Comparison of SGLT2 inhibitors vs. DPP4 inhibitors for patients with metabolic dysfunction associated fatty liver disease and diabetes mellitus

PURPOSE

This study aimed to examine the potential benefit of sodium-glucose cotransporter 2 (SGLT2) inhibitors for patients with metabolic dysfunction-associated fatty liver disease (MAFLD) and diabetes mellitus (DM) using a real-world database.

METHODS

We analyzed individuals with MAFLD and DM newly initiated on SGLT2 or dipeptidyl peptidase 4 (DPP4) inhibitors from a large-scale administrative claims database. The primary outcome was the change in the fatty liver index (FLI) assessed using a linear mixed-effects model from the initiation of SGLT2 or DPP4 inhibitors. A propensity score-matching algorithm was used to compare the change in FLI among SGLT2 and DPP4 inhibitors.

RESULTS

After propensity score matching, 6547 well-balanced pairs of SGLT2 and 6547 DPP4 inhibitor users were created. SGLT2 inhibitor use was associated with a greater decline in FLI than DPP4 inhibitor use (difference at 1-year measurement, - 3.8 [95% CI - 4.7 to - 3.0]). The advantage of SGLT2 inhibitor use over DPP4 inhibitor use for improvement in FLI was consistent across subgroups. The relationship between SGLT2 inhibitors and amelioration of FLI was comparable between individual SGLT2 inhibitors.

CONCLUSIONS

Our analysis using large-scale real-world data demonstrated the potential advantage of SGLT2 inhibitors over DPP4 inhibitors in patients with MAFLD and DM.

Efficacy and Safety of Docetaxel plus Ramucirumab for Patients with Pretreated Advanced or Recurrent Non-small Cell Lung Cancer: Focus on Older Patients

BACKGROUND

Combination therapy with docetaxel (DTX) and ramucirumab (RAM) has been used as a second-line treatment for advanced or recurrent lung cancer. However, there is insufficient evidence regarding the safety of angiogenesis inhibitors in older patients.

OBJECTIVE

This multicenter retrospective study aimed to investigate the efficacy and safety of second-line treatment regimens in older patients with advanced or recurrent non-small cell lung cancer (NSCLC).

PATIENTS AND METHODS

We retrospectively analyzed 145 patients aged ≥ 70 years with advanced or recurrent NSCLC treated with second-line chemotherapy after platinum-based therapy between April 1, 2016, and March 31, 2021. Patients were subdivided into the DTX + RAM (n = 38) and single-agent (n = 107) groups.

RESULTS

The median time to treatment failure was 6.3 months (95% confidence interval [CI] 3.6-9.6) in the DTX + RAM group and 2.3 months (95% CI 1.7-3.0) in the single-agent group (p < 0.01). The median overall survival was 15.9 months (95% CI 12.3-Not Achieved) in the DTX + RAM group and 9.4 months (95% CI 6.9-15.1) in the single-agent group (p = 0.01). Grade ≥ 3 adverse events frequency was not significantly different between the two groups, except for edema. Patients in the DTX + RAM group who did not discontinue treatment owing to adverse events exhibited the most favorable prognosis.

CONCLUSIONS

These findings suggest that the DTX + RAM combination is an effective second-line therapy for older patients with advanced or recurrent NSCLC, offering favorable efficacy without treatment discontinuation owing to adverse events.

Clinical and ultrasound features of difficult-to-treat rheumatoid arthritis: A multicenter RA ultrasound cohort study

OBJECTIVE

The optimal strategy for difficult-to-treat (D2T) rheumatoid arthritis (RA) has not been identified, and the ultrasound characteristics of D2T RA have not been reported. We investigated the clinical characteristics and factors contributing to the outcome in D2T RA in a multicentre RA ultrasound observational cohort.

METHOD

We reviewed 307 Japanese patients diagnosed with RA who underwent treatment with biological and targeted synthetic disease-modifying anti-rheumatic drugs (b/tsDMARDs). We compared the differences in patient characteristics between the D2T RA and non-D2T RA groups. We examined the factors contributing to a good response [defined as b/tsDMARD continuation and Clinical Disease Activity Index (CDAI) ≤ 10 at 12 months] in the D2T RA patient group.

RESULTS

Forty-three patients (14%) were categorized as D2T RA and the remaining 264 (86%) as non-D2T RA at baseline. The grey-scale (GS) score, disease duration, and CDAI at the initiation of treatment were significantly higher in the D2T RA group than in the non-D2T RA group. In contrast, the power Doppler (PD) score was not significantly different between the two groups. Of the 43 D2T RA patients, 20 achieved a good response. The introduction of CTLA4-Ig (n = 5) was significantly associated with a good response in analysis based on inverse probability weighting with propensity score. GS and PD scores at baseline were not significantly associated with therapeutic response at 12 months in D2T RA patients.

CONCLUSIONS

Patients with D2T RA had high clinical and ultrasound activity and poor responses to treatment with b/tsDMARDs. CTLA4-Ig was associated with a good response at 12 months in D2T RA patients.

Comparing Three Different Anti-Programmed Death-Ligand 1 Antibodies in Immunohistochemical Evaluation of Combined Chemoimmunotherapy Response in Patients With NSCLC: A Prospective Study

Introduction

Multiple programmed death-ligand 1 (PD-L1) immunohistochemistry assays performed using different antibodies including DAKO 22C3, DAKO 28-8, and Ventana SP142 PD-L1-predictive markers for response to various immune checkpoint inhibitors in NSCLC-have been approved in several countries. The differences in multiple PD-L1 immunohistochemistry assay results in predicting the therapeutic response to combined chemoimmunotherapy in patients with NSCLC remain unclear.

Methods

In this multicenter prospective observational study, we monitored 70 patients with advanced NSCLC treated with combined chemoimmunotherapy at 10 institutions in Japan. The expression of PD-L1 in pretreatment tumors was evaluated using the 22C3, 28-8, and SP142 assays in all patients.

Results

The PD-L1 level in tumor cells determined using the 22C3 assay was the highest among the three assays performed with different antibodies. According to the 22C3 assay results, the PD-L1 tumor proportion score greater than or equal to 50% group had a significantly longer progression-free survival period than the PD-L1 tumor proportion score less than 50% group. Nevertheless, the other assays did not reveal remarkable differences in the objective response rate or progression-free survival.

Conclusions

In our study, PD-L1 expression determined using the 22C3 assay was more correlated with the therapeutic response of patients with NSCLC treated with combined chemoimmunotherapy than that determined using the 28-8 and SP142 assays. Therefore, the 22C3 assay may be useful for clinical decision-making for patients with NSCLC treated with combined chemoimmunotherapy. Trial registration number: UMIN 000043958.

Prognostic impact of clinical factors for immune checkpoint inhibitor with or without chemotherapy in older patients with non-small cell lung cancer and PD-L1 TPS ≥ 50

Introduction

The proportion of older patients diagnosed with advanced-stage non-small cell lung cancer (NSCLC) has been increasing. Immune checkpoint inhibitor (ICI) monotherapy (MONO) and combination therapy of ICI and chemotherapy (COMBO) are standard treatments for patients with NSCLC and programmed cell death ligand-1 (PD-L1) tumor proportion scores (TPS) ≥ 50%. However, evidence from the clinical trials specifically for older patients is limited. Thus, it is unclear which older patients benefit more from COMBO than MONO.

Methods

We retrospectively analyzed 199 older NSCLC patients of Eastern Cooperative Oncology Group performance status (ECOG PS) 0-1 and PD-L1 TPS ≥ 50% who were treated with MONO or COMBO. We analyzed the association between treatment outcomes and baseline patient characteristics in each group, using propensity score matching.

Results

Of the 199 patients, 131 received MONO, and 68 received COMBO. The median overall survival (OS; MONO: 25.2 vs. COMBO: 42.2 months, P = 0.116) and median progression-free survival (PFS; 10.9 vs. 11.8 months, P = 0.231) did not significantly differ between MONO and COMBO group. In the MONO group, OS was significantly shorter in patients without smoking history compared to those with smoking history [HR for smoking history against non-smoking history: 0.36 (95% CI: 0.16-0.78), P = 0.010]. In the COMBO group, OS was significantly shorter in patients with PS 1 than those with PS 0 [HR for PS 0 against PS 1: 3.84 (95% CI: 1.44-10.20), P = 0.007] and for patients with squamous cell carcinoma (SQ) compared to non-squamous cell carcinoma (non-SQ) [HR for SQ against non-SQ: 0.17 (95% CI: 0.06-0.44), P < 0.001]. For patients with ECOG PS 0 (OS: 26.1 months vs. not reached, P = 0.0031, PFS: 6.5 vs. 21.7 months, P = 0.0436) or non-SQ (OS: 23.8 months vs. not reached, P = 0.0038, PFS: 10.9 vs. 17.3 months, P = 0.0383), PFS and OS were significantly longer in the COMBO group.

Conclusions

ECOG PS and histological type should be considered when choosing MONO or COMBO treatment in older patients with NSCLC and PD-L1 TPS ≥ 50%.

Osimertinib as first-line treatment for elderly patients with advanced EGFR mutation-positive non-small cell lung cancer in a real-world setting (OSI-FACT-EP)

OBJECTIVES

Osimertinib is the primary treatment for patients with epidermal growth factor receptor (EGFR) mutation-positive advanced non-small cell lung cancer. However, evidence of the outcomes of osimertinib treatment in patients over 75 years of age in the real-world setting is limited.

MATERIALS AND METHODS

This retrospective study analyzed the data of 538 patients (203 elderly and 335 non-elderly) with EGFR mutation-positive lung cancer in whom osimertinib was initiated as first-line treatment between August 2018 and December 2019. Patients over 75 years of age were classified as elderly. The data cut-off date was February 28, 2022.

RESULTS

The progression-free survival (PFS) did not significantly differ between the elderly and non-elderly groups [elderly group: median PFS, 16.9 months (95 % confidence interval (CI), 14.3-20.2); non-elderly group: median PFS, 22.1 months (95 % CI: 19.5-26.3); hazard ratio (HR) for the elderly against the non-elderly: 1.21 (95 % CI: 0.98-1.50), p = 0.079]. However, the time to treatment failure (TTF) was significantly shorter in the elderly than in the non-elderly [elderly group: median TTF, 14.0 months (95 % CI: 0.98-1.50); non-elderly group: median TTF, 21.8 months (95 % CI: 18.2-24.6); HR for the elderly against the non-elderly: 1.46 (95 % CI: 1.20-1.77), p < 0.001]. Furthermore, the rate of treatment discontinuation because of adverse events was 28.6 % in the elderly and 14.9 % in the non-elderly (p < 0.001). Among patients who discontinued treatment, the conversion rate to second-line treatment was 39.6 % in the elderly and 72.8 % in the non-elderly. In addition, the median overall survival was 30 months (95 % CI: 25.8-37.7) in the elderly and not reached (NR) (95 % CI: NR-NR) in the non-elderly (p < 0.001).

