Prognostic value of estimating appendicular muscle mass in heart failure using creatinine/cystatin C

Objectives

As heart failure with concomitant sarcopenia has a poor prognosis, simple methods for evaluating the appendicular skeletal muscle mass index (ASMI) are required. Recently, a model incorporating anthropometric data and the sarcopenia index, that is, the ratio of serum creatinine to cystatin C (Cre/CysC), was developed to estimate the appendicular skeletal muscle mass. We hypothesized that this model would be superior to the previous model, which uses only anthropometric data to predict the prognosis. This study aimed to compare the prognostic value of low ASMI as defined by the biomarker and anthropometric models in patients with heart failure.

Methods

Among 847 patients, we estimated ASMI using an anthropometric model consisting of age, body weight, and height in 791 patients and a biomarker model that incorporates age, body weight, hemoglobin, and Cre/CysC in 562 patients. Patients were divided into low and non-low ASMI groups according to the ASMI estimated by each model, using the cut-off proposed by the Asian Working Group for Sarcopenia. The primary outcome was all-cause mortality.

Results

Overall, 53.4% and 39.1% of patients were diagnosed with low ASMI by anthropometric and biomarker models, respectively. The agreement of the diagnosis of low ASMI between the two models was poor, with a kappa coefficient of 0.56 (95% confidence interval: 0.49–0.63). Kaplan-Meier curves showed that a low ASMI was significantly associated with all-cause death in both models. However, this association was retained after adjustment for other covariates in the biomarker model (hazard ratio: 2.60, p=0.003), but not in the anthropometric model (hazard ratio: 0.70, p=0.257).

Conclusions and implications

Among patients hospitalized with heart failure, a low ASMI estimated using the biomarker model, but not the anthropometric model, was significantly associated with all-cause mortality.

Funding Acknowledgement

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

Obstructive sleep apnoe and cardiovascular, heart failure and mortality outcomes with empagliflozin versus placebo in the EMPA-REG OUTCOME trial

Background/Introduction

Obstructive sleep apnoe (OSA) and type 2 diabetes (T2D) occurs more frequently in persons with obesity, and both OSA and T2D are associated with metabolic disturbances that increases the risk for cardiovascular disease (CVD). In EMPA-REG OUTCOME, a randomized placebo-controlled outcome trial involving 7020 patients with T2D and CVD, the sodium glucose co-transporter (SGLT)-2 inhibitor empagliflozin reduced HbA1c, systolic blood pressure, waist circumference, and weight, and also reduced the risk of 3-point major adverse CV events (3P- MACE) by 14%, CV death by 38% and hospitalization for heart failure (HHF) by 35%.

Purpose

We investigated incidence rates of CV, HHF, and mortality outcomes in patients with or without OSA at baseline, and the treatment effect of empagliflozin, in EMPA-REG OUTCOME.

Methods

The trial included patients from 42 countries with T2D (with HbA1c 7.0–9.0% for drug-naïve patients and 7.0–10.0% for those on stable glucose-lowering therapy), established CVD, and estimated glomerular filtration rate >30 mL/min/1.73 m2. Patients were randomised (1:1:1) to receive empagliflozin 10 mg, empagliflozin 25 mg, or placebo once daily in addition to standard of care. All CV outcomes were independently adjudicated and events were pooled for the 10 and 25mg doses. In this post-hoc analysis, OSA were assessed based on investigator reports using MedDRA 18.0 and incidence rates for outcomes were reported by adjusted event-rates per 100 patient-years. Analysis of effects on outcomes were performed using Cox regression models with multivariable adjustments.

Results

Of 7020 patients with T2D and CVD, OSA was reported in 391 (5.6% [placebo 5.4%; pooled empagliflozin doses 5.7%]. Compared with patients without OSA at baseline, those with OSA were more frequent males (82.9% vs 70.8%), living in region North-America (63.2% vs 17.3%), and had more obesity (BMI ≥35 kg/m2: 55.2% vs 18.2%) and more coronary artery disease (88.0 vs 74.9%). Over a median 3.1 years, individuals with OSA at baseline relative to those without OSA in the placebo group, experienced 1.3–2.0 fold higher event rates for 3P-MACE (OSA vs no OSA: 6.49 vs 4.27/100-patient-year), CV death (2.57 vs 1.99), HHF (2.71 vs 1.38) and all-cause mortality (4.29 vs 2.78). Empagliflozin improved CV, HHF, and mortality outcomes regardless of presence of OSA at baseline (p-for interactions >0.05 [Figure 1]).

