Cross-Sectional and Longitudinal Associations of Creatinine-to-Cystatin C Ratio with Sarcopenia Parameters in Older Adults

OBJECTIVES

Accumulating evidence from cross-sectional studies suggests that the serum creatinine-to-cystatin C ratio (CCR) may be a useful biomarker for sarcopenia. This study aimed to assess the cross-sectional and longitudinal associations of CCR with sarcopenia and its parameters in community-dwelling older adults.

DESIGN

Cross-sectional and longitudinal study.

SETTING AND PARTICIPANTS

This 6-year prospective cohort study included the repeated measurement data from 1,253 Japanese residents (662 males and 591 females) aged ≥65 years who underwent medical checkups in Kusatsu and Hatoyama, Japan. A total of 4,421 observations were collected.

MEASUREMENTS

The CCR was grouped into quartiles by sex (Q1-Q4) using Q4 as the reference category. Sarcopenia was defined according to the Asian Working Group for Sarcopenia 2019 algorithm. Skeletal muscle mass index (SMI) measured using segmental multifrequency bioelectrical impedance analysis, handgrip strength (HGS), usual gait speed (UGS), and maximal gait speed (MGS) were measured repeatedly as sarcopenia parameters. The association of the CCR with changes in sarcopenia, SMI, HGS, UGS, and MGS during the 6-year period were analyzed using a generalized linear mixed-effects model.

RESULTS

The prevalence of sarcopenia at baseline was 13.1% (11.9% in males and 14.5% in females). In a cross-sectional analysis, the CCR quartile was inversely associated with sarcopenia and was positively associated with SMI, HGS, and MGS (P for trend < 0.001). In a longitudinal analysis during the 6 years, a significant increase in sarcopenia in Q2 (B = 1.1% point/year; P = 0.026 for group-by-time interaction) and significant declines in SMI (B = -0.01 kg/m2/year; P = 0.044 for group-by-time interaction) and MGS (B = -0.008 m/sec/year; P = 0.041 for group-by-time interaction) in Q1 were observed compared with Q4. However, the dose-response relationship was significant only for MGS (P = 0.033 for trend). No significant group-by-time interaction was observed for HGS. CCR was not significantly associated with UGS either cross-sectionally or longitudinally.

CONCLUSIONS

CCR is a useful biomarker regarding the status of sarcopenia. It may be used for sarcopenia screening even in older adults whose physical function is difficult to assess. However, further longitudinal studies are needed to determine whether CCR can be a predictor of future sarcopenia.

Association between serum GDF-15, myostatin, and sarcopenia in cardiovascular surgery patients

Background

Myostatin is a negative regulator of skeletal muscle mass. On the other hand, growth differentiation factor (GDF)-15 is associated with lower muscle strength and muscle mass. We investigated the relationship between serum GDF-15, myostatin, and sarcopenia in patients receiving cardiovascular surgery through a ROC curve and a multivariate regression analysis.

Methods

Skeletal muscle mass index (SMI) by bioelectrical impedance analysis, hand-grip strength, knee extension strength, and walking speed were measured. Preoperative serum GDF-15 and myostatin levels were determined by ELISA. The sarcopenia index could be expressed as: −0.0042 × [myostatin] + 0.0007 × [GDF-15] + 0.0890 × age + 1.4030 × sex − 0.2679 × body mass index (BMI) − 2.1186. A ROC curve was plotted to identify the optimal cutoff level of the sarcopenia index to detect sarcopenia.

Results

120 patients receiving cardiovascular surgery were included in the study. SMI, hand-grip strength, knee extension strength, and walking speed inversely correlated with GDF-15, but positively correlated with myostatin. In the multivariate stepwise regression analysis, SMI was a determinant of myostatin, and both GDF-15 and myostatin were determinants of SMI and muscle thickness, even after adjustment for age, sex, and BMI. A ROC curve showed that the sarcopenia index was a determinant of sarcopenia (cutoff value −1.0634, area under the curve 0.901, sensitivity 96.9%, specificity 70.9%).

Conclusion

GDF-15 and myostatin are associated with skeletal muscle volume in patients receiving cardiovascular surgery, but these associations are different. The sarcopenia index calculated from GDF-15 and myostatin levels may be a biomarker of sarcopenia.