CONCLUSION

In a real-world clinical setting, elderly patients receiving osimertinib as first-line treatment should be aware of the frequent inability to transition to second-line treatment due to adverse events.

Chemoimmunotherapy Versus Pembrolizumab as a First-Line Treatment for Patients with Advanced Non-small Cell Lung Cancer and High PD-L1 Expression: Focus on the Role of Performance Status

BACKGROUND

Immune checkpoint inhibitor (ICI) monotherapy and ICI plus chemotherapy are approved first-line treatments for patients with non-small cell lung cancer (NSCLC) expressing high levels of programmed cell death-ligand 1 (PD-L1). However, appropriate treatment for patients showing high PD-L1 expression and poor performance status (PS) is not well defined.

OBJECTIVE

The aim of this study was to identify a treatment option that is better for these patients in a real-world setting.

PATIENTS AND METHODS

A total of 425 patients with NSCLC and high PD-L1 expression were included retrospectively. All patients received either pembrolizumab monotherapy or ICI plus chemotherapy as the first-line treatment. Patients were subdivided into good (PS score 0 or 1; n = 354) and poor PS groups (PS score 2 or 3; n = 71). Early progressive disease (PD) was defined as PD within 3 months of ICI-based therapy initiation.

RESULTS

The good PS group had significantly longer progression-free survival (PFS) and overall survival (OS) than the poor PS group upon ICI-based therapy administration. In the poor PS group, no significant difference was observed in PFS and OS between pembrolizumab monotherapy and ICI plus chemotherapy. In the good PS group, pembrolizumab monotherapy, PD-L1 50-89%, and liver metastasis were associated with early PD, as determined using multivariate logistic regression analyses. However, in the poor PS group, the multivariate logistic regression analyses did not show an association between pembrolizumab monotherapy and early PD.

CONCLUSIONS

In patients with NSCLC exhibiting poor PS and high PD-L1 expression, ICI plus chemotherapy did not confer PFS or OS benefit compared with pembrolizumab monotherapy.

Concomitant Proton Pump Inhibitor Use With Pembrolizumab Monotherapy vs Immune Checkpoint Inhibitor Plus Chemotherapy in Patients With Non-Small Cell Lung Cancer

Importance

Immune checkpoint inhibitor (ICI) monotherapy with pembrolizumab and ICI plus chemotherapy have been approved as first-line treatments for non-small cell lung cancer (NSCLC) for patients with a programmed cell death ligand-1 (PD-L1) tumor proportion score (TPS) of 50% or more, but the choice between these 2 therapeutic options is unclear.

Objective

To clarify the association of a history of concurrent medication use with treatment outcomes for ICIs with or without chemotherapy in patients with NSCLC with a high PD-L1 TPS and to determine whether these clinical histories are biomarkers for appropriate treatment selection.

Design, Setting, and Participants

This retrospective, multicenter cohort study at 13 hospitals in Japan included patients with advanced NSCLC with a PD-L1 TPS of 50% or more who had received pembrolizumab ICI monotherapy or ICI plus chemotherapy as the initial treatment between March 2017 and December 2020. The median (IQR) follow-up duration was 18.5 (9.2-31.2) months. Data were analyzed from April 2022 through May 2023.

Exposure

ICI monotherapy with pembrolizumab or ICI plus chemotherapy as first-line treatment.

Main Outcomes and Measures

The primary analysis was the association of treatment outcomes with baseline patient characteristics, including concomitant drug history, after propensity score matching. Cox proportional hazard models were used to determine the associations of patient characteristics with survival outcomes. Logistic regression analysis was used to determine the association of concomitant medication history with treatment outcomes and other patient characteristics.

Results

A total of 425 patients with NSCLC were enrolled in the study including 271 patients (median [range] age, 72 [43-90] years; 215 [79%] men) who were treated with pembrolizumab monotherapy as the first-line treatment and 154 patients (median [range] age, 69 [36-86] years; 121 [79%] men) who were treated with ICI plus chemotherapy as the first-line treatment. In multivariable analysis, a history of proton pump inhibitor (PPI) use was independently associated with shorter progression-free survival (PFS) in the pembrolizumab monotherapy group (hazard ratio [HR], 1.38; 95% CI, 1.00-1.91; P = .048), but not in the ICI plus chemotherapy group. In patients with a PPI history, both the median (IQR) PFS (19.3 [9.0 to not reached] months vs 5.7 [2.4 to 15.2] months; HR, 0.38; 95% CI, 0.20-0.72; P = .002) and the median (IQR) overall survival (not reached [9.0 months to not reached) vs 18.4 [10.5 to 50.0] months; HR, 0.43; 95% CI, 0.20-0.92; P = .03) were significantly longer in the ICI plus chemotherapy group than in the pembrolizumab monotherapy group. In patients without a history of PPI use, both the median (IQR) PFS (18.8 months [6.6 months to not reached] vs 10.6 months [2.7 months to not reached]; HR, 0.81; 95% CI, 0.56-1.17; P = .26) and the median (IQR) overall survival (not reached [12.6 months to not reached] vs 29.9 [13.3 to 54.3] months, HR, 0.75; 95% CI, 0.48-1.18; P = .21) did not differ between groups.

Conclusions and Relevance

This cohort study found that a history of PPI use could be an important clinical factor in treatment decision-making for patients with NSCLC with a PD-L1 TPS of 50% or more.

Age-Stratified Analysis of First-Line Chemoimmunotherapy for Extensive-Stage Small Cell Lung Cancer: Real-World Evidence from a Multicenter Retrospective Study

Chemoimmunotherapy improved overall survival (OS) and progression-free survival (PFS) in patients with extensive-stage small cell lung cancer (ES-SCLC) in two phase III trials. They set the age-stratified subgroup analyses at 65 years; however, over half of the patients with lung cancer were newly diagnosed at ≥75 years in Japan. Therefore, treatment efficacy and safety in elderly patients ≥ 75 years with ES-SCLC should be evaluated through real-world Japanese evidence. Consecutive Japanese patients with untreated ES-SCLC or limited-stage SCLC unfit for chemoradiotherapy between 5 August 2019 and 28 February 2022 were evaluated. Patients treated with chemoimmunotherapy were divided into the non-elderly (<75 years) and elderly (≥75 years) groups, and efficacy, including PFS, OS, and post-progression survival (PPS) were evaluated. In total, 225 patients were treated with first-line therapy, and 155 received chemoimmunotherapy (98 non-elderly and 57 elderly patients). The median PFS and OS in non-elderly and elderly were 5.1 and 14.1 months and 5.5 and 12.0 months, respectively, without significant differences. Multivariate analyses revealed that age and dose reduction at the initiation of the first chemoimmunotherapy cycle were not correlated with PFS or OS. In addition, patients with an Eastern Cooperative Oncology Group performance status (ECOG-PS) = 0 who underwent second-line therapy had significantly longer PPS than those with ECOG-PS = 1 at second-line therapy initiation (p < 0.001). First-line chemoimmunotherapy had similar efficacy in elderly and non-elderly patients. Individual ECOG-PS maintenance during first-line chemoimmunotherapy is crucial for improving the PPS of patients proceeding to second-line therapy.

Safety and Immunogenicity of mRNA Vaccines Against Severe Acute Respiratory Syndrome Coronavirus 2 in Patients With Lung Cancer Receiving Immune Checkpoint Inhibitors: A Multicenter Observational Study in Japan

INTRODUCTION

Patients with cancer have been prioritized for vaccination against severe acute respiratory syndrome coronavirus 2. Nevertheless, there are limited data regarding the safety, efficacy, and risk of developing immune-related adverse events (irAEs) associated with mRNA vaccines in patients with lung cancer, especially those being actively treated with immune checkpoint inhibitors.

METHODS

This multicenter observational study was conducted at nine hospitals in Japan. Patients with lung cancer (≥20 y) actively treated with immune checkpoint inhibitors between 4 weeks prefirst vaccination and 4 weeks postsecond vaccination were enrolled. The primary end point was the incidence of irAEs of any grade on the basis of an assumed incidence without vaccination rate of 35%. Immunogenicity was assessed by measuring anti-spike (S)-IgG antibody levels against severe acute respiratory syndrome coronavirus 2.

RESULTS

A total of 126 patients with lung cancer (median age, 71 y; interquartile range, 65-74) were enrolled from May to November 2021 and followed up until December 2021. There were 26 patients (20.6%, 95% confidence interval: 13.9%-28.8%) and seven patients (5.6%, 95% confidence interval: 2.3%-11.1%) who developed irAEs of any grade pre- and postvaccination, respectively, which was lower than the predicted incidence without vaccination. None of the patients experienced exacerbation of preexisting irAE postvaccination. S-IgG antibodies were seroconverted in 96.7% and 100% of the patients with lung cancer and controls, respectively, but antibody levels were significantly lower in patients with lung cancer (p < 0.001).

CONCLUSIONS

Patients with lung cancer who were actively treated with ICIs were safely vaccinated without an increased incidence of irAEs; however, their vaccine immunogenicity was lower. This requires further evaluation.

POS0687 INHIBITION OF BONE EROSION, DETERMINED BY HIGH-RESOLUTION PERIPHERAL QUANTITATIVE COMPUTED TOMOGRAPHY (HR-pQCT), IN RHEUMATOID ARTHRITIS PATIENTS RECEIVING A CONVENTIONAL SYNTHETIC DMARD (csDMARD) PLUS DENOSUMAB VS csDMARD THERAPY ALONE: RESULTS OF AN OPEN-LABEL, RANDOMIZED, PARALLEL-GROUP STUDY

Background

Denosumab, a human IgG2 monoclonal antibody with high affinity for RANKL, is approved for treatment of bone erosion (ER) in patients with RA, based on the results of clinical trials. However, its effectiveness in combination with conventional therapy in RA patients has not been fully investigated in clinical practice.

