Usefulness of ultra-sensitive troponin to predict anthracyclines and trastuzumab related cardiac dysfunction

Background

Cancer therapeutics–related cardiac dysfunction usually known as cardiotoxicity (CTX) is a common adverse effect of anthracyclines and anti-Her2 agents. In recent years, evidence of usefulness of ultrasensitive troponin for early diagnosis of CTX has increased, however the cut-off values of this biomarker remain uncertain.

Purpose

To assess the usefulness of ultrasensitive troponin T (UsTnT) to identify patients at risk of developing CTX and determine cut-off values for this biomarker.

Methods

Patients with diagnosis of solid or hematologic malignancies scheduled to receive therapy including anthracyclines and/or trastuzumab were prospectively included. Echocardiogram was performed prior to chemotherapy, and repeated 3 and 6 months later. UsTnT was measured at baseline and 3 months after starting chemotherapy and the increase of this biomarker from baseline was calculated. This UsTnT has a range of 3–10,000 pg/mL with a 99th percentile <15 pg/mL. Receiver operating characteristic curve was used to find out the best cut-off values followed by a multivariate analysis. The primary endpoint was the presence of CTX defined as a decline of left ventricular ejection fraction (LVEF) ≥10% at 6 months from baseline.

Results

A total of 141 patients were included (mean age 56±15 years, 85,8% were women, the most frequent diagnosis being breast cancer: 61.7%). Thirty-three patients (23.4%) met criteria of the primary endpoint of CTX. Patients with CTX showed significantly higher values of UsTnT at 3 months (18.2±14,9 vs 11.8±10,7 pg/mL, p=0.008) and also showed a higher increase of UsTnT from baseline (11.8±12.8 vs 5±8.2 pg/ml, p<0.001) (figure 1).

The value of UsTnT at 3 months ≥13 pg/mL and an increase of UsTnT from baseline ≥14 pg/mL were selected as the best cut-off values. Figure 2 resumes sensitivity, specificity and predictive values. Those patients who had UsTnT at 3 months ≥13 pg/mL had a 3.8 fold increased risk of developing CTX in a multivariate analysis adjusted by age and left ventricular hypertrophy (OR: 3.8 [95% CI: 1.6–9.3], p=0.003) while an increase of UsTnT from baseline ≥14 pg/mL showed almost 12 fold increased risk for the primary endpoint in the same model (OR: 11.95 [95% CI: 3.9–36.6], p<0.001).

Conclusions

UsTnT is a good biomarker for detecting early myocardial injury which allows the identification of patients at risk for developing CTX with only two measurements during cancer treatment.

Funding Acknowledgement

Type of funding sources: None.

Response to heart failure treatment in patients with anthracyclines and trastuzumab induced left ventricular dysfunction

Background

Chemotherapy treatments with anthracyclines and Trastuzumab are widely used in different hematologic or solid malignancies but myocardial injury and left ventricular dysfunction, usually called cardiotoxicity (CTX), is a frequent adverse effect. Some studies have demonstrated that early detection and treatment of CTX is essential for the recovery of left ventricular ejection fraction (LVEF), however its behavior after starting treatment is not well established.

Purpose

Evaluate the behavior of LVEF after starting treatment for heart failure in patients with diagnosis of CTX.

Methods

Patients with diagnosis of solid or hematologic malignancies scheduled to receive therapy including anthracyclines and/or trastuzumab were prospectively included. Echocardiogram was performed before starting treatment, and then 3 and 6 months after. CTX was defined, according to guidelines, as a drop of LVEF ≥10% to a value <53% and in these patients treatment of left ventricular dysfunction with B blockers and Enalapril/Losartan was promptly initiated and up-titrated to the maximal tolerated dose. Myocardial injury was defined as a drop of LVEF ≥10% and a value ≥53%, with a watchful waiting strategie, considering these patients as a control group. LVEF was re-evaluated 6 months after starting treatment or after diagnosis of myocardial injury. Primary endpoint was defined as a recovery of LVEF ≥10%.

