study.

Methods

Using data from a multicenter, prospective cohort of 2416 patients with suspected or known CAD enrolled in the ANOX (Development of Novel Biomarkers Related to Angiogenesis or Oxidative Stress to Predict Cardiovascular Events) study, we assessed the prognostic value of serum levels of SAA-LDL. The primary outcome was all-cause death. The secondary outcomes were cardiovascular death and major adverse cardiovascular events (MACE) defined as a composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke. Patients were followed up over 3 years.

Results

Stepwise regression analysis including baseline data on potential clinical confounders (i.e., age, sex, body mass index, hypertension, dyslipidemia, diabetes, current smoking, estimated glomerular filtration rate, the Gensini score, previous myocardial infarction, previous stroke, previous heart failure hospitalization, atrial fibrillation, malignancies, anemia, antihypertensive drug use, statin use, and aspirin use) and established cardiovascular biomarkers (i.e., N-terminal pro-brain natriuretic peptide, high-sensitivity cardiac troponin I [hs-cTnI], and high-sensitivity C-reactive protein [hs-CRP]) revealed that independent determinants of SAA-LDL levels were female sex, dyslipidemia, the Gensini score, absence of statin use, hs-cTnI, and hs-CRP. After adjusting for potential clinical confounders and established cardiovascular biomarkers, the highest quartile of SAA-LDL levels (vs. the lowest quartile) was significantly associated with the incidence of all-cause death (hazard ratio [HR], 1.51; 95% confidence interval [CI], 1.02–2.26), but not with that of cardiovascular death (HR, 1.11; 95% CI, 0.59–2.10) or MACE (HR, 1.57; 95% CI, 0.97–2.57). Stratified analyses revealed that this association was pronounced in patients with low hs-cTnI (<75th percentile) (HR, 1.85; 95% CI, 1.06–3.30) and in patients with low hs-CRP levels (≤1.0 mg/L) (HR, 2.30; 95% CI, 1.17–4.79).

Conclusions

Elevated SAA-LDL levels were independently associated with the risk of all-cause death in patients with suspected or known CAD. The SAA-LDL level appears to serve as a prognostic biomarker for risk stratification in relatively low-risk patients with low hs-cTnI (<75th percentile) or low hs-CRP (≤1.0 mg/L).

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The ANOX study is supported by a Grant-in-Aid for Clinical Research from the National Hospital Organization.

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 <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<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.

Proteomics profiling reveals signaling pathways associated with major adverse cardiovascular events in patients with hypertrophic cardiomyopathy

Background

Hypertrophic cardiomyopathy (HCM) is the most common genetic cardiomyopathy affecting 1 in 200–500 people in the US. It is characterized by a diverse clinical course, and only a subset of patients with HCM experience major adverse cardiovascular events (MACE) such as arrhythmias (e.g., ventricular tachycardia/fibrillation [VT/VF], atrial fibrillation [AF]), stroke, and heart failure. However, the molecular mechanisms underlying the presence of MACE in HCM are still not well understood.

Purpose

Our aim was to reveal signaling pathways associated with prior MACE in patients with HCM by applying plasma proteomics profiling.

Methods

We conducted a multicenter case-control study of patients with HCM comparing those with and without a prior history of MACE. We performed plasma proteomics profiling of 5032 proteins. We defined prior MACE as a composite outcome of sustained VT/VF, AF, stroke/transient ischemic attack, left ventricular ejection fraction ≤50%, New York Heart Association functional class ≥2 symptoms, resuscitated cardiac arrest, or appropriate implantable cardioverter defibrillator therapy. We applied the random forest method to derive a proteomics-based discrimination model developed in patients enrolled at one institution (training set) and externally validated the model on patients enrolled at another institution (test set). We then performed pathway analysis of proteins differentially regulated in patients with prior MACE. Pathways with a false discovery rate (FDR) <0.05 with at least 5 associated proteins were declared positive.