Objectives

This exploratory study aimed to compare, in patients receiving conventional synthetic disease-modifying anti-rheumatic drugs (csDMARD) for treatment of RA, the effectiveness of combined use of csDMARD and denosumab vs csDMARD alone, in terms of inhibition of ER determined by HR-pQCT.

Methods

Detail protocol of this open-label, randomized, parallel-group study has been published previously.1 RA patients with moderate or low disease activity and progressive ER were eligible, and were randomly assigned to receive denosumab in addition to the csDMARD (denosumab) group or to continued use of the csDMARD alone (csDMARD) group. Denosumab was administered every 6 months during the 12-month study period. The primary endpoint was change in ER-depth at the second and third metacarpal bones, determined by HR-pQCT at month 6. For the primary endpoint, a linear mixed effect model analysis was performed using treatment group, sex, anti-cyclic citrullinated peptide (CCP) antibody (positive vs negative), and baseline disease activity (DAS28-ESR) as fixed effects, patients as random effects, and baseline values as covariates. For extension data, measurement time-point and the interaction between treatment group and measurement time-point was further added as fixed effects. The adverse events (AEs) were recorded.

Results

A total of 46 patients were randomized to denosumab and csDMARD groups (both N=23), and baseline characteristics were similar between both groups. Although the difference was not significant, the estimate mean (95%CI) change of ER-depth at month 6 from baseline as the primary endpoint was −0.57 (−1.52, 0.39) in the denosumab group vs −0.22 (−0.97, 0.53) in the csDMARD group, respectively. At months 6 and 12, ER-depth, -width, and -volume (extension data) were numerically lower in the denosumab group than in the csDMARD group (Table 1). Compared with patients in the csDMARD group, those in the denosumab group had significantly higher volumetric bone mineral density (vBMD) at month 12. AEs were reported in 12 (52.2%) and 13 (56.5%) of patients in the denosumab and csDMARD groups, respectively. The most common AEs of denosumab groups was hypocalcemia (reported in 4), and all the events were causally related with denosumab. Serious AEs were reported in 1 (4.3%) and 2 (8.7%) of patients in the denosumab and csDMARD groups, and which were not related to treatment drug.

Table 1.

ER and microstructure in denosumab group vs csDMARD group

MonthDenosumab group (n=21)csDMARDs group (n=22)Difference (Denosumab- csDMARDs)n1Estimate Means [95%CI]n1Estimate Means [95%CI]Estimate Means [95%CI]ER-depth617−0.46 [−1.31, 0.39]25−0.20 [−0.89, 0.49]−0.27 [−0.86, 0.32]1217−0.56 [−1.41, 0.29]22−0.20 [−0.90, 0.49]−0.35 [−0.95, 0.24]ER-width617−0.26 [−1.10, 0.57]25−0.06 [−0.73, 0.61]−0.20 [−0.81, 0.40]1217−0.27 [−1.10, 0.56]22−0.03 [−0.70, 0.64]−0.24 [−0.85, 0.38]ER-volume616−6.21 [−23.89, 11.46]24−1.71 [−16.07, 12.66]−4.51 [−16.67, 7.65]1217−6.25 [−23.94, 11.44]21−3.18 [−17.56, 11.20]−3.07 [−15.32, 9.17]vBMD6426.41 [2.78, 10.03]442.46 [−1.33, 6.24]3.95 [−0.05, 7.94]12389.20 [5.46, 12.95]423.66 [−0.15, 7.46]5.55 [1.46, 9.63]*

These were extension data.

This is the efficacy analysis set which excluded 3 patients from the full analysis set.

*; p<0.01

n, number of patients; n1, number of measurement points

Conclusion

Our results suggest that adding denosumab to csDMARD therapy may help prevent ER, promote ER repair, and improve bone microstructure.

References

[1]Iwamoto N, et al., Trials. 2019;20(1):1–8.

Disclosure of Interests

Naoki Iwamoto Speakers bureau: Daiichi Sankyo Co., Ltd., Grant/research support from: Daiichi Sankyo Co., Ltd., Ko Chiba Speakers bureau: Daiichi Sankyo Co., Ltd., Shuntaro Sato: None declared, Kazuteru Shiraishi: None declared, Konosuke Watanabe: None declared, Nozomi Ohki: None declared, Akitomo Okada: None declared, Tomohiro Koga: None declared, Makiko Kobayashi Employee of: Daiichi Sankyo Co., Ltd. (retired at submission), Kengo Saito Employee of: Daiichi Sankyo Co., Ltd., Naoki Okubo Employee of: Daiichi Sankyo Co., Ltd., Atsushi Kawakami Speakers bureau: Daiichi Sankyo Co., Ltd., Grant/research support from: Daiichi Sankyo Co., Ltd.

Efficacy of Immune Checkpoint Inhibitor With or Without Chemotherapy for Non–Squamous Non-Small Cell Lung Cancer with Malignant Pleural Effusion: A Retrospective Multicenter Cohort Study

Introduction

Malignant pleural effusion (MPE) is associated with poor treatment outcome in patients with NSCLC receiving immune checkpoint inhibitors (ICIs). ICIs and chemotherapy (ICI/Chemo) combination therapy is currently the standard therapy for NSCLC, and some ICI/Chemo regimens for nonsquamous (non-Sq) NSCLC contain bevacizumab (BEV), which is effective for controlling MPE and may enhance immune response. This study aimed to determine the optimal first-line treatment for this clinical population.

Methods

We retrospectively enrolled consecutive patients with non-Sq NSCLC with MPE who received ICI/Chemo or pembrolizumab monotherapy. Treatment outcomes were analyzed in patients with programmed death-ligand 1 (PD-L1) tumor proportion score more than or equal to 50% who were administered ICI/Chemo or pembrolizumab monotherapy (PD-L1 high cohort) and in patients with any PD-L1 status, treated with ICI/Chemo with or without BEV (ICI/Chemo cohort). We used propensity score matching (PSM) to reduce bias.

Results

PD-L1 high and ICI/Chemo cohorts included 143 and 139 patients, respectively. In PD-L1 high cohort, 37 patients received ICI/Chemo. With PSM, the median progression-free survival was significantly longer in the ICI/Chemo group than in the pembrolizumab group (11.1 versus 3.9 mo, respectively, p = 0.0409). In the ICI/Chemo cohort, 23 patients received BEV. With PSM, no significant difference occurred in median progression-free survival between BEV and non-BEV groups (6.1 versus 7.4 mo, p = 0.9610).

Conclusion

ICI/Chemo seemed more effective than pembrolizumab monotherapy for patients with non-Sq NSCLC with MPE. Nevertheless, the synergistic effect of BEV with ICI/Chemo may be limited. Further studies are needed to clarify the key factor in the tumor-induced immunosuppression environment in these patients.

Phase 1b study of ramucirumab in combination with erlotinib or osimertinib for untreated EGFR-mutated non-small cell lung cancer patients with asymptomatic brain metastases

OBJECTIVES

The study was designed to investigate the safety of ramucirumab administered in combination with erlotinib or osimertinib for patients with untreated EGFR-mutated non-small cell lung cancer (NSCLC) and asymptomatic brain metastases, a patient subgroup in which these regimens have remained untested.

MATERIALS AND METHODS

This phase 1b study (RELAY-Brain) consisted of two cohorts with three patients each. Patients with asymptomatic brain metastases received ramucirumab every 2 weeks plus either daily oral erlotinib or osimertinib until disease progression or intolerable toxicity. The primary objective was to assess dose-limiting toxicity (DLT), defined as central nervous system (CNS) hemorrhage of grade ≥ 2.

RESULTS

Six patients were enrolled. Neither DLT nor serious or unexpected adverse events were observed. One treatment-related adverse event of grade ≥ 3 (hypertension of grade 3) was apparent. Common adverse events were generally manageable. The median number of ramucirumab administrations was 18.5 (range, 13 to 31), and there were no detected episodes of CNS hemorrhage. Five of the six patients showed an objective systemic response. Although only one patient had a measurable CNS lesion at baseline, a confirmed intracranial partial response was observed.

CONCLUSION

Ramucirumab in combination with erlotinib or osimertinib showed safety for EGFR-mutated NSCLC with brain metastases.

Prognostic Markers of Survival among Japanese Patients with Anaplastic Lymphoma Kinase-Positive Non-Small-Cell Lung Cancer Receiving First-Line Alectinib

The prognoses of patients with non-small-cell lung cancer (NSCLC) harboring anaplastic lymphoma kinase (ALK) gene rearrangement have dramatically improved with the use of ALK tyrosine kinase inhibitors. Although immunological and nutritional markers have been investigated to predict outcomes in patients with several cancers, their usefulness in targeted therapies is scarce, and their significance has never been reported in patients receiving first-line treatment with alectinib. Meanwhile, neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio (PLR) has been investigated during crizotinib treatment. This multicenter retrospective study evaluated 42 consecutive Japanese patients with ALK-positive NSCLC who received first-line treatment with alectinib. Immunological and nutritional markers were evaluated at baseline and 3 weeks after alectinib introduction, and their significance in predicting progression-free survival (PFS) was explored. PFS duration was significantly associated with baseline PLR (hazard ratio (HR): 2.49, p = 0.0473), systemic immune-inflammation index (SII; HR: 2.65, p = 0.0337), prognostic nutrition index (PNI; HR: 4.15, p = 0.00185), and the 3-week values for SII (HR: 2.85, p = 0.0473) and PNI (HR: 3.04, p = 0.0125). Immunological and nutritional markers could be useful in predicting the outcomes of first-line treatment with alectinib. Since PLR and SII consist of platelet counts, platelet count could be an important constituent of these markers.

Cardio-renal protective effects of SGLT2 inhibitors in patients with type 2 diabetes mellitus and severely impaired renal function

Background

Prognostic impact of Sodium-Glucose Cotransporter 2 (SGLT2) inhibitors on cardiovascular and renal outcome was unknown in patients with type-2 diabetes mellitus (DM) and severely impaired renal function.

Methods

From July 2015 to December 2020, patients with type-2 DM who were taken SGLT2 inhibitors for more than six months were retrospectively screened. Patients with estimated glomerular filtration rate (eGFR) over 60ml/min/1.73m2 were excluded. We divided those patients into two groups by eGFR; less than 45ml/min/1,73m2 were group A and 46–60ml/min/m2 were group B. Randomly selected patients with DM not taking SGLT2 inhibitors and having severe renal dysfunction: eGFR less than 45ml/min/m2 (Group C) were set as controls. The primary outcome was a composite of cardiovascular/renal death, initiation of dialysis, doubling of the serum creatine level, decline in the eGFR more than 30%, nonfatal myocardial infraction, nonfatal stroke, and hospitalization for heart failure.