Results

Of a total of 141 patients of the entire cohort (mean age 56±15 years, 85,8% women and 61,7% with diagnosis of breast cancer),17 patients (12%) met criteria of CTX and 21 (14,9%) of myocardial injury. There were no differences in relation to clinical characteristics or chemotherapy schemes between groups. In patients with CTX (intervention group), 88,2% reached the primary endpoint of recovery of LVEF ≥10% while only 23,8% did it in the control group (p<0,001). Patients with CTX had lowest LVEF at baseline, however no significant differences were observed at 12 months of follow up. Figure 1 represents the behavior of LVEF at baseline, 3, 6 and 12 months. A paired before-after analysis was performed between LVEF at baseline and at 12 months. Patients who received treatment showed no differences in LVEF (63,3±7,2% vs 61,5±9,6%, p=0,5). In contrast, patients who did not receive treatment showed a significant drop in LVEF (72,7±4,4% vs 66,2±5,4%; p<0,001) (figure 2).

Conclusion

Treatment of left ventricular dysfunction in patients with CTX is associated with a greater recovery of LVEF.

Funding Acknowledgement

Type of funding sources: None.

Discontinuation of anticoagulation and its associated factors in atrial fibrillation

Background/Introduction

Oral anticoagulation has been shown to reduce the incidence of embolic events associated with atrial fibrillation, however the discontinuation of these drugs observed in clinical trials may not be representative of the real-world setting due to the inclusion of selected populations.

Purpose

The objective of the study was to compare whether there is a difference in the incidence rate of discontinuation between vitamin K antagonists and direct anticoagulants and to evaluate the factors associated with non-adherence in patients newly diagnosed with atrial fibrillation.

Methods

This was a prospective cohort study. Adult patients (age >18 years) who had newly started anticoagulation therapy for atrial fibrillation or atrial flutter were enrolled. Patients with previous oral anticoagulation, mechanical prosthetic heart valves or creatinine clearance less than 30 mL/min were excluded. The follow-up period was 12 months. As the treatment allocation was not randomized, a propensity score weighting was performed considering baseline characteristics potentially associated with exposure and outcome. Factors associated with anticoagulant discontinuation were evaluated using a weighted Cox model.

Results

A total of 379 patients were included (mean age 78±9 years, 58% females). The median follow-up was 362 days (IQR 347–370). Loss to follow-up was 1%. The anticoagulation discontinuation rate was 24.6% in the direct anticoagulant group and 15.6% in the vitamin K antagonist group. A weighted model of time to discontinuation of anticoagulation treatment showed a crude HR of 1.40 (95% CI 0.79–2.48) for the direct anticoagulant therapy group compared to the vitamin K antagonist group, and a model adjusted for age, type of atrial fibrillation, radiofrequency ablation, bleeding, number of chronic drugs, and cardiology consultations during follow-up showed an adjusted HR of 1.26 (95% CI 0.75–2.12). The main reason for discontinuation of anticoagulation was high risk of bleeding in the vitamin K antagonist group and performance of a radiofrequency ablation procedure in the direct anticoagulant group. There was no statistically significant difference in the discontinuation rate between both groups when the baseline characteristics of the patients were considered.

Conclusion(s)

There was no statistically significant difference in the discontinuation rate between both groups when the baseline characteristics of the patients were considered.

The study showed that the discontinuation of anticoagulants in atrial fibrillation in our setting was not associated with the type of drug used, the age of patients, or the type of arrhythmia.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Boehringer Ingelheim Figure 1

Effect of the earthquake-tsunami (Chile, 2010) on toxic metal content in the Chilean abalone mollusc Concholepas concholepas

