Efficacy and Safety of Ensovibep for Adults Hospitalized With COVID-19 : A Randomized Controlled Trial

BACKGROUND

Ensovibep (MP0420) is a designed ankyrin repeat protein, a novel class of engineered proteins, under investigation as a treatment of SARS-CoV-2 infection.

OBJECTIVE

To investigate if ensovibep, in addition to remdesivir and other standard care, improves clinical outcomes among patients hospitalized with COVID-19 compared with standard care alone.

DESIGN

Double-blind, randomized, placebo-controlled, clinical trial. (ClinicalTrials.gov: NCT04501978).

SETTING

Multinational, multicenter trial.

PARTICIPANTS

Adults hospitalized with COVID-19.

INTERVENTION

Intravenous ensovibep, 600 mg, or placebo.

MEASUREMENTS

Ensovibep was assessed for early futility on the basis of pulmonary ordinal scores at day 5. The primary outcome was time to sustained recovery through day 90, defined as 14 consecutive days at home or place of usual residence after hospital discharge. A composite safety outcome that included death, serious adverse events, end-organ disease, and serious infections was assessed through day 90.

RESULTS

An independent data and safety monitoring board recommended that enrollment be halted for early futility after 485 patients were randomly assigned and received an infusion of ensovibep (n = 247) or placebo (n = 238). The odds ratio (OR) for a more favorable pulmonary outcome in the ensovibep (vs. placebo) group at day 5 was 0.93 (95% CI, 0.67 to 1.30; P = 0.68; OR > 1 would favor ensovibep). The 90-day cumulative incidence of sustained recovery was 82% for ensovibep and 80% for placebo (subhazard ratio [sHR], 1.06 [CI, 0.88 to 1.28]; sHR > 1 would favor ensovibep). The primary composite safety outcome at day 90 occurred in 78 ensovibep participants (32%) and 70 placebo participants (29%) (HR, 1.07 [CI, 0.77 to 1.47]; HR < 1 would favor ensovibep).

LIMITATION

The trial was prematurely stopped because of futility, limiting power for the primary outcome.

CONCLUSION

Compared with placebo, ensovibep did not improve clinical outcomes for hospitalized participants with COVID-19 receiving standard care, including remdesivir; no safety concerns were identified.

PRIMARY FUNDING SOURCE

National Institutes of Health.

COVID-19 and the Heart: Could Transient Takotsubo Cardiomyopathy Be Related to the Pandemic by Incidence and Mechanisms?

Typical emergency hospital care during the COVID-19 pandemic has centered on pulmonary-focused services. Nonetheless, patients with COVID-19 frequently develop complications associated with the dysfunction of other organs, which may greatly affect prognosis. Preliminary evidence suggests that cardiovascular involvement is relatively frequent in COVID-19 and that it correlates with significant worsening of clinical status and mortality in infected patients. In this article, we summarize current knowledge on the cardiovascular effects of COVID-19. In particular, we focus on the association between COVID-19 and transient takotsubo cardiomyopathy (TTC)—two conditions that preliminarily seem epidemiologically associated—and we highlight cardiovascular changes that may help guide future investigations toward full discovery of this new, complex disease entity. We hypothesize that coronary endothelial dysfunction, along with septic state, inflammatory storm, hypercoagulability, endothelial necrosis, and small-vessel clotting, may represent a fundamental hidden link between COVID-19 and TTC. Furthermore, given the likelihood that new genetic mutations of coronaviruses or other organisms will cause similar pandemics and endemics in the future, we must be better prepared so that a substantial complication such as TTC can be more accurately recognized, its pathophysiology better understood, and its treatment made more justifiable, timely, and effective.

Managing Ischemic Heart Disease in Women: Role of a Women's Heart Center

PURPOSE OF REVIEW

Heart centers for women (HCW) were developed due to the rising cardiovascular morbidity and mortality in women in the United States in the early 1990s. Our review encompasses the epidemiology, risk factors, diagnostic strategies, treatments, and the role of HCW in managing women with ischemic heart disease (IHD).

RECENT FINDINGS

HCW use a multidisciplinary team to manage women with IHD. Due to the paucity of randomized controlled trials investigating various manifestations of IHD, some treatments are not evidence-based such as those for coronary microvascular dysfunction and spontaneous coronary artery dissection. Sex-specific risk factors have been identified and multimodality cardiac imaging is improving in diagnosing IHD in women. Treatments are being studied to help improve symptoms and outcomes in women with IHD. There has been progress in the care of women with IHD. HCW can be instrumental in treating women with IHD, doing research, and being a source of research study participants.