Results

Totally 418 patients were enrolled. Median age was 71 years (group A, n=106), 64 years (group B, n=115), and 77 years (group C, n=201) (p&lt;0.001). After median 24 months follow-up, primary endpoints were observed 24.5% in group A, 4.3% in group B, 36.8% in group C (p&lt;0.001). In Kaplan-Meier analysis, significantly lower incidence of primary endpoints were observed in SGLT2 groups (group A and B) than controls (p&lt;0.001, Figure 1). In patients with severe renal dysfunction, taking SGLT2 inhibitors tended to decrease future renal event (Figure 2). The incidence of SGLT2 related adverse events was not different between 2 groups (A and B).

Conclusions

Even in patients with severe renal dysfunction, SGLT2 inhibitors would have cardio-renal protective effects without drug-related adverse effects.

Funding Acknowledgement

Type of funding sources: None.

Impact of polypharmacy on prognosis in patients with acute decompensated heart failure: from the CURE-HF registry

Background

Polypharmacy would be associated with poor prognosis in patients with heart failure (HF).

Methods

In 863 patients who discharged after treatment for HF were prospectively enrolled. Number of tablets prescribed at discharge was counted. Death, non-fatal myocardial infarction, non-fatal stroke, and hospitalization for HF were tracked.

Results

In our study cohort (median age, 78), 447 patients experienced adverse events during median 503 days follow-up. In Kaplan-Meier analysis, a greater number of prescribed tablets was associated with future adverse cardiac events in the crude population. Although patients with the greater number of non-HF medications showed worse outcome, those of HF medications were not associate with the outcome (Figure). Furthermore, the number of tablets was an independent predictor of future cardiovascular events after adjustment for age, gender, B-type natriuretic peptide, hemoglobin, albumin, estimated glomerular filtration rate, and left ventricular ejection fraction (HR 95% CI: 1.295 (1.066–1.573), p=0.009).

Conclusions

Polypharmacy was associated with poor prognosis. Although the numbers of tablets and non-HF medications were significantly associated with worse out come in HF patients, the number of HF medications was not.

Funding Acknowledgement

Type of funding sources: None.

Real-world survey of pneumonitis and its impact on durvalumab consolidation therapy in patients with non-small cell lung cancer who received chemoradiotherapy after durvalumab approval (HOPE-005/CRIMSON)

OBJECTIVES

The incidence of real-world pneumonitis and durvalumab rechallenge during chemoradiotherapy and durvalumab consolidation for non-small cell lung cancer is unknown.

MATERIALS AND METHODS

We retrospectively evaluated the medical records of 302 consecutive patients diagnosed with non-small cell lung cancer who started chemoradiotherapy between May 2018 and May 2019.

RESULTS

Median age was 70 (range: 40-87) years. Volume of lung parenchyma that received 20 Gy (V20) exceeded 35% in 2% and mean lung dose exceeded 20 Gy in 1% of patients. Durvalumab consolidation was delivered to 225 patients (75%). Overall, 83% (n = 251), 34% (n = 103), 7% (n = 21), and 1% (n = 4) of the patients developed any grade of pneumonitis, symptomatic pneumonitis, ≥grade 3 pneumonitis, and fatal (grade 5) pneumonitis, respectively. Corticosteroids were administered to 25% of the patients to treat pneumonitis. Multivariate analysis identified the predictive factors for the development of symptomatic pneumonitis: V20 Gy or more ≥ 25% (odds ratio [OR]: 2.37, P = 0.008) and mean lung dose (MLD) ≥ 10 Gy (OR: 1.93, P < 0.0047). Of the 52 patients who received corticosteroids for pneumonitis after durvalumab initiation, 21 were rechallenged with durvalumab. Overall, 81% of patients met the PACIFIC study's rechallenge criteria and did not experience a severe pneumonitis relapse.

CONCLUSION

High V20 and MLD were independent risk factors of symptomatic pneumonitis. More than 80% of the patients who were rechallenged with durvalumab after pneumonitis met the PACIFIC study's rechallenge criteria. Consequently, severe relapse did not occur. Cooperation between radiation and medical oncologists is important for safe chemoradiotherapy and the safe completion of durvalumab consolidation therapy.

Ultrasound efficacy of targeted-synthetic disease-modifying anti-rheumatic drug treatment in rheumatoid arthritis: a multicenter prospective cohort study in Japan

OBJECTIVE

This study investigated the effectiveness of treatment with Janus kinase (JAK) inhibitors in rheumatoid arthritis (RA) assessed by ultrasonography (US) activity, and the influence of patient characteristics and previous treatments.

METHOD

This prospective study assessed 60 treatment initiations among 53 Japanese patients diagnosed with RA who underwent treatment with JAK inhibitors during June 2013 to February 2020. Of the 53 patients, seven patients were enrolled in duplicate because they were treated with two different JAK inhibitors at different periods. For each case, the improvement rate on the power Doppler (PD) score was assessed at 6 month follow-up. Median improvement rate of PD score was used to classify cases as either US responders or non-responders, and patient characteristics were compared between the two groups.

RESULTS

All indicators of clinical disease activity and US activity showed a significant improvement at 3 months compared with baseline. Although the JAK inhibitor-cycler group and the interleukin-6 (IL-6) inhibitor inadequate response (IR) group tended to show a later improvement for US activity, all indicators of clinical disease activity and US activity showed a significant improvement at 6 months compared with baseline for both groups. Multivariate analysis showed that concomitant methotrexate use and an IR to the previous biologic or targeted-synthetic disease-modifying anti-rheumatic drug (b/tsDMARD) treatment were independently and significantly associated with US responders.

CONCLUSION

Use of a JAK inhibitor in combination with methotrexate and an absence of IR to any previous b/tsDMARDs demonstrated superior effectiveness for patients with RA.

POS0674 DIRECT COMPARISON OF EFFECTIVENESS AND SAFETY OF TOFACITINIB AND BARICITINIB IN PATIENTS WITH RHEUMATOID ARTHRITIS IN REAL-WORLD SETTINGS

Background:

Tofacitinib is a non-selective first-generation JAK inhibitor and baricitinib was approved for the treatment of Rheumatoid arthritis several years after approve of tofacitinib. Randomized controlled trials have shown good treatment response for RA in these two drugs. However, the evaluation of these two drugs in real-world setting have been rarely reported, moreover, until now, no published data of a direct comparison among JAK inhibitors in RA have been available.

Objectives:

To compare the efficacy and safety of the JAK inhibitors tofacitinib and baricitinib in patients with rheumatoid arthritis (RA) by using propensity score matching in a real-world setting.

Methods:

A total of 242 patients with RA who were treated with tofacitinib (n=161) or baricitinib (n=81) were enrolled. To avoid confounding, we performed propensity score matching based on multiple baseline characteristic variables, and then 80 baricitinib-treated patients and 57 tofacitinib-treated patients were extracted for the direct comparison. A mixed effect model with a repeated measures analysis of variance (ANOVA) was performed to ascertain whether there were significant differences in clinical efficacy between the two treatment groups during the treatment period.Finally, We evaluated the predictive factor of clinical responses by performing univariate and multivariable logistic regression analyses.

Results:

The mean delta disease activity scores (DAS)28-ESR from baseline to 6 months were −1.60 (tofacitinib) and −1.46 (baricitinib). The remission rate defined by the DAS28-ESR at 24 weeks were 21.1% (tofacitinib) and 25.0% (baricitinib). There was no significant difference in the clinical response between the baricitinib-treated and tofacitinib-treated groups. Although there was no significant difference, the concomitant use of methotrexate (MTX) showed better clinical efficacy in the cases of baricitinib treatment as compared with in the case of tofacitinib treatment. In both groups, the most common AE was herpes zoster infection, and the AE rates were similar between the two groups. However, the predictive factors contributing to clinical response differed. The concomitant use of oral steroid was independently associated with the achievement of DAS-low disease activity in both groups, whereas in the baricitinib group, the number of biological and/or targeted synthetic DMARDs previously used and the DAS28-ESR at the time of initiation were associated with DAS-low disease activity.

Conclusion:

This study indicate that tofacitinib and baricitinib had comparable efficacies and safety profiles in a real-world setting. However, the influence of clinical characteristics on the treatment response differed between these two drugs. Direct comparison between two JAK inhibitors provide useful information to optimal use of JAK inhibitors in real-world settings.

Disclosure of Interests:

None declared

Discrepancy between clinical and ultrasound remissions in rheumatoid arthritis: a multicentre ultrasound cohort study in Japan

Objectives: Using multicentre ultrasound (US) cohort data among patients with rheumatoid arthritis (RA), we aimed to identify baseline factors that permit differentiation between two patient cohorts achieving US remission and clinical remission, and to determine the factors contributing to the discrepancy.Method: We reviewed 248 Japanese patients diagnosed with RA who underwent treatment with biological disease-modifying anti-rheumatic drugs at 13 centres. We performed US assessments of the synovia of 22 joints. We assessed the percentages of patients with clinical remission and US remission, defined as total power Doppler scores of 0 at 12 months.Results: The 87 patients who achieved US remission were divided into a group that achieved both clinical and US remission (n = 53) and a group that achieved US remission only (n = 34). Baseline factors that were significantly and independently associated with clinical remission at 12 months among patients who also achieved US remission included short disease duration, the presence of concomitant methotrexate use, and low patient global assessment score (p < 0.05, p < 0.05, and p < 0.005, respectively).Conclusions: RA patients with baseline high patient global assessment scores and long disease duration at baseline were unlikely to achieve clinical remission even after achieving US remission. Objective joint assessments using US provide additional information of potential importance for the management of RA.

IL-15 is a biomarker involved in the development of rapidly progressive interstitial lung disease complicated with polymyositis/dermatomyositis

BACKGROUND

Polymyositis/dermatomyositis (PM/DM) is an autoimmune disease that is sometimes complicated with rapidly progressive interstitial lung disease (RPILD). However, serum and lung biomarkers that can predict RPILD development remain unclear.

OBJECTIVES

To determine potential serum and lung biomarkers that can predict RPILD development in patients with PM/DM-ILD.