Toxic metal content were measured in samples of mollusc Concholepas concholepas obtained from the Chilean coast. Samples were collected during two periods, one before and one after the earthquake-tsunami which occurred in the Maule Region, Chile, February 27th, 2010 as a result of an earthquake with a magnitude of 8.8. Quantification of toxic metals in samples of hepatopancreas and muscle tissue was performed using flame atomic absorption spectroscopy. The analytical methodology was validated with certified reference material. The content means measured in muscle tissue for January 2010 were Cu: 10.3; Cr: 0.7; Cd: < 0.1; Mn: 3.6 and Zn: 38.6 µg g^-1 (dry weight). For October 2014, the means were Cu: 8; Cr: 2.4; Cd: < 0.1; Mn: 5.6 and Zn: 45.4 µg g^-1 (dry weight). In hepatopancreas tissue, the content means were Cu: 14.8; Cr: 2.4; Cd: 246.2; Mn: 4.4 and Zn: 1552.9 µg g^-1 (dry weight). For October 2014, the means were Cu: 53.7; Cr: 3.5; Cd: 118; Mn: 13.4 and Zn: 1352.3 µg g^-1 (dry weight). Cd, Cr, Cu, Mn and Zn content in the samples of hepatopancreas were generally higher than those recorded in muscle tissue however they were not always statistically significant. Statistical analysis showed that Cu and Mn content in the post-tsunami period increased in the hepatopancreas tissue. The concentrations of Cd, Cr, Cu, Mn, and Zn measured in the muscular tissue (edible part) of the species Conchalepas concholepas, were lower than the maximum contents allowed by the current legislation (FAO/WHO, 2004; EU, 2001) and its consumption is not a risk to human health.

Trimetazidine for stable angina

BACKGROUND

Patients with stable angina not controlled by monotherapy with nitrates, beta blockers, or calcium channel blockers are often treated with combinations of these drugs. There may be adverse effects from, or contraindications to, the use of combinations. In low risk groups, medical treatment appears to be as good an option as percutaneous transluminal coronary angioplasty in terms of averting myocardial infarction, death, or subsequent revascularization. Revascularization procedures are too costly or inaccessible for many patients in developing countries therefore effective and safe medical treatment is needed. Trimetazidine is a less well known anti-anginal drug that controls myocardial ischaemia through intracellular metabolic changes. Trimetazidine has been reported, in some studies, to be better tolerated than combined anti-anginal therapy; however it is not considered in published guidelines.

OBJECTIVES

To determine the efficacy and tolerability of trimetazidine in patients with stable angina.

SEARCH STRATEGY

We searched The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, LILACS and SCISEARCH, without language restriction, from inception to October 2003. Experts in the field were contacted to locate unpublished studies.

SELECTION CRITERIA

Randomised studies comparing trimetazidine with placebo, or other anti-angina drug in adults with stable angina.

DATA COLLECTION AND ANALYSIS

Two reviewers independently applied the inclusion criteria, assessed trial quality and extracted data.

MAIN RESULTS

Twenty-three studies (1378 patients) met the inclusion criteria. There was a paucity of information about mortality, cardiovascular events and quality of life. Trimetazidine, compared with placebo, reduced the number of weekly angina attacks ( mean difference -1.44, 95% CI -2.10 to -0.79; P < 0.0001), reduced weekly nitroglycerin tablet consumption (95% CI -1.47 to -2.20, -0.73; P < 0.0001) and improved exercise time to 1 mm segment depression (P=0.0002). Four small trials (263 patients) compared trimetazidine against other anti-anginal agents. One favoured trimetazidine over nitrates. Three tended to favour alternative regimens but with confidence intervals consistent with both major increases and decreases in frequency of angina episodes. In this subgroup, adverse events were considered in 5 trials (448 patients) and totals of 2 versus 12 drop outs due to adverse events were observed in the trimetazidine and alternative regimens respectively, but this was mostly driven by a single trial.

AUTHORS' CONCLUSIONS

Trimetazidine is effective in the treatment of stable angina compared with placebo, alone or combined with conventional anti-anginal agents. Trimetazidine may result in fewer dropouts due to adverse events. Large, long term trials comparing trimetazidine with other anti-anginal drugs assessing clinically relevant important outcomes are required to establish its role in clinical management.