Results

A total of 396 patients were included, with 278 in the training set and 118 in the test set. In this cohort, 251 (63%) patients had prior MACE (171 in the training set and 80 in the test set). Using the proteomics-based model derived from the training set, the area under the receiver operating characteristic curve was 0.81 (95% CI 0.73–0.88) in the test set (Figure 1). There were 632 differentially expressed proteins (univariable p<0.05). Pathway analysis identified significantly dysregulated pathways in patients with prior MACE (Figure 2). This included both pathways known to be associated with MACE (e.g., TGF-β [FDR=0.03]) and novel pathways (e.g., Ras-MAPK [FDR=0.01] and its upstream PI3K-Akt [FDR=7.7x10–7] pathways). Pathways involved in cellular metabolism/proliferation (e.g., HIF 1 [FDR=0.01] and Wnt [FDR=0.04] pathways) and inflammation (e.g., complement and coagulation cascades [FDR=2.7x10–21], cytokine-cytokine receptor interaction [FDR=8.1x10–16]) were also significantly dysregulated.

Conclusions

Our study in patients with HCM reveals that those with a prior history of MACE have a distinctive plasma proteomics profile. We further identified both previously known and novel pathways dysregulated in this subset with a more severe form of HCM. Our findings may aid in development of targeted therapies for the prevention of MACE in HCM.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): R01 HL157216

Wnt signaling promotes tooth germ development through YAP1-TGF-β signaling

Tooth germ development involves continuous and sequential steps with reciprocal interactions between odontogenic epithelium and the adjacent mesenchyme. Several growth factors, including Wnt, are essential for tooth germ development. Molecular mechanisms underlying Wnt/β-catenin-regulated tooth germ development are poorly understood. In tooth germ rudiments culture, we recently demonstrated that Semaphorin 3A (Sema3A), an axonal guidance factor, stimulation reversed Wnt/β-catenin signaling-dependent decreased cell proliferation but did not completely rescue the morphological anomalies of tooth germ, suggesting that an uncharacterized signaling pathway may be essential in Wnt/β-catenin signaling-dependent tooth germ development. Herein, an enrichment analysis using DNA microarray data, which was obtained in our previous research, revealed that Wnt/β-catenin signaling negatively regulates YAP1 and/or TGF-β signalings. In odontogenic epithelial cells and tooth germ rudiments, Wnt/β-catenin signaling activation reduced YAP1 expression, thereby suppressing YAP1 and TGF-β signalings sequentially. Additionally, YAP1 signaling induced TGF-β2 expression to promote TGF-β signaling in the cells. Finally, Wnt/β-catenin signaling-dependent disorganized tooth germ development, in which YAP1 signaling was suppressed, was reversed by TGF-β stimulation. These results suggest that Wnt/β-catenin signaling contributes to the tooth germ development through YAP1-TGF-β signaling.

Relationship between the housing coldness/warmth evaluation by CASBEE Housing Health Checklist and psychological distress based on TMM Community-Based Cohort Study: a cross-sectional analysis

OBJECTIVES

Previous studies have reported the relationship between housing environment and health, although due to cost and effort, it was difficult to conduct housing condition surveys on a large scale. The CASBEE Housing Health Checklist (the Checklist) made it possible to easily evaluate the housing condition from the resident's perspective. This study examined the relationship between housing coldness/warmth evaluation using the Checklist and psychological distress in a large-scale general Japanese population.

STUDY DESIGN

A cross-sectional study.

METHODS

We analysed data from 29,380 people aged ≥20 years who lived in Miyagi Prefecture, Japan. As an assessment of housing coldness/warmth, we used the Checklist. We classified participants' total scores on the Checklist related to coldness/warmth into quartiles. The Kessler 6 scale was used as an indicator of psychological distress. Multivariable logistic regression models were used to estimate the adjusted odds ratio (OR) and 95% confidence intervals (CIs). Adjusted OR and P-values for linear trends were calculated using the quartiles of the Checklists' score.