Conclusions

In this post-hoc exploratory analysis, patients with OSA had higher frequency of events for 3P-MACE, HHF and mortality. The cardio-protective effects of empagliflozin was consistent in those with and without OSA at baseline.

Figure 1. Sleep apnea and empagliflozin

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Boehringer Ingelheim and Eli Lilly Diabetes Alliance

Prognostic significance of 2019 Asian Working Group for Sarcopenia update on definition of sarcopenia

Background/Introduction

Sarcopenia plays a major role in the pathophysiology of frailty and is associated with worse outcome in the elderly population including patients with heart failure. A recent update of the most common definition of sarcopenia in Asia, Asian Working Group for Sarcopenia (AWGS2019), included significant changes in the diagnostic algorithm with newly dividing sarcopenia into severe and “non-severe” sarcopenia.

Purpose

The objective of this study was to evaluate the differences between AWGS2014 and AWGS2019 in patients with heart failure.

Methods

In the multicenter prospective FRAGILE-HF registry, which included elderly (≥65 years old) patients who were hospitalized with heart failure, we studied 865 patients (80±8 years old, 42% female). All-cause death in 1-year follow-up was tracked.

Results

Based on the original version of AWGS (AWGS2014), 183 patients (21%) were diagnosed with sarcopenia, which was associated with higher age, lower physical performance, less muscle mass, and greater heart failure risk (all p<0.001) as well as higher rate of all-cause death (HR 1.90, p=0.004 after adjustment by multivariable regression). Those patients with sarcopenia by AWGS2014 were reclassified mainly to severe sarcopenia (155, 84.7%) by AWGS2019, and 25 (13.7%) and 2 (1.1%) were classified into sarcopenia and non-sarcopenia. Meanwhile, 24 (3.5%) and 4 (0.6%) of patients without sarcopenia by AWGS2014 were reclassified into sarcopenia and severe sarcopenia, respectively. Although severe sarcopenia by AWGS2019 was associated with higher age, lower physical performance, less muscle mass, and greater heart failure risk (all p<0.001), patients with “non-severe” sarcopenia was rather younger (p<0.001) and had better physical performance (p=0.021) despite less muscle mass (p<0.001) than those without sarcopenia. Multivariate Cox analysis demonstrated severe sarcopenia by AWGS2019 was an independent prognostic factor (HR 1.77, p=0.014), but “non-severe” sarcopenia was not (HR 1.52, p=0.37). The prognosis of patients who were reclassified from non-sarcopenia to sarcopenia or severe sarcopenia were comparable to those remained non-sarcopenia. When added to other risk factors, the prognostic predictability of AWGS2019 was significantly lower than AWGS2014 (net reclassification improvement −0.26, p=0.025).

Conclusions

About a half of “non-severe” sarcopenia in AWGS2019 were patients without sarcopenia in AWGS2014. The prognosis of such patients who were newly diagnosed as sarcopenia was good, resulting in low overall prognostic predictability of AWGS2019. A further consideration for diagnostic algorithms of sarcopenia may be warranted in patients with heart failure.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Japan Heart Foundation

Validation and comparison of BIOSTAT risk score and AHEAD score for patients with acute heart failure

Background/Introduction

Acute heart failure (AHF) is one of the major causes of mortality, and identifying the patients at high risk of mortality at the time of admission is crucial to improve clinical outcomes. Although some risk prediction models for patients with AHF have been proposed mainly from randomized clinical trials, the patients in such studies tend not to be similar to those in the real world. Recently, BIOSTAT risk score and AHEAD score derived from two large-scale registry dataset are proposed as useful risk stratification tools for patients with AHF. However, these scores have not been well externally validated and their prognostic prediction performance has not been directly compared.

Purpose

To validate and compare prognostication of BIOSTAT risk score and AHEAD score in AHF patients.

Methods

Patients who consecutively admitted to the cardiac intensive-care unit in our institution with a diagnosis of AHF from 2007 to 2011 were analyzed. Among them, patients with acute coronary syndrome, dialysis, malignancy were excluded. BIOSTAT risk score was calculated using 5 factors (age, blood urea nitrogen, BNP, hemoglobin, prescription of beta blockers), and AHEAD score was also calculated with 5 factors (atrial fibrillation, hemoglobin, age, creatinine, and diabetes mellitus). We also developed AHEAD + BNP model incorporating BNP into AHEAD score. Endpoint was 1-year all-cause death.