METHODS

In total, 49 patients with PM/DM-ILD were enrolled. We measured the serum levels of 41 cytokines/chemokines, ferritin and anti-MDA5 antibody, compared them between the RPILD (n = 23) and non-RPILD (n = 26) groups, and ranked them by their importance through random forest analysis. To distinguish the two groups, we determined biomarker combinations by logistic regression analysis. We also measured the bronchoalveolar lavage fluid (BALF) levels of 41 cytokines/chemokines. Using immunohistochemistry, we examined IL-15 expression in lung tissues. The IL-15 production was also investigated using A549 and BEAS-2B cells.

RESULTS

The RPILD group had significantly higher IL-15, IL-1RA, IL-6, CXCL10, VCAM-1, anti-MDA5 antibody and ferritin serum levels than the non-RPILD group, but it had a significantly low CCL22 level. Meanwhile, anti-MDA5 antibody, IL-15, CXCL8, CCL22, IL-1RA and ferritin were the best combination to distinguish the two groups. IL-15 and CCL22 were also predictive marker for RPILD development in anti-MDA5 antibody-positive patients. Additionally, the RPILD group had significantly high IL-15 levels in BALF. The lung tissues expressed IL-15, which increased after cytokine stimulation in the A549 cells.

CONCLUSION

This study identified a combination of biomarkers predicting PM/DM-RPILD progression, and IL-15 is an important cytokine for predicting RPILD development and reflecting ILD severity.

Prognostic impact of free-fat mass index on elderly patients with acute decompensated heart failure: from CURE-HF registry

Background

Free-Fat Mass Index (FFMI) is an indicator of malnutrition and sarcopenia. We hypothesized that low FFMI would be associated with worse prognosis in elderly patients with heart failure.

Methods

In 800 patients who discharged after treatment for HF were prospectively enrolled from 13 medical centers. Free-Fat Mass Index was calculated dividing the square of the patients heights in meters into lean body mass. All-cause mortality (cardiovascular, non-cardiovascular) was followed-up by telephone interview and chart review.

Results

In our study cohort (median age, 78 [range 72–87]), FFMI was 16.7 [15.2, 18.0]. All-cause mortality was observed in 211 patients during 631 [266, 983] days follow-up. In Kaplan-Meier analysis, lower FFMI was associated with all-cause mortality. Furthermore, FFMI was an independent predictor of mortality after adjustment for age, gender, albumin, hemoglobin, creatinine, brain natriuretic peptide, and left ventricular ejection fraction (HR 95% CI: 0.841 (0.745–0.944), p=0.004). In subgroup analysis, low FFMI was associated with both cardiac and non-cardiac mortality in patients with HF with reduced ejection fraction (EF) (Log-rank p=0.002, p=0.013, respectively) (Figure). Furthermore, low FFMI was significantly associated non-cardiac death in patients with preserved EF (Log-rank p=0.033) (Figure).

Conclusions

Free-Fat Mass Index was significantly associated with mortality in elderly patients with HF.

Funding Acknowledgement

Type of funding source: None

Phenotypic difference of sarcopenia in the prediction of mortality for elderly patients with heart failure: from CURE-HF registry

Background

Sarcopenia and malnutrition are associated with mortality in elderly patients with heart failure (HF). However, impact of phenotypic difference of sarcopenia on mortality is not well investigated. We hypothesized that evaluation using both body mass index (BMI) and free-fat mass index (FFMI) enabled distinction of phenotypic difference of sarcopenia and risk stratification for mortality in elderly patients with heart failure.

Methods

In 800 patients who discharged after treatment for HF were prospectively enrolled from 13 medical centers. Body mass index and FFMI was evaluated. Free-fat mass index was calculated dividing the square of the patients' heights in meters into lean body mass. All-cause mortality was followed-up. Patients were divided into 3 subgroups according to BMI and FFMI values, and compared incidence of mortality among them.

Results

In our study cohort (median age, 78 [range 72–87]), BMI was 21.1 [18.9, 23.8] and FFMI was 16.7 [15.2, 18.0]. 211 patients were experienced all-cause mortality during 631 [266, 983] days follow-up. In Kaplan-Meier analysis, lower BMI and lower FFMI was associated with all-cause mortality (Log-rank p&lt;0.001, p&lt;0.001, respectively). Furthermore, FFMI was an independent predictor of adverse events after adjustment for age, gender, albumin, hemoglobin, creatinine, brain natriuretic peptide, and left ventricular ejection fraction (HR 95% CI: 0.841 (0.745–0.944), p=0.004). In subgroup analysis, comparing with low-BMI and low-FFMI subgroup, better prognosis was observed in the other 2 subgroups (Log-rank p&lt;0.001, p=0.022, Figure 1).

Conclusions

Phenotypic difference was evident in elderly patients with HF. A combination of BMI and FFMI would be useful for risk stratification of mortality in those patients.

Figure 1

Funding Acknowledgement

Type of funding source: None

Stroke, systemic embolism and bleeding rate in non-valvular atrial fibrillation patients without anticoagulation on the real world data in Japan

Background

Anticoagulant therapy is recommended in patients with non-valvular atrial fibrillation (NVAF) for those with CHADS2 ≥2. However, there have been significant number of subjects with CHADS2 ≥2 who receive no anticoagulation. Most of reported real world data have been collected mainly before wide spread use of DOAC. This study evaluated the clinical outcome of no anticoagulant drug therapy in NVAF.

Methods

This study is a non-interventional, observational, retrospective cohort study of NVAF patients in Mie-LIP Database, which is a regional clinical database joining 1 university hospital and 8 general hospitals in Mie prefecture in Japan. Patient enrolment was conducted from 1st Jan. 2016 to 31st Dec. 2018. The primary outcome events are ischemic stroke, systemic embolism, and bleeding events (bleeding to need a blood transfusion, intracranial bleeding, intraocular bleeding, and gastrointestinal bleeding).

Results

7001 patients were included in the current analysis, 2550 patients, 36.4% were treated without any anticoagulant drug therapy. Table 1 shows patients with no anticoagulant drug therapy, mean age was 75.4 years and 42.2% of patients were female. The most frequent comorbidities included hypertension (50.0%), diabetes mellitus (28.2%), heart failure (14.0%), ischemic stroke (12.7%), vascular disease (14.4%) respectively. The annual incidence of ischemic stroke, systemic embolism per 100 person-years is 3.7, and that in each CHADS2 group is 0: 1.4, 1: 1.4, 2: 3.2, 3–6: 8, respectively in Figure 1. The annual incidence of bleeding events is 1.5, and that in each CHADS2 group is 0: 0.7, 1: 1.0, 2: 1.2, 3–6: 2.9, respectively.

Conclusions

Approximately one-thirds of subjects have not received any anticoagulation in the modern DOAC in daily clinical practice in Japan. The rate of ischemic stroke and systemic embolism increased by CHADS2. Stroke or SEE rate was very low in subjects with CHADS2 ≤1, supporting no indication of anticoagulation in current guidelines. Regarding subjects with CHADS2&gt;2, considering the higher risk of stroke, use of anticoagulant drug therapy is recommended.

Funding Acknowledgement

Type of funding source: None

Prognostic differences between atrial functional mitral regurgitation and ventricular functional mitral regurgitation

Introduction

Atrial functional mitral regurgitation (A-FMR) has been under-recognized until recently as a cause of FMR, and the prognostic difference between A-FMR and ventricular FMR (V-FMR) has not been fully elucidated. As there has been different mechanisms of FMR suggested in A-FMR and V-FMR, we hypothesized that prognosis and prognostic predictors of A-FMR may differ from those of V-FMR.

Purpose

To investigate the prognosis and prognostic predictors of A-FMR in comparison with V-FMR.

Methods

Among 1312 consecutive patients with grade 3+ (moderate to severe) or 4+ (severe) MR, 378 consecutive FMR patients were identified by excluding patients with degenerative MR, previous cardiac surgery, or concomitant aortic valve disease and/or mitral stenosis. FMR with ejection fraction (EF) &lt;40% or FMR due to regional wall motion abnormalities with leaflet tethering were classified as V-FMR (N=288), and FMR due to left atrial (LA) and/or annular dilatation with preserved or mid-range EF (≥40%) were classified as A-FMR (N=90). All-cause death and heart failure hospitalization were analyzed as cardiovascular (CV) events in this study. Surgical or percutaneous mitral valve intervention without CV events was handled as not reaching an endpoint and these cases were censored.

Results

A-FMR were significantly older (76 [69–82] vs. 70 [58–77] years), higher rates of female (64 vs. 35%) and atrial fibrillation (88 vs. 42%), and lower B-type natriuretic peptide (BNP) values (169 [101–318] vs. 447 [213–952] pg/ml) compared to V-FMR (all P&lt;0.05). On echocardiography, LV end-diastolic and end-systolic dimensions (52 [48–57] vs. 64 [58–72] mm, 34 [31–37] vs. 55 [48–64] mm), respectively) were smaller, and EF (55 [50–60] vs. 28 [19–35] %) and LA volume (99 [73–137] vs. 73 [57–91] ml/m2) were larger in A-FMR (all P&lt;0.05). Effective regurgitant orifice area (32 [26–40] vs. 31 [24–45] mm2) and regurgitant volume (50±15 vs. 52±16 ml) were similar (both n.s.). During a median follow up of 1407 days, 206 (54%) patients developed CV events. Kaplan-Meier analysis revealed that V-FMR had a significantly higher rates of CV events compared to A-FMR (Figure) with adjusted hazard ratio (HR) of 1.762 [1.168–2.660], P=0.007 after adjusted for variables including age, sex, New York Heart Association functional class, previous heart failure hospitalization, estimated glomerular filtration rate (eGFR) and BNP. Further, stepwise multivariate analysis showed that independent prognostic predictors of A-FMR were LA volume and eGFR, while those for V-FMR were LA volume, age, and LV end-systolic dimension.

Conclusions

A-FMR had relatively better prognosis compared to V-FMR, and there were different prognostic predictors between A-FMR and V-FMR. Our results suggest that different treatment strategies need to be considered between A-FMR and V-FMR.

The Kaplan-Meier life table

Funding Acknowledgement

Type of funding source: None

The impact of hyperuricemia on all patients and low-BMI patients after endovascular treatments: from I-PAD registry

Background

Hyperuricemia (≥7.0 mg / dl) is known to be one of the risks of arteriosclerosis. For a long time, it has been said that metabolic syndrome and high-BMI has been implicated to hyperuricemia and also that it's a consequence of those patient background, not a cause of arteriosclerosis. Now, the accumulation of data about hyperurisemia is still not enough. Also the importance of secondary prevention for patients after endovascular treatment (EVT) is still unclear too.