RESULTS

Among participants in Q1 (i.e., poorer subjective house condition), the percentage of people with psychological distress was high. Compared to the highest quartile, Q1 showed poorer evaluation of housing coldness/warmth, and higher OR for psychological distress. The OR (95% CI) of psychological distress for Q3, Q2, and Q1 compared with Q4 were 1.93 (1.74-2.14), 2.82 (2.55-3.12), and 5.78 (5.25-6.35), respectively.

CONCLUSIONS

Housing coldness/warmth evaluation was significantly related to psychological distress. This finding suggests that maintaining a comfortable thermal environment at home could be important for residents' mental health.

Long-term outcomes of ruptured hepatocellular carcinoma: An international multicentric propensity score-matched study

Objective

Long-term outcomes of patients with ruptured hepatocellular carcinoma (rHCC) remain scant. This study aimed to assess disease-free survival (DFS) and overall survival (OS) after surgical resection of rHCC compared to non-ruptured HCC (nrHCC).

Methods

Patients with rHCC and nrHCC were collected from 8 centers in Europe, Asia, and North America. Resected rHCC patients were matched 1:1 to patients undergoing surgery for nrHCC using propensity score and nearest-neighbor method (matching criteria: age, tumor size, cirrhosis, Child-Pugh score, Barcelona Clinic Liver Cancer stage, resection status, grade, and microvascular invasion). Survival rates were calculated using Kaplan-Meier method.

Results

A total of 2033 patients were included: 226 rHCC patients (172 operated: 68 with upfront surgery and 104 after embolization) and 1807 nrHCC patients. Median DFS and OS of rHCC patients (all treatments confounded) were 10 months (95% CI 7–13) and 22 months (95% CI 13–31). Prognostic factors for worse OS among rHCC patients were absence of preoperative arterial embolization (HR 2.3, 95% CI 1.2–4.6, p=0.016), cirrhosis Child B/C (HR 2.4, 95% CI 1.1–5.4, p=0.040), and R1/R2 margins (HR 2, 95% CI 1–5, p=0.049). Survivals were similar between Western and Eastern rHCC patients.

After propensity score matching, 106 rHCC patients and 106 nrHCC patients displayed similar characteristics. Patients with rHCC had shorter median DFS (12 months, 95% CI 7–17 vs. 22 months, 95% CI 12–32, p=0.011), but similar median OS compared to nrHCC patients (43 months, 95% CI 21–65 vs. 63 months, 95% CI 21–105, p=0.060).

Conclusion

In this large dataset including Eastern and Western patients, rHCC was associated with shorter DFS compared to nrHCC, while OS was similar.

Selective targeting of multiple myeloma cells with a monoclonal antibody recognizing the ubiquitous protein CD98 heavy chain

Cancer-specific cell surface antigens are ideal therapeutic targets for monoclonal antibody (mAb)-based therapy. Here, we report that multiple myeloma (MM), an incurable hematological malignancy, can be specifically targeted by an mAb that recognizes a ubiquitously present protein, CD98 heavy chain (hc) (also known as SLC3A2). We screened more than 10,000 mAb clones raised against MM cells and identified R8H283, an mAb that bound MM cells but not normal hematopoietic or nonhematopoietic cells. R8H283 specifically recognized CD98hc. R8H283 did not react with monomers of CD98hc; instead, it bound CD98hc in heterodimers with a CD98 light chain (CD98lc), a complex that functions as an amino acid transporter. CD98 heterodimers were abundant on MM cells and took up amino acids for constitutive production of immunoglobulin. Although CD98 heterodimers were also present on normal leukocytes, R8H283 did not react with them. The glycoforms of CD98hc present on normal leukocytes were distinct from those present on MM cells, which may explain the lack of R8H283 reactivity to normal leukocytes. R8H283 exerted anti-MM effects without damaging normal hematopoietic cells. These findings suggested that R8H283 is a candidate for mAb-based therapies for MM. In addition, our findings showed that a cancer-specific conformational epitope in a ubiquitous protein, which cannot be identified by transcriptome or proteome analyses, can be found by extensive screening of primary human tumor samples.