Use of Social Media at Cardiovascular Congresses: Opportunities for Education and Dissemination

Social Media includes different forms of online communication from Twitter, Facebook, Instagram, LinkedIn, podcasts, YouTube etc. and has advanced how information is exchanged. A notable use is engaging on Twitter at medical conferences, both for those attending the conference and the global audience who are not able to attend. It is also increasingly used as an educational tool similar to e-learning. The objective of this paper is to: 1) highlight the impact of using Twitter at cardiovascular congresses as an interactive platform for active learning as compared to passively listening to a presentation; 2) present perspectives from not only clinicians, researchers but also patients on how this information is interpreted; 3) provide recommendations for conference organizers for best practice live tweeting to share the information and knowledge beyond those in attendance; with potential for not only engagement but also educating our global community.

Clinical impact of calcified nodules in patients with heavily calcified lesions requiring rotational atherectomy

Coronary atherectomy has been around for many years, and the body of evidence for its use in complex calcified lesions has grown. Calcific coronary disease presents a particularly challenging clinical scenario in PCI, having poorer outcomes than noncalcified lesions. This study is the first to identify calcified nodules as an independent predictor of worse outcomes after atherectomy and PCI. Continued study of lesion characteristics will improve our understanding of PCI outcomes and help manage patients in the long-term after PCI and stenting.

Effect of concomitant aortic regurgitation on early hypoattenuated leaflet thickening after transcatheter aortic valve replacement in patients with symptomatic severe aortic stenosis

Identification of hypoattenuated leaflet thickening (HALT) and subacute leaflet thrombosis has become widely recognized. Patients with anatomical changes associated with moderate or greater aortic regurgitation (larger sinus of Valsalva and eccentric left ventricular remodeling) appear to have less HALT early postprocedure compared with those without. Further research on the risk factors including anatomical and hemodynamic variables should further our knowledge of these entities so we can better manage patient both pre and post TAVR.

Exercise cardiac MRI unmasks cardiac dysfunction in childhood and adolescent cancer survivors with reduced cardiopulmonary fitness

Background

Young cancer survivors are at increased risk of impaired cardiopulmonary fitness (VO2peak) and heart failure. Assessment of exercise cardiac reserve may reveal sub-clinical abnormalities that better explain impairments in fitness and long term heart failure risk.

Purpose

To investigate the presence of impaired VO2peak in pediatric cancer survivors with increased risk of heart failure, and to assess its relationship with resting cardiac function and cardiac reserve

Methods

Twenty pediatric cancer survivors (aged 8–24 years) treated with anthracycline chemotherapy underwent cardiopulmonary exercise testing to quantify VO2peak, with a value &lt;85% of predicted defined as impaired VO2peak. Resting cardiac function was assessed using 3-dimensional echocardiography, with cardiac reserve quantified from resting and peak exercise heart rate (HR), stroke volume index (SVi) and cardiac index (CI) using exercise cardiac magnetic resonance imaging.

Results

12 of 20 survivors (60%) had impaired VO2peak (97±14% vs. 70±16% of age and gender predicted). There were no differences in echocardiographic or CMR measurements of resting cardiac function between survivors with normal or impaired VO2peak. However, those with reduced VO2peak had diminished cardiac reserve, with a lesser increase in CI (Fig. 1A) and SVi (Fig. 1B) during exercise (Interaction P=0.001 for both), whilst the HR response was similar (Fig. 1C; P=0.71).

Conclusions

Resting measures of cardiac function are insensitive to significant cardiac dysfunction amongst pediatric cancer survivors with reduced VO2peak. Measures of cardiopulmonary fitness and cardiac reserve may aid in early identification of survivors with heightened risk of long-term heart failure.

Figure 1

Funding Acknowledgement

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

Assessing atherothrombotic burden with optical coherence tomography analysis may facilitate post-PCI prognostication and antiplatelet therapy

Atherothrombotic burden (ATB) correlates with myocardial blush grade (MBG), a known predictor of mortality and outcome after ST-elevation myocardial infarction. Quantitative or semiquantitative analysis of ATB with optical coherence tomography may assist interventional cardiologists in post-PCI prognostication and, perhaps, in rendering more aggressive antiplatelet therapy. Future studies comparing treatment strategies for post-PCI patients with elevated ATB or depressed MBG may identify best practices after acute coronary syndromes.