Purpose

To investigate the impact of hyperuricemia on prognosis of all patients and low-BMI patients after EVT.

Methods

From July 2015 to July 2016, 335 consecutive PAD patients who performed EVT were enrolled in I-PAD registry. And we divided them into 2 groups; with hyperuricemia or not, and analyzed them. In addition to that, among them, we selected 245 low-BMI patients (&lt;25) and divided them into 2 groups; with hyperuricemia or not, and analyzed them. The primary end point was all-cause-death and the secondary endpoint was MACLE (Major Adverse Cardiovascular and limbs Events) at 3-years.

Result

At 3 years in the patients group with hyperuricemia, overall survival and freedom from MACLE were significantly lower (57.7% vs 83.4% P=0.0012; 30.3% vs 68.6% P=0.0095) than the group without hyperuricemia. Even among the low-BMI patients, in the patients with hyperuricemia, overall survival and freedom from MACLE were significantly lower (55.2% vs 77.1% P=0.003; 48.2% vs 69.9% P=0.002) than the patients without hyperuricemia at 3 years.

Conclusion

In this study, the prognosis of patients after EVT with hyperuricemia was worse than the patient without. And even among the low-BMI patients, The prognosis after EVT with hyperuricemia was worse than the patient without.

Funding Acknowledgement

Type of funding source: None

Recurrences of disease activity in patients with cardiac sarcoidosis under corticosteroid therapy: prevalence, clinical background and prognosis

Background

Corticosteroid therapy (CTx) has been widely accepted as first-line therapy for cardiac sarcoidosis (CS), but there are very limited data regarding recurrence of disease activity of CS. We retrospectively investigated the prevalence, patient characteristics and prognostic significance in patients with recurrences of CS.

Methods

We identified 102 consecutive patients who were clinically diagnosed CS (admission: 2012 and 2019) and whose disease activity was diminished clinically at least once. Recurrence of CS was defined as detection of increased uptake of 18F-fluoro-2-deoxyglucose or gallium-67 in the follow-up examination. Composite adverse events (events) were defined as all-cause of death or hospitalization for heart failure. Echocardiographic and laboratory data before initiation of CTx were obtained.

Results

During the follow-up term (median: 4.9 years), the recurrences of CS occurred in 28 patients at 30 months (median) after the initiation of CTx. In patients with recurrence, left ventricular (LV) ejection fraction before initiation of CTx was lower than in those without recurrences (median: 31% vs. 39%, p&lt;0.05). After the detection of CS recurrences, 17 patients were treated with only increases of PSL and remaining 11 patients were treated with adding other immunosuppressive therapies to CTx. The univariate analysis demonstrated that there were no parameters in echocardiographic and laboratory examinations to predict the recurrences of CS. The results of univariate analysis for event occurrences (n=12) are shown in the Table. Additionally, the Kaplan-Meier analysis showed that there were no differences in event free survival rate in the patients with and without CS recurrences (Figure).

Conclusion

This study showed that the recurrences of disease activity were observed in a substantial number of patients with CS even under the CTx. All patients received intensification of CTx or additional immunosuppressive therapy, and LV systolic function, rather than the recurrence itself, was associated with clinical outcomes in this study.

Kaplan-Meier analysis for events

Funding Acknowledgement

Type of funding source: None

Significance of anti-Ro/SSA antibodies in the response and retention of abatacept in patients with rheumatoid arthritis: a multicentre cohort study

Objective: To determine whether the positivity of baseline anti-Ro/Sjögren's syndrome antigen A (SSA) antibodies influences the response to abatacept, we compared therapeutic responses between anti-Ro/SSA antibody-negative and -positive patients with rheumatoid arthritis (RA) using a multicentre RA ultrasonography prospective cohort. Method: We reviewed Japanese patients with RA who started abatacept as the first biological disease-modifying anti-rheumatic drug between June 2013 and April 2018. We assessed 28-joint Disease Activity Score-erythrocyte sedimentation rate (DAS28-ESR) change between baseline and 6 or 12 months after treatment in RA patients treated with abatacept, and European League Against Rheumatism (EULAR) response at 6 and 12 months. The Global OMERACT-EULAR Synovitis Score (GLOESS) was calculated at baseline and at 6 and 12 months. Results: Overall, 51 patients were enrolled and divided into anti-Ro/SSA antibody-negative and -positive groups of 35 and 16, respectively. Median age at baseline was significantly higher in the anti-Ro/SSA antibody-negative group (p = 0.04). The retention rate and percentage of EULAR good responders at 12 months were significantly higher in the anti-Ro/SSA antibody-negative group (both p = 0.02). Anti-Ro/SSA antibody-negative patients exhibited larger decreases in both DAS28-ESR and DAS28-C-reactive protein at 12 months than anti-Ro/SSA antibody-positive patients (p = 0.02 and 0.04, respectively). GLOESS decreased significantly at 6 months in anti-Ro/SSA antibody-negative patients (p = 0.03). Multivariate analyses showed that anti-Ro/SSA antibody positivity was an independent factor associated with change in the DAS28-ESR at 6 months (p < 0.05). Conclusion: Anti-Ro/SSA antibody positivity predicts a poor response to abatacept and low retention rate.

A Randomized Phase II Study of Maintenance Bevacizumab, Pemetrexed or Bevacizumab Plus Pemetrexed for Advanced Non-squamous Non-small Cell Lung Cancer

BACKGROUND/AIM

Continuation maintenance therapy is standard for advanced nonsquamous non-small cell lung cancer; however, the optimal maintenance strategy has yet to be determined.

PATIENTS AND METHODS

Patients without disease progression after four cycles of carboplatin (CBDCA)+ pemetrexed (PEM)+ bevacizumab (BEV) were randomized to maintenance therapy with BEV, PEM, or BEV+PEM. The primary endpoint was 1-year progression-free survival (PFS) rate.

RESULTS

Of the 90 patients enrolled, 64 were randomly assigned to maintenance therapy. The 1-year PFS rate was 9.1% in the BEV arm, 19.1% in the PEM arm, and 19.1% in the BEV+PEM arm. The median PFS and overall survival (OS) were 4.0 and 43.1 months in the BEV arm, 4.5 and 32.0 months in the PEM arm, and 6.4 and 41.8 months in the BEV+PEM arm.

CONCLUSION

The median PFS was numerically better in the BEV+PEM arm, but the median OS was not significantly different among the three arms.

P1496Impact of electrical reverse remodeling by cardiac resynchronization therapy on adverse cardiac events in patients of heart failure with reduced ejection fraction

Background

Recently, structural reverse remodeling (SRR) and electrical reverse remodeling (ERR) after cardiac resynchronization therapy (CRT) have been reported in patients of heart failure with reduced ejection fraction (HFrEF). However the relationship between ERR and subsequent adverse cardiac events is still unknown. We aimed to elucidate the impact of ERR after CRT on the occurrence of heart failure events and ventricular arrhythmias.

Methods

A total of 36 HFrEF patients who underwent newly CRT implantation were investigated retrospectively. The intrinsic QRS duration (iQRSd) had been recorded before and more than 6 months after CRT implantation. Biventricular pacing was temporarily turned off during measurement of iQRSd. ERR was defined as positive shortening of iQRSd and SRR was defined as reduction of left ventricular end systolic volume by more than 15% after CRT implantation. The primary endpoint was a composite of all cause death, heart failure hospitalizations and ventricular tachyarrhythmia events.

Results

ERR was observed in 17 patients (47.2%) and SRR in 22 patients (61.1%). The group with ERR included more patients with lower NYHA class prior to CRT and patients with SRR. The primary endpoint was observed in 15 patients (51.4 %) for a median of 181 [63, 367] days during follow-up. Kaplan-Meier analysis revealed that the group without ERR was poor prognosis compared with the group with ERR (p = 0.022, Log-rank test).

Conclusion

Patients of HFrEF with ERR after CRT may have fewer adverse cardiac events such as worsening heart failure or ventricular arrhythmia events from this short-term study.

Abstract Figure. Adverse cardiac events and ERR

FRI0098 ASSOCIATION BETWEEN THE SEROLOGIC STATUS OF ISOTYPE-SPECIFIC AUTOANTIBODIES AND THERAPEUTIC EFFICACY IN RHEUMATOID ARTHRITIS PATIENTS TREATED WITH ABATACEPT: A PROSPECTIVE ULTRASOUND COHORT STUDY IN JAPAN

Background:

The presence of anti-cyclic citrullinated protein antibodies (ACPA) and anti-carbamylated protein (anti-CarP) antibody is specific for rheumatoid arthritis (RA). Recently, it was reported that the serological status of ACPA is associated with the therapeutic response of the T-cell co-stimulation blocker abatacept (1, 2). However, it is currently unclear whether the serological status of each isotype levels of these autoantibodies before treatment introduction or the changes during treatment are associated with the therapeutic response of abatacept.

Objectives:

To evaluate longitudinal changes in the isotypes of ACPA and anti-CarP in RA patients treated with abatacept, and associations between the baseline serological status/ these changes and clinical response/ ultrasonographic response.

Methods:

This study is part of an ongoing non-randomized multicenter prospective cohort study of patients with active RA who received biological or targeted DMARD therapy at 13 participating rheumatology centers from the Kyushu region of Japan since June 2013 (3). As of the present report, we enrolled 43 consecutive Japanese patients with active RA who have introduced treatment with abatacept and had finished the first 12-month observation period. We evaluated disease activity by clinical composite measure and ultrasound score at baseline, 3, 6, 9 and 12 months. In ultrasound of bilateral hands from 22 sites, the findings obtained by gray-scale (GS) and power Doppler (PD) assessments were graded on a semi-quantitative scale from 0 to 3 and the sum of GS or PD scores was used as the total GS or PD score. The serum levels of IgG/IgM/IgA-type of ACPA and anti-CarP were measured by the ELISA method in Leiden University Medical Center. We evaluated the association between serologic status of autoantibodies and clinical /ultrasonographic therapeutic efficacy.