Effect of Tocilizumab Treatment on Patients with Coronavirus Disease 2019 and Bacteremia: A Retrospective Cohort Study

INTRODUCTION

This study aimed to determine if tocilizumab treatment for coronavirus disease 2019 (COVID-19) increases bacteremia and suppresses fever and inflammatory reactants.

METHODS

In this single-center, retrospective, observational study, all patients with COVID-19 admitted to our emergency intensive care unit from March 2020 to August 2021 were categorized into tocilizumab-treated and tocilizumab-naïve groups, and the incidence of bacteremia and other factors between the two groups were compared. Patients with bacteremia were further classified into tocilizumab-treated and tocilizumab-naïve groups to determine if fever and inflammatory reactants were suppressed.

RESULTS

Overall, 144 patients were included in the study, 51 of whom received tocilizumab, which was administered on the day of admission. Further, of the 24 (16.7%) patients with bacteremia, 13 were in the tocilizumab-treated group. Results revealed a significant difference in the C-reactive protein level (p < 0.001) at the onset of bacteremia between the tocilizumab-treated group [median 0.42 mg/dL (0.27-0.44 mg/dL)] and the tocilizumab-naïve group [7.48 mg/dL (4.56-13.9 mg/dL)]. The median number of days from admission to onset of bacteremia was not significantly different between the tocilizumab-treated group [10 days (9-12 days)] and the tocilizumab-naïve group [9 days (7.5-11 days)] (p = 0.48). There was no significant difference in fever between the groups. Multivariate logistic analysis showed that tocilizumab treatment did not affect the probability of bacteremia.

CONCLUSION

Treatment of patients with COVID-19 with tocilizumab does not increase the risk of bacteremia. Tocilizumab suppresses C-reactive protein levels but not fever. Therefore, careful monitoring of fever can reduce the risk of missed bacteremia.

IM-7 Identification of novel glioblastoma specific antigen using patient derived tumor cell for CAR-T cell therapy

Chimeric antigen receptor T (CAR-T) cell therapy is a newly developed antitumor immunotherapy presenting remarkable clinical response with leukemia, and is expected to be applied to other malignant solid tumors including glioblastoma (GBM). However, for development of CAR-T therapy against GBM, identification of novel and suitable tumor specific antigen is required to expect higher therapeutic efficacy. Herein, we developed our original method to detect novel GBM specific antigen using patient derived GBM (PD-GBM) cells. First, BALB/c mice were immunized by footpad injection of PD-GBM cells. B cells were extracted from lymph nodes of the mice, fused with murine myeloma cells, and then cultured to produce monoclonal antibodies for GBM cells. About 500 GBM binding monoclonal antibody lines were established, and then each antibody was again analyzed by flow cytometry with multiple PD-GBM cells and human non-tumor brain cells to find out GBM specific antibodies. Consequently, two GBM specific antibody lines were selected and genetically analyzed to identify the recognized antigen. CAR-T cells targeting the detected antigens were successfully generated, and the cytotoxicity against GBM cells was confirmed by chromium releasing assay and bioluminescent cytokine assay. Remarkably, one of the identified tumor specific antigens proved to be B7-H3, which is known pan-cancer antigen expected to be one CAR-T therapeutic target for malignant solid tumors, also expressed in most GBM cells. This result confirms that our experimental method using murine antigen-antibody reaction is feasible for detecting antigen as a novel CAR-T therapeutic target for GBM. Moreover, this method can also detect antigens derived from post-translational conformational changes such as glycosylation, which might have been overlooked by conventional methods. In addition, these results suggest our method using PD-GBM cells can identify potential targets of CAR-T therapy for each GBM patients respectively, thus leading to precision immunotherapy for GBM.

Successful Embolization of Collaterals from the Round Ligament Artery during Uterine Artery Embolization for Traumatic Uterine Leiomyoma Rupture: A Case Report

We describe the case of a 48-year-old woman who presented with traumatic rupture of a giant leiomyoma and massive hemoperitoneum caused by slipping and falling in the bathroom. She was in shock on arrival, and resuscitation was performed. Contrast-enhanced computed tomography showed massive intra-abdominal hematoma and extravasation from the subserous leiomyoma. Uterine artery embolization was performed, but she went into shock again after 6 h. The second contrast-enhanced computed tomography revealed persistence of extravasation. During 2^nd UAE, an angiogram revealed extravasation originating from left round ligament artery. After the embolization of the left round ligament and bilateral uterine arteries, the patient recovered from shock. Total abdominal hysterectomy was performed on day 2 of admission to prevent re-bleeding and infection, then she discharged on day 19 of admission.