Results

Overall, 591 eligible patients were enrolled (mean age was 70±14 years old, 64.8% were male) and 96 patients (16.2%) died during the follow-up of 1-year. The median [interquartile range] of AHEAD score and BIOSTAT risk score were 2 [1–3] and 3 [2–4], respectively. The areas under the curves of receiver operating characteristic curve (AUC) were 0.66 for AHEAD, 0.68 for AHEAD + BNP, and 0.72 for BIOSTAT, respectively. The calibration plots for AHEAD, AHEAD + BNP, and BIOSTAT models showed good calibration (Hosmer-Lemeshow test: p=0.89, 0.74, and 0.74, respectively). The BIOSTAT model's AUC was significantly higher compared to AHEAD (p=0.018) and marginally statistically higher compared to AHEAD + BNP (p=0.054). However, BIOSTAT model showed statistically significant net reclassification improvement compared to both AHEAD (NRI: 0.43, p<0.001) and AHEAD + BNP (NRI: 0.43, p<0.001).

Conclusion

The BIOSTAT score comprised of five readily available clinical variables predict 1-year mortality of patients with AHF with good discrimination and calibration.

ROC curves

Funding Acknowledgement

Type of funding source: None

Social frailty provides additive prognostic impact on one-year outcome in aged patients with congestive heart failure

Background

Frailty is associated with multisystem declines in physiologic reserve and increased vulnerability to stressors, resulting in increased risks of adverse clinical outcomes in patients with heart failure (HF). Although frailty is conceptualized as an accumulation of deficits in multiple areas, most of the studies have focused mainly on physical frailty, and the social domains is one of the least investigated area.

Objectives

We prospectively evaluated the incidence and prognostic implication of social frailty (SF) in older patients with HF.

Methods

The FRAGILE-HF is a multicenter, prospective cohort study including patients hospitalized for HF and aged ≥65 years old. We defined SF by Makizako's 5 items, which are 5 questions proposed and validated to be associated with future disability. The primary endpoint of this study was a composite of death from any cause and rehospitalization due to HF. The impact of SF on all-cause mortality alone was also evaluated.

Results

Among 1,240 hospitalized HF patients, 5 simple questions revealed that 825 (66.5%) were in SF. During 1-year observation period after the discharge, the combined endpoint was observed in 399 (32.2%) patients, and 145 (11.7%) patients died. Kaplan-Meier analysis showed that SF patients had significantly higher rates of both the combined endpoint and all-cause mortality than those without SF (Log-rank test: p<0.05 for both, Figures). Moreover, SF remained independently associated with higher event rate of the combined endpoint (hazard ratio: 1.30; 95% confidence interval: 1.02 to 1.66; p=0.038) and all-cause mortality (hazard ratio: 1.53; 95% confidence interval: 1.01 to 2.30; p=0.044), even after adjusting for other covariates. Significant incremental prognostic value was shown when information on social frailty was added to known risk factors for combined endpoint (NRI: 0.189, 95% confidence interval: 0.063–0.316, p=0.003) and all-cause mortality (NRI: 0.234, 95% confidence interval: 0.073–0.395, p=0.004).

Conclusions

Among older hospitalized patients with heart failure, two-thirds of the population was with SF. Evaluating SF provides additive prognostic information in elderly patients with heart failure.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Novartis Pharma Research Grants, Japan Heart Foundation Research Grant

Changes in the ear canal microbiota of dogs with otitis externa

AIMS

Otitis externa (OE), one of the most common ear diseases in dogs, is caused by bacterial pathogens such as Staphylococcus sp. To understand the network of microbial communities in the canine ear canal affected with OE, we performed a cross-sectional study using next-generation sequencing.

METHODS AND RESULTS

Ear swab samples were collected from 23 OE-affected and 10 healthy control dogs, and the 16S rRNA gene sequenced using Illumina MiSeq. The otic microbiota in the OE-affected dogs showed significantly decreased alpha diversity compared to controls. The community composition also differed in the affected group, with significantly higher relative abundance of the phylum Firmicutes and the genus Staphylococcus (P = 0·01 and 0·04 respectively). Contrary to our expectations, the severity of the disease did not impact the otic microbiota in OE-affected dogs.

CONCLUSIONS

The ear canal microbiota of OE-affected dogs is distinct from that of healthy dogs, irrespective of disease status.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study, one of the few detailed analyses of the otic microbiota, can provide practical information for the appropriate treatment of canine OE.