OP0238 CLINICAL ANALYSIS OF 34 CASES OF CARDIAC COMPLICATIONS REQUIRING SURGICAL INTERVENTION IN SYSTEMIC LUPUS ERYTHEMATOSUS AND ASSESSMENT ABOUT MECHANISM OF DEVELOPMENT WITH IMMUNOLOGICAL ANALYSIS

Background

In cases of systematic lupus erythematosus (SLE) that lead to surgery due to the development of heart diseases such as valvular disease, ischemic heart disease and aortic aneurysm, early detection and careful monitoring are important. An absence of background diseases or immunopathological examination of the myocardial tissue in SLE cases with cardiovascular lesions demonstrates the lack of knowledge in this area. In recent years, however, there have been reports of neutrophil extracellular traps being involved in the fulminant onset of SLE.

Objectives

This study aimed to analyze clinically and immunohistopathologically the pathophysiology of heart diseases associated with SLE.

Methods

We performed left atrial appendage resection in 34 patients, including patients with cardiovascular lesions, who underwent heart surgery for SLE complications from 2012 to 2021. Tissue analysis was conducted in 9 cases. The left atrial appendage, in cases of non-collagen valvular disease, was used as the control. Tissue staining of cardiomyocytes was carried out by adding anti-neutrophil extracellular(NE) antibodies(Abs) to anti-human IgG antibody (Ab), anti-IgM Ab and anti-C3 Ab.

Results

Of the 34 SLE patients 14 had valvular disease, 8 had ischemic heart disease and 12 had aneurysms. Preoperative SLE activity was relatively stable with only 1 patient below the CH50 standard and 6 patients above the anti-DNA Ab standard. The Ab positivity rate for the patients in this study was higher than that of the 687 SLE patients who were previously tested in 2019. The presence of anti-CL Abs was 55.6%, which was higher than the 25.5% observed in previous SLE patients. In this study, anti-SS-A and anti-RNP Abs tended to be relatively numerous. An example of immunohistochemical staining of IgG in the left atrial appendage is presented (Figure 1a). IgG deposits were not observed on the left side of the myocardial fibers in the control group, whereas IgG deposits were observed on the right side in the SLE group. Deposits were also observed in tissues that were not located in the affected areas. The presence or absence of tissue deposition in the myocardial fibers and clinical findings in 2 cases of the control group and 9 cases of the SLE complication group are reported in Table 1. IgG deposits were found in the myocardial fibers of 6 of the 9 patients in the SLE complication group, and deposits were found in the left atrial appendage tissue regardless of the type of heart disease, suggesting a potential change in the heart tissue. In the SLE group, 5 cases were positive for antiphospholipid (APS) Abs, while 7 cases were positive for either anti-SS-A or anti-RNP Abs. Only 2 cases had elevated preoperative anti-DNA Ab and complement reduction. Of the SLE complication group, 2 of the 9 cases were negative for all Abs but IgG deposits were observed in a case. Of these 4 cases were selected and stained with anti-IgM, anti-C3 and anti-NE Abs. However IgM and C3 deposits were only observed in one patient who developed myocardial infarction at the age of 39 and was triple positive for APS, anti-SS-A and anti-RNP Abs (Figure 1b). There were also no NE deposits in any of the cases. Even if complement and anti-DNA Ab levels in the serum are normal, attention should be paid to heart disease complications during the long-term observation of SLE patients. In particular, attention should be paid to various autoantibody-positive cases such as APS, anti-SS-A Ab and anti-RNP Ab. The anti-NE Ab was not stained in this study because the tissue was different from the lesion site and because it occurred during the chronic course.

Conclusion

In SLE patients who developed cardiovascular lesions and required surgery, immunological abnormalities may occur in the myocardial tissue even if serum complement and anti-DNA Ab levels are stable.

References

[1]Stephane Zuily et al. Valvular Curr Rheumatol Rep (2013) 15:320.

[2]Zawadowski GM et al. Lupus. 2012;21(13):1378-84.

[3]Daniel Appelgren et al. Autoimmunity 2018,vol51,No.6,310-318.

Disclosure of Interests

None declared

Risk factors of recurrence and major bleeding in patients with intermediate-risk for recurrence of venous thromboembolism: from the COMMAND VTE Registry

Background/Introduction

Patients with venous thromboembolism (VTE), including pulmonary embolism (PE), have a long-term risk of recurrence, and anticoagulation therapy is recommended for the prevention of recurrence. The latest 2019 European Society of Cardiology (ESC) guideline classified the risks of recurrence into low- (&lt;3%/year), intermediate- (3–8%/year), and high- (&gt;8%/year) risk, and recommended the extended anticoagulation therapy of indefinite duration for high-risk patients as well as intermediate-risk patients. However, extended anticoagulation therapy of indefinite duration for all of intermediate-risk patients have been a matter of active debate. Thus, additional risk assessment of recurrence in intermediate-risk patients might be clinically relevant in defining the optimal duration of anticoagulation therapy. Furthermore, bleeding risk during anticoagulation therapy should also be taken into consideration for optimal duration of anticoagulation therapy. However, there are limited data assessing the risk of recurrence as well as bleeding in patients with intermediate-risk for recurrence based on the classification in the latest 2019 ESC guideline.