Adhesion of probiotic lactobacilli to chick intestinal mucus

In the present work, interactions between three Lactobacillus strains (Lactobacillus fermentum CRL1015, Lactobacillus animalis CRL1014, and Lactobacillus fermentum CRL1016) and chicken small intestinal mucus were determined. Three lactobacilli isolated from chicken and selected by their potentially probiotic properties were able to grow in mucus preparations. Three peaks from gel filtration chromatography of intestinal mucus were obtained. The adhesion to three mucus fractions (I, II, and III), especially fraction III, was higher (P < 0.01) in L. fermentum CRL1015 than L. animalis CRL1014. Pretreatment of this fraction with proteases and metaperiodate showed lower (P < 0.01) adhesion values than that of the control, suggesting that a glycoprotein from the mucus acts as a receptor for L. fermentum CRL1015. Highest adhesion values were obtained at pH 7 and 42 °C, and neither the removal of divalent cations with ethylenediaminetetraacetic acid (EDTA) nor the addition of calcium produced significant variation from the adhesion values of the control (P > 0.01). This adhesion was only inhibited by N-acetyl-glucosamine. Salmonella pullorum and Salmonella gallinarum showed high (P < 0.01) values of adhesion to chick intestinal mucus. The results obtained from assays of the inhibition of adherence of Salmonella spp. to mucus, immobilized in polystyrene tissue culture wells, indicated that the pathogen adhesion was not reduced by lactobacilli (P > 0.05) or their spent culture supernatants (P > 0.05), suggesting that these strains did not interfere with the binding sites for Salmonella spp. adhesion to the small intestinal mucus.Key words: mucus, adhesion, Lactobacillus, probiotic, chicken.

C-reactive protein and the stress tests for the risk stratification of patients recovering from unstable angina pectoris

We assessed the 90-day prognostic value of stress tests and C-reactive protein (CRP) after medical stabilization of unstable angina. We included 139 consecutive patients with unstable angina who were free of complications or did not undergo revascularization during hospitalization. Blinded CRP assays and a stress test (95 exercise electrocardiograms, 44 dobutamine echocardiograms) were performed within the first week after discharge. Of 139 participants, 44 (31.6%) had an ischemic stress test response. CRP was elevated (> 1.5 mg/dl) in 40 patients (28.7%). CRP >1.5 mg/dl was more frequently observed among patients who experienced death or myocardial infarction at 90 days (88.2% vs 20.5%, p <0.0001). Compared with the stress tests, CRP showed greater sensitivity (88% vs 47%) and specificity (81% vs 70%) for increased risk, and higher positive (37.5% vs 18.2%) and negative (98% vs 90%) predictive values. The area under the receiver operating curve of the relation with the 90-day outcome increased from 0.58 +/- 0.07 to 0.83 +/- 0.05 when the CRP data were added to the stress tests results (p <0.001). Elevation of CRP differentiated stress tests negative patients with increased risk of major events during follow-up. In patients who respond to medical treatment for unstable angina, CRP elevation may be a better parameter than the stress test in identifying the presence of persistent plaque instability.

Primary care. Communal living

From this month, 80 per cent of health authorities will have at least one personal medical services pilot scheme in their area. The extension of the schemes raises concerns about equity and management issues for HAs. An HA where schemes will cover almost a third of the population has had to adopt an off-the-peg approach to development.

Independent prognostic value of elevated C-reactive protein in unstable angina

BACKGROUND

There is growing evidence of the prognostic importance of C-reactive protein (CRP) in unstable angina. However, the independent value of CRP relative to other conventional markers at different stages of treatment has not been established. Therefore, we assessed the in-hospital and 90-day prognostic values of serum CRP in unstable angina. We also compared the relation of CRP at admission and discharge with 90-day outcome.

METHODS AND RESULTS

One hundred ninety-four consecutive patients were included in a derivation (n = 105) and a validation set (n = 89). Serum CRP was measured at admission, at 48 hours, and at hospital discharge. A cutoff point of 1.5 mg/dL for CRP provided optimum sensitivity and specificity for adverse outcome, based on the receiver operator curves. No association was found between CRP on admission and in-hospital outcome. CRP at admission, adjusted for age, ECG findings on admission, silent ischemia, left ventricular wall motion score, and high-risk clinical presentation, was related to the combined end point of refractory angina, myocardial infarction, or death at 90 days (hazard ratio [HR] 1.9, 95% CI 1.2 to 8.3, P = 0.002). CRP at hospital discharge was the strongest independent marker of an adverse outcome (HR 3.16, 95% CI 2.0 to 5.2, P = 0.0001). These results were confirmed in the validation set (CRP at discharge: HR 3. 3, 95% CI 2.0 to 7.69, P = 0.0001).

CONCLUSIONS

In unstable angina, CRP is a strong independent marker of increased 90-day risk. Compared with CRP at admission, CRP at discharge is better related to later outcome and could be of great utility for risk stratification.