Drug-induced oral lichenoid reaction during nivolumab therapy

Oral lichenoid reaction, an immune-related adverse event of immunotherapy, has been reported in very few patients receiving anti-programmed cell death receptor-1 (anti-PD-1) therapy. Here, we describe a case of severe stomatitis (grade ≥3 by the Common Terminology Criteria for Adverse Events, version 4.0) accompanied by pharyngolaryngitis that was observed in a patient receiving nivolumab therapy. The stomatitis was diagnosed as drug-induced lichenoid reaction. Nivolumab therapy was discontinued, and the patient was administered systemic prednisolone (1mg/kg). Most of the patient's mucosal changes in the oral cavity and pharyngolarynx resolved within approximately 3 weeks after starting the prednisolone. Clinicians should be aware that severe oral lichenoid reactions can occur in patients receiving anti-PD-1 therapy.

Long-term clinical impact of serum albumin in coronary artery disease patients with preserved renal function

BACKGROUND AND AIMS

Low serum albumin level is reportedly associated with worse clinical outcomes in patients with chronic kidney disease (CKD). However, associations between decreased serum albumin level and outcomes in non-CKD patients with coronary artery disease (CAD) remain unclear. Therefore, we aimed to evaluate the prognostic value of serum albumin concentrations in stable CAD patients with preserved renal function.

METHODS AND RESULTS

We studied 1316 patients with CAD and preserved renal function (estimated glomerular filtration rate ≥60 mL/min/1.73 m²) who underwent their first PCI between 2000 and 2011 and had data available for pre-procedural serum albumin. Patients were assigned to quartiles based on pre-procedural albumin concentrations. The incidence of major adverse cardiac events (MACE), including all-cause death and non-fatal myocardial infarction, was evaluated. Mean albumin concentration was 4.1 ± 0.4 g/dL. During the median follow-up of 7.5 years, 181 events occurred (13.8%). Kaplan-Meier curves revealed that patients with decreased serum albumin concentrations showed a higher event rate for MACE (log-rank, p < 0.0001). Using the highest tertiles (>4.3 g/dL) as reference, adjusted hazard ratios were 1.97 (95% CI, 1.12-3.55), 1.77 (95% CI, 0.99-3.25), and 1.19 (95% CI, 0.68-2.15) for serum albumin concentrations of <3.9, 3.9-4.0, and 4.1-4.3 g/dL, respectively. Decreased serum albumin concentration was associated with MACE even after adjusting for other independent variables (HR, 2.21 per 1-g/dL decrease; 95% CI, 1.37-3.56, p = 0.001).

CONCLUSION

Decreased serum albumin concentration independently predicted worse long-term prognosis in non-CKD patients after PCI. Pre-procedural serum albumin concentration could offer a useful predictor for patients with CAD and preserved renal function.

Structure-activity Relationships for α-Glucosidase Inhibition of Baicalein, 5,6,7-Trihydroxyflavone: the Effect of A-Ring Substitution

In order to estimate the effects of the A-ring hydroxyl group of baicalein (5,6,7-trihydroxyflavone, 1) on rat intestinal alpha-glucosidase inhibition, flavone, monohydroxyflavones, dihydroxyflavones, and methylated derivatives of 5,6,7-trihydroxyflavone were used for the structure-activity relationship (SAR) study. The importance of the 6-hydroxyl group of baicalein was validated for an exertion of the activity. And also, the tested flavones which lacked a hydroxyl substituent on any of positions 5, 6, or 7, showed no activity. Hence, the 5,6,7-trihydroxyflavone structure was concluded to be crucial for the potent inhibitory activity. In addition, an introduction of electron-withdrawing or electron-donating groups at position 8 of baicalein led to a dramatic decrease for activity, except for 8-fluoro-5,6,7-trihydroxyflavone, which carried a less bulky substituent on position 8. Hence, this result suggested that a sterically bulky substituent on C-8 of baicalein was detrimental for the activity regardless of its electronic nature. Through examining the inhibitory mechanism of baicalein against rat intestinal alpha-glucosidase, it was suggested to be a mixed type inhibition.