Distinct association of VEGF-C and VEGF-D with prognosis in patients with chronic heart failure: the PREHOSP-CHF study

Background

The lymphatic system has been suggested to play an important role in cardiovascular (CV) diseases including heart failure (HF). Vascular endothelial growth factor C (VEGF-C) and VEGF-D are key regulators of lymphoangiogenesis.

Purpose

To investigate the association of VEGF-C and VEGF-D with prognosis in patients with chronic HF (CHF).

Methods

The PREHOSP-CHF study is a multicenter prospective cohort study to determine the predictive value of angiogenesis-related biomarkers in CHF. A total of 1,024 patients (mean age, 75.5±12.6 years; male, 58.7%) admitted to acute decompensated HF were included in the analyses. The primary outcome was MACE defined as a composite of CV death or HF hospitalization. The secondary outcomes were all-cause death, CV death, and HF hospitalizations. Serum levels of VEGF-C and VEGF-D, as well as N-terminal pro B-type natriuretic peptide (NT-proBNP), high sensitivity cardiac troponin-I (hs-cTnI), high sensitive C reactive protein (hs-CRP), VEGF, and soluble VEGF receptor-2 (sVEGFR-2) were measured at the time of discharge. Patients were followed-up over two years.

Results

Median [interquartile range] of VEGF-C and VEGF-D levels were 4821 [3633–6131] pg/ml and 404 [296–559] pg/ml, respectively. In multivariate stepwise regression analysis, independent determinants of VEGF-C levels were younger age, female gender, absence of prior HF hospitalization, chronic kidney disease, and anemia, lower ejection fraction, lower NT-proBNP levels, higher VEGF levels, and higher sVEGFR-2 levels, while those of VEGF-D levels were lower body mass index, presence of diabetes and atrial fibrillation, and higher NT-proBNP levels. During the follow-up, a total of 209 (20.4%) all-cause deaths, 112 (10.9%) CV deaths, and 309 (30.2%) HF hospitalizations occurred. After adjusting for established risk factors and CV biomarkers, VEGF-C levels were significantly and inversely associated with the incidence of MACE and non-CV death (Fig.1, model 4). On the other hand, VEGF-D levels were significantly and positively associated with the incidence of HF hospitalization (Fig. 1, model 4). When we divided the patients into 4 groups based on the median of VEGF-C and VEGF-D levels, patients with low VEGF-C and high VEGF-D showed significantly higher incidence of MACE, all-cause death, CV death, and HF hospitalization compared to those with high VEGF-C and low VEGF-D (Fig. 2).

Conclusions

Among patients with CHF, VEGF-C and VEGF-D had different characteristic and association with the incidence of adverse events. VEGF-C levels were inversely associated with the incidence of MACE and non-CV death, and VEGF-D levels were positively associated with the incidence of HF hospitalization. These results suggests different effects of VEGF-C and VEGF-D in CHF. Combination of VEGF-C and VEGF-D enables us to make good risk stratification in patients with CHF.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Grant-in-Aid for Clinical Research from the National Hospital Organization Figure 1Figure 2

Habitual exercise provides better prognosis for cardiac arrest with coronary artery disease

Background

Although regular physical activity has beneficial cardiovascular effects, exercise can trigger sudden cardiac arrest (SCA). Coronary artery disease (CAD) was identified as the most common cause of an exercise-related out-of-hospital cardiac arrest (OHCA). Regular exercise has been reported to reduce the risk of plaque rupture in animal studies and basic research. Therefore, we compared the coronary artery findings in CAD-OHCA patients with and without habitual exercise.