Results:

The median age was 72 years, and the disease duration was 54 months. Methotrexate was concomitant in 22 (51%). Sixteen (37%) patients had a history of previous use of biological DMARDs. Nineteen (44%) and 23 (54%) patients achieved SDAI remission and PD remission (total PD score =0) at 12 months, respectively. The serum levels of all isotypes of ACPA/anti-CarP significantly decreased at 12 months from baseline. The reduction of IgM-ACPA level significantly correlated with the reduction of SDAI (rs=0.33, p=0.031) and total PD score (rs=0.49, p=0.0007). Both clinical and ultrasonographic therapeutic responses were better in patients with the detectable IgM-ACPA at baseline than in patients without that (Figure): the reduction of SDAI (p=0.0078) and that of total PD score (p=0.0079) were significantly larger in the former than in the latter. All isotype of anti-CarP did not associate with therapeutic response.

Conclusion:

Treatment of abatacept induced to the reduction of the autoantibody levels. The IgM-ACPA level at baseline and the change in IgM-ACPA associated with both clinical and ultrasonographic therapeutic response in patients treated with abatacept. IgM-ACPA, compared with usual IgG-ACPA, better reflects the treatment response of abatcept in patients with RA

References:

[1]Ann Rheum Dis. 2016;75:709, 2) RMD Open. 2018;4:e000564, 3)Arthritis Care Res (Hoboken). 2018;70:1719.

Acknowledgments:

We have acknowledged for all the members of Kyushu multicenter rheumatoid arthritis ultrasound prospective observational cohort study group.

Disclosure of Interests:

Shin-ya Kawashiri Grant/research support from: This work was supported by Bristol-Myers Squibb and Ono Pharmaceutical. co., Yushiro Endo: None declared, Ayako Nishino: None declared, Toshimasa Shimizu: None declared, Yukitaka Ueki: None declared, Nobutaka Eiraku: None declared, Akitomo Okada: None declared, Naoki Matsuoka: None declared, Tamami Yoshitama: None declared, Hideki Nakamura: None declared, Mami Tamai: None declared, Tomoki Origuchi: None declared, Rene Toes: None declared, Thomas Huizinga Grant/research support from: Ablynx, Bristol-Myers Squibb, Roche, Sanofi, Consultant of: Ablynx, Bristol-Myers Squibb, Roche, Sanofi, Atsushi Kawakami: None declared

P1353Echocardiographic predictor of sick sinus syndrome following catheter ablation of persistent atrial fibrillation

Funding Acknowledgements

Abbott Medical Japan, Medtronic Japan, Boston Scientific Japan, Biotronic Japan, Japan Life Line

Background / Introduction

Although sick sinus syndrome(SSS) can be associated with atrial fibrillation(AF), predictive factors of SSS following catheter ablation(CA) of persistent atrial fibrillation(perAF) are not well known.

Purpose

We investigated echocardiographic parameters to predict occurrence of SSS after restoration of sinus rhythm by CA for perAF patients.

Methods

Ninety-eight consecutive perAF patients from June 2014 to May 2018 treated with CA were retrospectively reviewed. Twelve patients(12%, SSS group) developed SSS after successful CA and 86 patients(88%, non-SSS group) did not. Baseline characteristics, blood exam, and echocardiographic findings(RA area size, LA area size, EF, etc) before AF CA were analyzed using Student’s t test, Mann-Whitney test, Chi-square test and Univariate analysis. Multivariate logistic analysis was then performed using those parameters. The atrial area size was calculated from 4 chamber view at the atrial end- systole.

Results

The multivariate analysis for predictive factors of SSS is shown in the table. Right atrium(RA) area could predict SSS(17.3 ± 4.8cm2 vs. 14.7 ± 3.6cm2, odds ratio 1.468; 95% confidence interval 1.088 to 1.981, p = 0.012). Gender (female) was also an independent predictor(4/12 (33%) vs. 8/86 (9%), odds ratio 39.832; 95% confidence interval 2.589 to 612.938, p = 0.008). The other echocardiographical findings(LA area size, EF, etc), baseline characteristics and blood exam results were not related to SSS after successful CA of perAF patients.

Conclusions

The large RA area size and gender (female) could predict SSS in perAF patients after restoration of sinus rhythm by successful CA. We may need to inform possible SSS after CA to female patients with a large RA before CA.

Multivariate Logistic analysis Total(N = 98) SSS group (N = 12) Non SSS group (N = 86) Odds ratio 95% CI P-value Age 64(58-69) 68(60-72) 63(57-69) 1.032 0.929-1.145 0.560 Gender/Female 12(12%) 4(33%) 8(9%) 39.832 2.589-612.938 0.008 CKD 27(28%) 6(50%) 21(24%) 1.264 0.179-8.945 0.814 BNP 91(53-180) 206(167-304) 82(48-169) 1.003 0.993-1.012 0.609 RDW 45.1 ± 3.9 46.4 ± 4.8 44.9 ± 3.8 1.242 0.971-1.588 0.085 RA area 15.1 ± 3.8 17.3 ± 4.8 14.7 ± 3.6 1.468 1.088-1.981 0.012 LA area 24.2(17.0-24.9) 24.4(17.7-26.3) 24.1(16.8-24.4) 0.967 0.803-1.165 0.726 Right atrium area and gender were the independent predictor of SSS in persistent atrial fibrillation patients after restoration of sinus rhythm

Real-world survey of pneumonitis/radiation pneumonitis among patients with locally advanced non-small cell lung cancer treated with chemoradiotherapy after durvalumab approval: A multicenter retrospective cohort study (HOPE-005/CRIMSON)

9039

Background: Durvalumab was approved as a consolidation therapy after chemoradiotherapy (CRT) for locally advanced non-small cell lung cancer (NSCLC) and established as the standard of care. However, since the approval of durvalumab, little has been reported on the frequency, severity, or clinical course of pneumonitis/radiation pneumonitis throughout the course of CRT. Methods: We conducted a 17-center, retrospective cohort study of consecutive patients with locally advanced NSCLC who received concurrent chemoradiotherapy (CCRT) with platinum-based chemotherapy between May 2018 and May 2019. Results: A total of 275 patients were included; their median age was 69.9 (range, 40.3-87.5), mean V20 was 19.4% (range, 1.4-37.9), and mean "mean lung dose" was 10.9 Gy (range, 1.5-31.3). Of these, 204 patients received durvalumab consolidation therapy (74.2%). Median follow-up time from the initiation of CCRT was 8.4 months (range, 1.5-15.7). During follow-up, 225 patients (81.8%) developed any-grade pneumonitis/radiation pneumonitis. Of these, more than half (134 of 225) were asymptomatic (grade 1), 18 (6.5%) were ≥grade 3, and 4 patients (1.5%) had fatal pneumonitis/radiation pneumonitis. By the time of initial assessment of response to CCRT, 64 (23.3%) patients had developed radiation pneumonitis. Logistic regression revealed that only V20 ≥25 % was an independent risk factor of symptomatic (≥grade 2) pneumonitis/radiation pneumonitis (OR: 2.74, 95% CI: 1.35-5.53, p = 0.0045). Of the 275 patients, 67 were treated with corticosteroids for pneumonitis/radiation pneumonitis (24.7%), and 14 (5.1%) needed home oxygen therapy after the treatment of pneumonitis/radiation pneumonitis. Among patients treated with corticosteroids, 21 patients received durvalumab rechallenge. Of the 21 patients, 6 (29%) showed pneumonitis/radiation pneumonitis relapse, of which 3 (14%) resulted in suspension of durvalumab rechallenge, but none were fatal. Conclusions: Although over four-fifths of the patients treated with CCRT after the approval of durvalumab developed pneumonitis/radiation pneumonitis, more than half of them were asymptomatic, and ≥grade 3 events accounted for 6.5%. Sometimes patients needed corticosteroid therapy, which was in many occasions effective, and some also underwent durvalumab rechallenge. V20 was an independent risk factor of symptomatic pneumonitis/radiation pneumonitis.

Predictive value of the Lung Immune Prognostic Index (LIPI) in locally advanced non-small-cell lung cancer (NSCLC) patients treated with concurrent chemoradiotherapy (CCRT) in the multicenter retrospective study

e21076

Background: PD-L1 inhibitor, durvalumab has been approved since the PACIFIC study showed its efficacy as consolidation therapy after CCRT for locally advanced NSCLC. But predictive factor for the efficacy of CCRT on this post PACIFIC era have not been known. LIPI has been proposed as a new biomarker for the anti-PD-1 therapy of advanced NSCLC. In this study, we investigated the usefulness of LIPI as a predictive marker in multicenter cohort of patients with locally advanced NSCLC who received CCRT as initial treatment. Methods: 219 patients with available baseline LIPI were reviewed. The progression free survival (PFS) was estimated by the Kaplan-Meier method, and LIPI were calculated at baseline. Kaplan-Meier estimates of PFS and recurrence were compared using the log-rank test for trend. Multivariable analysis was conducted using the Cox and logistic regression models, respectively, adjusted for age, sex, ECOG-PS, smoking, histology, TNM stage, chemotherapy regimens, Body mass index (BMI), PD-L1 status, EGFR or ALK mutation, and baseline LIPI. Results: 62.5% (n = 137) of the patients had a good (0 factors) LIPI, while 37.5% (n = 82) had intermediate (1 factor) and poor (2 factors) LIPI respectively. In multivariable analysis, good LIPI (0 factors) were significantly associated with longer PFS (HR = 0.46, 95% CI 0.28-0.75; P < 0.01) as did ECOG-PS0 (P < 0.01), ≤stageIIIA (P < 0.01), being treated with durvalumab after CRT (P = 0.04). There were no difference in the patient characteristics between good LIPI and intermediate/poor LIPI, significantly. Higher LIPI (1 or 2 factors) were strongly prognostic factor for recurrence after CCRT in multivariate analysis (P = 0.04), along with ECOG-PS1≤ (P < 0.01), stage IIIB≤ (P < 0.01). Conclusions: The good LIPI predictive value for PFS and disease control in patients treated with CCRT was confirmed. Although a strong statistical significance, we needs to be confirmed further with longer follow-up and prospective study.

P943The impact of diabetes on patients with frail after endovascular treatments: from I-PAD registry

Background

Diabetes mellitus (DM) is known to be one of the risks of arteriosclerosis. However, it is still unknown whether DM is a risk factor also in secondary prevention of frail patients after endovascular treatments (EVT)

Purpose

To investigate impact of diabetes on patients with frail after EVT.