Purpose

The current study aimed to identify the risk factors of recurrence as well as major bleeding in patients with intermediate-risk for recurrence, using a large observational database of VTE patients in Japan.

Methods

The COMMAND VTE Registry is a multicenter registry enrolling consecutive 3027 patients with acute symptomatic VTE among 29 centers in Japan. The current study population consisted of 1703 patients with intermediate-risk for recurrence. The primary outcome measure was recurrent VTE during the entire follow-up period, and the secondary outcome measures were recurrent VTE and major bleeding during anticoagulation therapy.

Results

In the multivariable Cox regression model for recurrent VTE incorporating the status of anticoagulation therapy as a time-updated covariate, off-anticoagulation therapy was strongly associated with an increased risk for recurrent VTE (HR 9.42, 95% CI 5.97–14.86). During anticoagulation therapy, the independent risk factor for recurrent VTE was thrombophilia (HR 3.58, 95% CI 1.56–7.50), while the independent risk factors for major bleeding were age ≥75 years (HR 2.04, 95% CI 1.36–3.07), men (HR 1.52, 95% CI 1.02–2.27), history of major bleeding (HR 3.48, 95% CI 1.82–6.14) and thrombocytopenia (HR 3.73, 95% CI 2.04–6.37).

Conclusions

Among VTE patients with intermediate-risk for recurrence, discontinuation of anticoagulation therapy was a very strong independent risk factor of recurrence during the entire follow-up period. The independent risk factors of recurrent VTE and those of major bleeding during anticoagulation therapy were different: thrombophilia for recurrent VTE, and advanced age, men, history of major bleeding, and thrombocytopenia for major bleeding.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Research Institute for Production Development, Mitsubishi Tanabe Pharma Corporation

POS0687 A RANDOMISED DOSE RANGING, PLACEBO-CONTROLLED, PHASE II STUDY ASSESSING THE EFFICACY AND SAFETY OF BI 655064, AN ANTAGONISTIC ANTI-CD40 ANTIBODY, IN PATIENTS WITH LUPUS NEPHRITIS

Background:

In patients with SLE, activation of the CD40–CD40L pathway results in stimulation and proliferation of B cells and other inflammatory cell types. The subsequent generation of autoantibodies and their deposition in the kidney, as well as activation of myeloid and resident kidney cells, result in local inflammation and eventually, kidney injury. Thus, CD40 is an appealing therapeutic target in lupus nephritis (LN). BI 655064 is a humanised anti-CD40 monoclonal antibody that blocks the CD40 pathway in a nanomolar range and downregulates activated B cells.

Objectives:

To assess the efficacy and safety over 52 weeks of three doses of subcutaneous BI 655064 compared with placebo, as add-on to mycophenolate and steroids, in patients with active proliferative LN (ClinicalTrials.gov number: NCT02770170).

Methods:

Overall, 121 patients with LN were randomised, double blind, in a 2:1:1:2 ratio to placebo or BI 655064 120 mg, 180 mg or 240 mg, and received a weekly loading dose for the first 3 weeks, followed by dosing every 2 weeks for the 120 and 180 mg doses, and weekly (120 mg) for the 240 mg group. Key inclusion criteria included an active ISN/RPS class III or IV (±V) renal biopsy within 3 months prior to screening and a screening protein/creatinine ratio of ≥1 mg/mg. Randomisation was stratified based on race (Asian vs non-Asian) and screening protein/creatine (UP/UC) ratio (<3 vs ≥3). The primary efficacy endpoint was complete renal response (CRR), defined as 24 h proteinuria <0.5 g/day and stable eGFR at Week 52.

Results:

The placebo response in this trial was higher than expected (48.3%; Table 1); none of the

BI 655064 doses increased rates of CRR at Week 52 compared with placebo. However, CRR at Week 52 based on creatinine-adjusted proteinuria, assessed using spot urine, showed a better response in the 180 mg group (50%) vs placebo (42.5%), and the 180 mg dose showed a greater change from baseline over time vs placebo from Week 4. Time to CRR was shorter in the 180 mg group (17.3 weeks) vs placebo (20.4 weeks). The 180 mg group also showed improvement vs placebo in total SLEDAI (SELENA) and its subscores.

The unexpected high placebo response prompted a post hoc analysis evaluating confirmed CRR (cCRR), whereby confirmation of the endpoint was required at both Weeks 46 (penultimate visit on treatment) and 52. A 15.2% higher cCRR in the 180 mg group (44.3%) vs placebo (29.1%) was observed (p=0.26).