432 Traditional markers of myocardial dysfunction fail to detect marked reductions in physical capacity amoung chemotherapy patients

Methods

95 patients who were due to commence anti-cancer treatment (n = 58 anthracycline chemotherapy for breast cancer; n = 25 Bruton’s tyrosine kinase inhibitor and n = 12 allogeneic stem cell transplant for haematological cancers) completed a pre-treatment and follow-up assessment within 6 months of initiating treatment. Changes in echocardiographic measures of LV function (LVEF, GLS), cardiac biomarkers (troponin and BNP) and cardiopulmonary exercise test (CPET, VO2peak) were measured.

Results

Of 95 participants who underwent baseline testing, follow-up CPET and echocardiography data was available in 89 participants. LV function was normal prior to treatment (LVEF 61.5 ± 5.9%; GLS -19.4 ± 2.3) but VO2peak (23.4 ± 6.5ml/kg/min) was only 83 ± 21% (range 47-146%) of age-predicted. After treatment, we observed marked reductions in fitness (Δ-2.1 ± 3.7 ml/kg/min or -9 ± 15%, P &lt; 0.001) which was associated with small non-clinically significant changes in LV function (LVEF Δ-2.4 ± 6.4% P = 0.001; GLS Δ-0.5 ± 1.9 P = 0.018). Troponin was increased significantly (4.0 ± 5.5 to 23.5 ± 22.5ng/ml, P &lt; 0.001), with no change in BNP (37.5 ± 31.4 to 32.7 ± 22.0pg/ml, P = 0.87). Current diagnostic criteria for cardiac toxicity were not met in any patient despite some patients developing disabling reductions in functional capacity (VO2peak &lt; 16ml/min/kg).

Conclusion

Despite normal resting LV function prior to commencing treatment VO2peak was below age predicted. Treatment further impaired exercise cardiovascular function with minimal impact on resting measures of LV function. The assessment of cardiovascular function using CPET prior to, and following chemotherapy may be a more sensitive means of identifying patients at increased risk of future heart failure.

P5 Clinical utility of stress echocardiography in remote indigenous and non-indigenous populations: a 10-year study in central Australia

Background

Central Australia is a vast, geographical region spanning some 830,000 square kilometres. It is the most populous Indigenous region in Australia (44%) and a great distance from tertiary centres (1,500km). Non-invasive testing is important in this setting due to the high prevalence of cardiovascular disease and long-distance travel required for coronary angiography, the latter with significant logistical, financial, and cultural barriers. Although stress echocardiography has been extensively validated as a long-term prognostic tool in selected populations, we are not aware of prior studies in remote Indigenous and non-Indigenous individuals.

Purpose

To determine whether stress echocardiography can adequately risk stratify and quantify the long-term prognosis of Indigenous and non-Indigenous individuals in remote Central Australia.

Methods

Consecutive individuals undergoing stress echocardiography in Central Australia between 2007 and 2017 were included. Exercise or dobutamine stress echocardiography was performed and reported via standard protocols.  Individuals were followed up for the primary outcome of all-cause mortality.

Results

One thousand and eight patients (54% Indigenous, 63% dobutamine stress) were included. Indigenous patients were younger, more likely to be female, and had a greater prevalence of cardiometabolic comorbidities (p &lt; 0.05 for all). Overall, 797 (79%) patients had no abnormality during rest or stress echocardiography, with no difference according to ethnicity (p &gt; 0.05).  After a mean follow up of 3.5 ± 2.4 years, 54 (5%) of patients were deceased; 127 (14%) patients underwent revascularization and were censored from follow-up. In patients with a normal test, annual mortality averaged 1.3% over 5 years of follow up, with annual mortality being significantly higher in Indigenous compared to non-Indigenous individuals (2.0% vs 0.6% respectively). Individuals with either ischemia or scar had a significantly worse long-term outcome compared to those with a normal test (Figure). In multivariate analyses, increasing age (HR 1.04 [95% CI 1.01-1.08]), chronic kidney disease (HR 4.83 [1.79-13.02]), and lack of ACEI/ARB use (HR 0.19 [95% CI 0.09-0.42]) were associated with all-cause mortality. Although Indigenous ethnicity was a univariate predictor of mortality, this association was attenuated and non-significant in multivariate analyses.