Methods

From July 2015 to July 2016, 371 consecutive PAD patients who performed EVT were enrolled in I-PAD registry. We could conduct follow up survey 361 patients (446 lesions) and divided into 2 groups; with diabetes (185 patients, 226 lesions) or without diabetes (176 patients, 220 lesions) and analyzed. And among them,we selected 96 patients with frail and divided into 2 groups; with diabetes (49 patients, 70 lesions) or without diabetes (46 patients, 58 lesions) and analyzed. We defined frail patients as the patients with Clinical Frailty Scale 5 (mild frail) or higher. The primary end point was all-cause-death and major adverse limb events (MALE: TLR, TVR, major amputations) at 1 year.

Result

At 1 years in the patients group with diabetes, overall survival and freedom from MALE were significantly lower (81.7% vs 95.8% P<0.0001; 80.0% vs 94.6%, P<0.0001) than the group without diabetes.Among the patients with frail, between the patients group with diabetes and the group without, there is no significant differences in overall survival and freedom from MALE (88.2% vs 88.9% P=0.83; 80.7% vs 84.1%, P=0.55) at 5 years.

Conclusion

The prognosis of patients with diabetes after EVT was worse than the patient without. On the other hand, the prognosis of frail patients with diabetes after EVT was no difference with the frail patient without diabetes in this study.

P942Impact of left ventricular ejection fraction in patients with critical limb ischemia: from I-PAD registry

Introduction

In patients with critical limb ischemia (CLI) it is known that malnutrition, low BMI, inflammation and so on are prognostic factors. But, it is unclear whether left ventricular ejection fraction (LVEF) affects prognosis of CLI patients. So we investigated that LVEF affects prognosis of CLI patients.

Methods

From July 2015 to July 2016, 371 consecutive peripheral artery disease patients who performed endovascular treatment (EVT) were enrolled in I-PAD registry. 179 of them were patients with CLI. We could conduct follow up survey about 126 (age 75.5±11.1, men 63.5%) and divided two groups according to their LVEF (group with LVEF≤40%, n=13, group without LVEF≤40%, n=113). The primary end point was major adverse limb events (MALE: TLR, TVR, major amputations) and secondary end point was all-cause death.

Results

The median follow-up period was 11.5±6.7 months. The 18 months MALE rate was significant higher in the group with low LVEF than group without low LVEF (76.9% vs 37.2% p<0.05). The 18months all-cause death tended to be higher in the group with low LVEF, however there was not statistical significance in the two groups (53.8% vs 24.8% p=0.09).

Conclusion

LVEF was associated with MALE in patients with CLI.

P5551Comparison of prognostic predictors of heart failure admission and progression to end-stage in hypertrophic cardiomyopathy

Background

Heart failure (HF) is a common complication within the clinical spectrum of hypertrophic cardiomyopathy (HCM). HCM-related HF is recognized to be multifactorial, including outflow obstruction, diastolic dysfunction, or progression to end-stage; however, prognostic predictors of HF events are not fully understood. We sought to investigate predictors for various HF outcomes in HCM.

Methods

We studied 289 consecutive HCM patients with EF≥50%. Patients with outflow obstruction (peak pressure gradient ≥30mmHg) were defined as obstructive HCM. HF events assessed in this study were 1) HF admission and 2) progression to end-stage (EF<50%).

Results

The mean age was 63±16 years, 53% male, EF 61±5%, NYHA class 1.8±0.7, and 39% obstructive. During a median follow up of 5.2 [3.7–7.0] years, 48 HF admission and 19 progression to end-stage were observed. Only 8/48 (17%) patients with HF admission had progressed to end-stage; while 11/19 (58%) patients with progression to end-stage remained free from HF admission. Univariate Cox regression hazard analysis showed different prognostic predictors between HF admission and progression to end-stage (Table). Multivariate Cox regression hazard analysis showed atrial fibrillation was an independent predictor of HF admission (adjusted HR 2.711 [1.094–7.389], P=0.031); while LV end-systolic dimension was an independent predictor of progression to end-stage (adjusted HR 1.114 [1.018–1.229], P=0.025).

Cox hazard analysis for predicting event HF admission Progression to end-stage HR (95% CI) P value HR (95% CI) P value Age, 1 year 1.042 (1.017–1.071) <0.001 1.002 (0.975–1.035) 0.89 Male sex 1.052 (0.595–1.882) 0.86 2.853 (1.034–10.02) 0.043 Atrial fibrillation 3.247 (1.809–6.608) <0.001 1.434 (0.570–3.559) 0.44 Non-obstructive 0.850 (0.481–1.531) 0.58 5.439 (1.558–34.30) 0.005 LV end-diastolic dimension, 1mm 1.027 (0.981–1.077) 0.25 1.120 (1.035–1.218) 0.005 LV end-systolic dimension, 1mm 1.059 (1.008–1.110) 0.023 1.167 (1.080–1.258) <0.001 EF, 1% 0.974 (0.926–1.032) 0.36 0.894 (0.825–0.980) 0.018 LA volume, 1ml/m2 1.012 (1.001–1.020) 0.044 1.006 (0.978–1.023) 0.64 Transmitral E wave, 1m/s 1.013 (1.002–1.024) 0.025 1.006 (0.987–1.023) 0.50 Transmitral DcT, 1msec 0.999 (0.995–1.003) 0.59 0.985 (0.974–0.994) <0.001 E/e', 1.0 1.062 (1.012–1.109) 0.015 1.089 (1.010–1.164) 0.027

Conclusions

Different prognostic predictors were found for HF admission and progression to end-stage, suggesting the difficulty and multifactorial nature of HCM-related HF.

P1957Impact of fraility on the super elderly patients with peripheral artery disease

Background

The current consensus is that frail patients have high risks of mortality. However, it remains unclear whether frailty is associated with mortality risks in super-elderly patients with peripheral artery disease (PAD).

Methods

The I-PAD registry was a prospective multicenter observational study involving 12 institutions in Nagano prefecture in Japan. From July 2015 to July 2016, the I-PAD registry enrolled 371 consecutive PAD patients who had undergone endovascular therapy (EVT). Among them, we selected and analysed 109 PAD patients who were >80 years old when they had undergone EVT and divided them into two groups: those with frailty (Clinical Frailty Scale≥5, n=47) and those without frailty (Clinical Frailty Scale≤4, n=62). The primary endpoints were overall survival and major adverse limb events (MALE), defined as a composite of all-cause death, major amputation and revascularization.

Results

The median follow-up period was 1.58±0.3 years. Overall, 109 patients with a mean age of 84.8±4.0 years, of whom 63.3% were men, were included. Overall survival and freedom from MALE were significantly lower among patients with frailty than among those without frailty (60.5% vs. 91.6%, P<0.001; 51.4% vs. 87.5%, P<0.001; respectively).

Conclusion

The prognosis of super-elderly patients with frailty is worse than that of patients without frailty.

P936Impact of left ventricular ejection fraction in patients with peripheral artery disease: from I-PAD registry

Introduction

In patients with peripheral artery disease (PAD) it is known that CVD is one of prognostic factors. But, it is unclear whether left ventricular ejection fraction (LVEF) affects prognosis of PAD patients. So we investigated that LVEF affects prognosis of PAD patients.

Methods

From July 2015 to July 2016, 371 consecutive PAD patients who performed endovascular treatment (EVT) were enrolled in I-PAD registry. We could conduct follow up survey about 337 (age 73.8±9.6, men 72.4%) patients and divided two groups according to their LVEF (group with LVEF≤40%, n=18, group without LVEF≤40%, n=319). The primary end point was major adverse limb events (MALE: TLR, TVR, major amputations) and secondary end point was all-cause death.

Results

The median follow-up period was 13.6±5.7 months. The 18 months MALE and all-cause death rate were significantly higher in the group with low LVEF than group without low LVEF (61.1% vs 21.6% p<0.001, 44.4% vs 11.6% p<0.001).

Conclusion

LVEF was significantly associated with MALE and all-cause death in patients with PAD.

P915Clinical characteristics, natural history and predictors of disease progression in patients with degenerative mitral stenosis

Background

Mitral annular calcification (MAC) is a common echocardiographic finding and an increasingly recognized cause of degenerative mitral stenosis (DMS). However, little is known about the natural history and predictors of disease progression of DMS, especially compared with rheumatic mitral stenosis (RMS).

Purpose

To compare the clinical characteristics and disease progression among patients with DMS and those with RMS, and to investigate the determinants of disease progression in DMS patients.

Methods

We retrospectively reviewed consecutive MS patients with a trans-mitral mean gradient ≥2 mmHg who underwent echocardiography at our institution between January 2014 and December 2017. We selected patients who had an initial and follow-up echocardiography with a ≥3-month interval and without prior and interim mitral valve intervention. DMS was defined as MS with MAC with normal or minimally reduced leaflet motion without tips restriction. RMS was defined as MS with tip restriction, thickening and restriction of leaflet mainly. We defined MAC severity as mild (focal), moderate (marked density >1/3 but <1/2 of the mitral annulus) and severe (marked density involving >1/2 of the mitral annulus) based on previous reports. We calculated disease progression from the annual increase rate of trans-mitral mean gradient. First, we compared the backgrounds and disease progression between DMS group and RMS group. Second, we investigated the predictors of disease progression in DMS group.

Results

We enrolled 111 patients (64 in DMS group and 47 in RMS group) with a mean follow-up period of 2.1 years. Patients in DMS group were significantly older (79±9 vs. 70±10 years; P<0.01), had higher prevalence of hypertension (P<0.01) and coronary artery disease (P=0.02), and had higher plasma BNP level (P<0.01) than those in RMS group. Baseline trans-mitral mean gradient was slightly lower in DMS group than in RMS group (3.9±1.9 vs. 4.7±1.8 mmHg; P=0.02). There were wide variations among individuals in progression rate (range: 0 to 3.5 mmHg/year in DMS group and 0 to 5.8 mmHg/year in RMS group, respectively), and the progression rate was comparable between DMS group and RMS group (0.49±0.79 vs. 0.61±1.37 mmHg/year; P=0.59). In DMS group, higher prevalence of dyslipidemia (P=0.01) and lower baseline trans-mitral mean gradient (P<0.01) were significantly associated with disease progression even after adjustment for age and sex. Unexpectedly, there was no significant difference in the disease progression regardless of the MAC severity among DMS group (Picture).

MAC severity and disease progression

Conclusions

Progression in DMS group is highly variable, but generally slow as that in RMS group. Initial mean gradient was inversely associated with disease progression in DMS group. Furthermore, baseline MAC severity did not correlate with the progression, suggesting the importance of follow-up echocardiography in spite of the MAC severity and initial mean gradient.