There have been few reports on whether regular exercise changes the prognosis in OHCA due to CAD (CAD-OHCA). We investigated the association between the better clinical outcome and the regular exercise in patients with CAD-OHCA.

Methods

This is a single-center retrospective analysis from 2006 to 2019. The consecutive 397 patients with OHCA due to myocardial ischemia underwent coronary angiography (CAG). After excluding 73 patients with vasospastic angina, the remaining 324 patients with CAD were enrolled in this study. We divided these patients into two groups according to whether they were habitually exercising (Exercise group: N=37) or not/unknown (Non-Exercise group: N=287).

Clinical outcome was a 30-day survival with minimal neurologic impairment represented by a Glasgow-Pittsburgh Cerebral Performance Categories Scale value 1 or 2.

Results

The patients in the Exercise Group were significantly younger (exercise vs. non-exercise, 57±12 vs. 64±12 years; P&lt;0.01) than those in the non-exercise group. The Exercise group had a lower incidence of diabetes mellitus (22% vs. 42%; P=0.02) and a higher incidence of dyslipidemia (81% vs. 62%; P=0.02) than the non-exercise group. The time from collapse to cardiopulmonary resuscitation (1.4±4.0 vs. 3.0±4.8min) and from collapse to return of spontaneous circulation (11.9±10.0 vs. 28.0±25.3min) were shorter in Exercise group (all p&lt;0.05). The ST-segment elevation was recorded on electrocardiography in fewer of the Exercise group (22% vs. 63%; P&lt;0.01). The finding of culprit lesion in the coronary arteries on arrival resulted significant differences between the 2groups (good collateral and/or TIMI3 flow: 62% vs. 25%, the plaque rupture and/or thrombus: 22% vs. 73%) (all p&lt;0.01) (Figure 1). Kaplan-Meier curve showed Exercise group has better neurological outcome at 30days compared than Non-Exercise (95% vs 51%; P&lt;0.001, log-rank test) (Figure 2). Multivariable Cox proportional hazards models revealed that a habitual exercise was one of the predictors of a good neurological outcome (HR 0.21, 95% CI 0.05–0.92; P=0.039).

Conclusions

The patients with habitual exercise had less plaque rupture, less coronary thrombosis than non-exercise. The patients with regular exercise had better clinical outcomes than non-exercise after CAD-OHCA.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Tokyo Metropolitan Goverment Figure 1. Findings of the culprit lesion in coronar arteriesFigure 2. Kaplan-Meier analysis

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.

Prediction of major adverse cardiovascular events in patients with hypertrophic cardiomyopathy using proteomics profiling

Background

Hypertrophic cardiomyopathy (HCM) is one of the most common genetic cardiac diseases, affecting 1 in 200–500 people in the US. HCM often causes major adverse cardiovascular events (MACE) – e.g., arrhythmias (atrial fibrillation, ventricular tachycardia/fibrillation), cerebrovascular accident, heart failure (HF), and sudden cardiac death (SCD). Although these HCM-related morbidities and mortality substantially affect the patients' quality and quantity of life, no systems are available to predict MACE. Furthermore, it remains unclear which signaling pathways mediate MACE.

Purpose

To prospectively determine protein biomarkers that predict MACE in patients with HCM and to identify signaling pathways differentially regulated in patients with HCM who subsequently develop MACE.

Methods

In this multi-center prospective cohort study of patients with HCM, we carried out plasma proteomics profiling of 4,979 proteins upon enrollment. We defined MACE as a composite of new-onset arrhythmias, cerebrovascular accident, increase in New York Heart Association class, HF death, SCD, and emergency department visit or non-elective hospitalization for HCM-related morbidities. We performed a sparse partial least squares discriminant analysis to develop a proteomics-based model to predict MACE using data from one institution (i.e., the training set). We tested the predictive ability in independent samples from the other institution (i.e., the test set) and performed time-to-event analysis. Additionally, we executed pathway analysis of the predictive proteins. A pathway was declared positive (i.e., dysregulated) if the false discovery rate (FDR) of the pathway was &lt;0.01 and there were ≥5 proteins that map to the pathway.