Cancer stem cells converted from pluripotent stem cells and the cancerous niche

Nowadays, the cancer stem cells are considered to be significantly responsible for growth, metastasis, invasion and recurrence of all cancer. Cancer stem cells are typically characterized by continuous proliferation and self-renewal as well as by differentiation potential, while stem cells are considered to differentiate into tissue- specific phenotype of mature cells under the influence of micro-environment. Cancer stem cells should be traced to the stem cells under the influence of a micro-environment, which induces malignant tumors. In this review, we propose this micro-environment as a ‘cancerous niche’ and discuss its importance on the formation and maintenance of cancer stem cells with the recent experimental results to establish cancer stem cell models from induced pluripotent stem cells. These models of cancer stem cell will provide the great advantages in cancer research and its therapeutic applications in the future.

The upper airway in sleep-disordered breathing: UA in SDB

Sleep disordered breathing (SDB) is a common condition and could be a risk factor for cardiovascular morbidity and mortality. However, the pathogenesis of SDB remains to be elucidated. In general, SDB is divided into two forms, obstructive and central sleep apnea (OSA and CSA, respectively). OSA results from the sleep-related collapse of the upper airway (UA) in association with multiple factors like race, gender, obesity and UA dimensions. CSA primarily results from a fall in PaCO2 to a level below the apnea threshold during sleep through the reflex inhibition of central respiratory drive. It has been reported that UA alterations (i.e., collapse or dilation) can be observed in CSA. This review highlights the roles of the UA in the pathogenesis and pathophysiology of SDB.

Involvement of autoimmunity to REG, a regeneration factor, in patients with primary Sjögren's syndrome

The regenerating gene (Reg) was isolated originally as a gene specifically over-expressed in regenerating pancreatic islets and constitute a growth factor family. Reg gene product (Reg) is important in the pathophysiology of various human inflammatory diseases. Recently, the possible involvement of human REG in the regeneration of salivary ductal epithelial cells of patients with primary Sjögren's syndrome (SS) was reported. However, the expression of the REG family genes in minor salivary glands (MSG) and the occurrence of anti-REG Iα autoantibodies in SS patients were obscured. In this study, we examined the expression of REG family genes in the MSG of SS and screened anti-REG Iα autoantibodies in SS. The mRNA levels of REG family genes in MSG were quantified using real-time reverse transcription-polymerase chain reaction (RT-PCR) and REG Iα expression in the MSG was analysed by immunohistochemistry. The mRNA level of REG Iα in the MSG of SS patients was significantly higher than that of control. REG Iα protein was expressed highly in SS ductal epithelial cells. Anti-REG Iα autoantibodies in the sera were found in 11% of SS. All the MSG in the anti-REG Iα autoantibody-positive group showed REG Iα expression, whereas only 40% showed REG Iα expression in the anti-REG Iα autoantibody-negative group. The anti-REG Iα autoantibody-positive group showed significantly lower saliva secretion and a higher ratio of grade 4 (by Rubin-Holt) in sialography. These data suggest strongly that autoimmunity to REG Iα might play a role in the degeneration of MSG ductal epithelial cells in primary SS.

Long insular artery infarction: characteristics of a previously unrecognized entity

BACKGROUND AND PURPOSE

The infarctions arising in the long insular arteries of the M2 segment have been poorly described in the past. The purpose of this study was to investigate the incidence, clinical characteristics, and pathogenesis of long insular artery infarcts.

MATERIALS AND METHODS

Patients with acute isolated infarcts in territories of the long insular arteries and lenticulostriate arteries were retrospectively reviewed. The long insular artery territory was defined as the area above the lenticulostriate artery territory at the level of centrum semiovale. On the coronal section, it lies between the tip of the anterior horn and the top of the superior limb of the insular cleft. Clinical features and prevalence of embolic sources were compared between the 2 groups.

RESULTS

Of 356 consecutive patients with acute ischemic stroke, 8 (2.2%) had a long insular artery infarct (long insular artery group) and 50 (14.0%) had a lenticulostriate artery infarct (lenticulostriate artery group). There were no differences in age, sex, prevalence of risk factors, neurologic deficit, or incidence of lacunar syndromes between these groups. Abrupt onset was more common in the long insular artery than in the lenticulostriate artery group (P = .004). The prevalence of embolic high-risk sources (eg, atrial fibrillation) was not significantly different between these groups, but the combined prevalence of all embolic sources, including moderate-risk sources, was significantly higher in the long insular artery group (P = .048).

CONCLUSIONS

Isolated infarction caused by long insular artery occlusion is not rare. Abrupt onset is more common for long insular artery infarction, and this finding could be attributed to the higher incidence of an embolic etiology as the pathogenesis of infarction.