Conclusion

Indigenous patients in remote Central Australia with a normal stress echocardiogram had a significantly higher annual rate of mortality compared to their non-Indigenous counterparts. However, this association may be in large part due to comorbid conditions. A normal test in Indigenous individuals was still able to adequately risk-stratify and identify a lower risk group of patients in whom ongoing local medical management and focusing on cardiometabolic risk factor reduction is likely to be appropriate.

Abstract P5 Figure. Kaplan Meier survival curve

Investigation of faecal volatile organic metabolites as novel diagnostic biomarkers in inflammatory bowel disease

BACKGROUND

The aetiology of inflammatory bowel disease (IBD) remains poorly understood. Recent evidence suggests an important role of gut microbial dysbiosis in IBD, and this may be associated with changes in faecal volatile organic metabolites (VOMs).

AIM

To describe the changes in the faecal VOMs of patients with IBD and establish their diagnostic potential as non-invasive biomarkers.

METHODS

Faecal samples were obtained from 117 people with Crohn's disease (CD), 100 with ulcerative colitis (UC), and 109 healthy controls. Faecal VOMs were extracted using solid-phase micro-extraction and analysed by gas chromatography mass spectrometry. Data analysis was carried out using partial least squares-discriminate analysis (PLS-DA) to determine class membership based on distinct metabolomic profiles.

RESULTS

The PLS-DA model showed clear separation of active CD from inactive disease and healthy controls (P < 0.001). Heptanal, 1-octen-3-ol, 2-piperidinone and 6-methyl-2-heptanone were up-regulated in the active CD group [variable important in projection (VIP) score 2.8, 2.7, 2.6 and 2.4, respectively], while methanethiol, 3-methyl-phenol, short-chain fatty acids and ester derivatives were found to be less abundant (VIP score of 3.5, 2.6, 1.5 and 1.2, respectively). The PLS-DA model also separated patients with small bowel CD from healthy controls and those with colonic CD from UC (P < 0.001). In contrast, less distinct separation was observed between active UC, inactive UC and healthy controls.

CONCLUSIONS

Analysis of faecal volatile organic metabolites can provide an understanding of gut metabolomic changes in IBD. It has the potential to provide a non-invasive means of diagnosing IBD, and can differentiate between UC and CD.

Characterization of Monodisperse Aqueous Latex Dispersions Prepared with N-Isopropylacrylamide

Poly-N-isopropylacrylamide (poly-NIPAM) is a water soluble nonionic polymer that exhibits a lower consolute solution temperature (LCST) of about 31°C. This paper describes the preparation and characterization of a monodisperse, hydrophilic polymer latex of poly-NIPAM, crosslinked by N,N'-methylenebisacrylamide. The presence of these crosslinking moieties will prevent dissolution of the particles at low temperatures; rather the particles will be swollen with solvent such that a microgel is formed. The swelling and rheological behaviour of the latex has been studied. The results show that at high temperatures the particles are ˜ 30 nm whilst at 25°C, the particles were ˜ 130 nm in diameter. This four fold increase in the particle diameter correspond to a ˜ sixty fold increase in volume. The rheological properties, both continuous and oscillatory shear, of these systems have also been studied and is strongly temperature dependant, reflecting the changes in phase volume of the NIPAM latex.

Renal medullary carcinoma: sonographic, computed tomography, magnetic resonance and angiographic findings

Renal medullary carcinoma is a recently described, highly aggressive tumour, occurring predominantly in young patients of African descent with sickle cell trait (SCT). All have been metastatic at surgery. Surgery, radiotherapy and chemotherapy do not appear to alter the course of the disease. The survival time is very short. Presentation is usually with haematuria, abdominal pain and weight loss. Forty-nine patients have been reported from the USA, of these 47 were African/Americans. The reports have mostly appeared in pathology journals. On review of the imaging findings reported in the radiological journals, it becomes apparent that it is possible for a radiologist to suggest a specific diagnosis in the appropriate demographic and clinical setting. Here the first British patient of Afro-Caribbean decent in whom a pre-operative diagnosis was suggested on the imaging findings of a centrally located renal pelvic tumour, encasing the pelvis on a background of SCT in a 28-year-old is described. It is expected that a high index of suspicion in the appropriate clinical setting may lead to earlier diagnosis, treatment and survival of patients. The patient is alive and reasonably well 9 months after surgery. The full range of imaging findings in renal medullary carcinoma are described.