Results

The study included 257 patients with HCM (n=186 in the training set; n=71 in the test set). The median follow-up duration was 2.5 years (interquartile range, 1.4–3.1 years). Each year, 11.7% of patients had MACE. Using the proteomics-based prediction model derived from the training set, the area under the receiver-operating-characteristic curve was 0.84 (95% confidence interval [CI] 0.72–0.96) in the test set (Figure 1). The sensitivity was 0.82 (95% CI, 0.72–0.91) and the specificity was 0.84 (95% CI, 0.79–0.89) in the test set. In the test set, high-risk group determined by the proteomics-based predictive model had significantly higher rate of developing MACE (hazard ratio 20.2; 95% CI 2.4–168; p=0.005; Figure 2). The Ras-MAPK and related pathways were upregulated in patients who subsequently developed MACE (FDR&lt;0.001). Pathways involved in inflammation and fibrosis – e.g., the TGF-β pathway – were also upregulated.

Conclusions

This multi-center prospective cohort study with validation serves as the first to demonstrate the ability of proteomics profiling to predict MACE in HCM, exhibiting both novel (e.g., Ras-MAPK) and known (e.g., TGF-β) pathways that are differentially regulated in patients who subsequently experience MACE.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Institute of Health, American Heart Association Figure 1Figure 2

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.

Proteomics profiling reveals distinct molecular subtypes of hypertrophic cardiomyopathy with differential risks of major adverse cardiovascular events

Background

Hypertrophic cardiomyopathy (HCM) is a heterogeneous disease, and a subset (10–15%) of patients per year experience major adverse cardiovascular events (MACE). Current risk prediction models based solely on clinical data have yielded limited power in predicting MACE. Although the diagnosis of HCM is made based on clinical features, the heterogeneity of HCM suggests that “HCM” may actually encompass several subtypes of disease with distinct biological mechanisms that can only be elucidated via molecular-level investigation. Proteomics profiling measures concentrations of thousands of proteins simultaneously and has the potential to reveal underlying molecular mechanisms of disease and distinct subtypes of HCM.

Purpose

Our aim was to derive distinct subtypes of HCM in our multi-center biorepository of patients with HCM using proteomics profiling, and to examine their associations with MACE.

Methods

We applied unsupervised machine learning methods to derive HCM molecular subtypes using plasma proteomics profiling data from 258 patients in our multi-center HCM prospective cohort study. The primary outcome was MACE, defined as a composite of arrhythmias, progressive heart failure, stroke, and sudden cardiac death. We performed time-to-event analysis with a Cox proportional hazards model, using the subtype with the lowest risk as the reference group. We also performed pathway analysis of proteins differentially regulated in patients in the highest-risk subtype.

Results

We identified 4 distinct HCM subtypes. Patients in subtype D (n=74) were older on average compared to the other groups and more likely to be female. 50% of patients in subtype D had NYHA class II or greater heart failure symptoms compared to 37% in the rest of the groups combined. There were no significant differences in echocardiographic parameters or rates of genotype positivity between the four subtypes. Compared to the reference group (i.e., subtype A), patients in subtype D had a higher rate of MACE with a hazard ratio of 2.59 (95% CI 1.21–5.57, p=0.01 compared to subtype A; Figure). Pathway analysis identified significantly upregulated signaling pathways in the high-risk subtype D compared to the other subtypes (Table), with a number of upstream and downstream pathways associated with the Ras-MAPK pathway (FDR 0.0005).

Conclusions

Our study exhibits not only the presence of HCM molecular subtypes but also their distinct pathobiological mechanisms associated with different MACE risks. The four subtypes identified bore similar clinical characteristics and would not have been distinguishable based on the conventional analysis of clinical and echocardiographic parameters alone, but rather required deeper investigation at the molecular level. Furthermore, pathway analysis revealed an upregulation of Ras-MAPK pathways in the subtype with the highest risk of MACE, implicating this pathway as a potential underlying mechanism of more severe disease.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): NIH