While based on a small sample size, there were more reports of infection-related severe and serious adverse events and neutropenia in the 240 mg group compared with placebo. Of note, in those who experienced neutropenia, a clinical impact (e.g. increase in infections) was not established. Aside from these observations, safety data were comparable across treatment groups.

Larger decreases from baseline were observed in the percentage of CD27−IgD−CD95+, CD27−IgD+CD95+, CD27+IgD+CD95+ and CD27+IgD−CD95+ B-cell subsets in the 180 and 240 mg groups compared with placebo.

Treatment-emergent anti-drug antibodies (ADAs) were detected in five patients treated with BI 655054, all at low titre, and in one who received placebo; ADAs had no impact on pharmacokinetics or safety.

Conclusion:

The trial did not meet its primary CRR endpoint. However, when confirmation of CRR was required at both Weeks 46 and 52, the resultant decrease in the placebo response generated an effect size of 15.2% and 9.1% in favour of 180 mg and 240 mg BI 655064, respectively.

Table 1.

Efficacy endpoints at Week 52

Placebo (n=40)BI 655064120 mg (n=21)180 mg (n=20)240 mg (n=40)Observed CRR, n208918Adjusted* CRR, %48.338.34544.6Observed cCRR, n135916Adjusted* cCRR, %29.122.544.338.2Mean change from baseline in SLEDAITotal score−6.5−6.1−9.7−8.2Non-renal score−1.4−3.0−2.8−3.1Renal score−5.1−3.7−6.8−5.0Clinical score−5.7−3.9−7.9−6.5

CRR based on 24 h proteinuria; cCRR based on UP/UC (spot urine) at Weeks 46 and 52. *Logistic regression model including treatment and the covariates race and proteinuria at screening.

Disclosure of Interests:

David Jayne Consultant of: DRJ has received consulting fees from AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline Research & Development Ltd, Novartis, and Roche, Juergen Steffgen Employee of: JS is employed by Boehringer Ingelheim., Juanita Romero-Diaz Consultant of: JRD has received research consulting fees from Boehringer Ingelheim, Hirofumi Amano Grant/research support from: HA has received research grants from Boehringer Ingelheim, Kajohnsak Noppakun Consultant of: KN has received honoraria from Boehringer Ingelheim, Novartis, Roche, Jansen, AstraZeneca, Otsuka Pharmaceuticals, Astellas Pharma, Abbott, Sanofi and Novo Nordisk, Grant/research support from: KN has received research grants from Boehringer Ingelheim, GlaxoSmithKline Research & Development Ltd, Visterra Inc., Kalbe Genexine Biologics, Aurinia Pharmaceuticals Inc., and Omeros Corporation., Harold Michael Gomez Speakers bureau: HMG has received speaker’s fees for Pfizer, MSD, Unilab, Astellas Pharma, AstraZeneca, GlaxoSmithKline Research & Development Ltd, and Aurinia Pharmaceuticals Inc., Rhona Recto: None declared, Valérie Belsack Employee of: Boehringer Ingelheim, Nora Fagan Employee of: Boehringer Ingelheim, Steven Padula Employee of: Boehringer Ingelheim, Ivette Revollo Employee of: Boehringer Ingelheim, Jing Wu Employee of: Boehringer Ingelheim, Sudha Visvanathan Employee of: Boehringer Ingelheim, Richard Furie Consultant of: RF has received research consulting fees, Grant/research support from: RF has received clinical trial support

Early restenosis and late catch-up phenomenon after newer biodegradable- and durable-polymer drug-eluting stent implantations

Background

It is yet to be known whether mechanisms underlying restenosis in newer-generation durable-polymer (DP) and biodegradable-polymer (BP) drug-eluting stents (DES) are different.

Purpose

This study aims to assess the incidences and predictors of early restenosis and late catch-up phenomenon after newer-generation durable-polymer (DP) and biodegradable-polymer (BP) DES.

Methods

Between 2010 and 2017, 13858 lesions in 6350 patients were treated with DES (4393 BP-DES, 9465 DP-DES). The early-term (within 1 year) and late-term (from 1 to 2 years) follow-up angiographies were scheduled. Late catch-up phenomenon was defined as in-stent restenosis (ISR) in lesions that evaded ISR within 1 year after stent implantation. ISR was defined as angiographic restenosis of more than 50%.

Results

The mean patient age was 71 years, and 76.7% were male. Early-term angiographies were performed in 10955 lesions (79.0%). Of those without early-term ISR, late-term angiographies were performed in 7771 lesions (56.1%). The incidences of mid-term restenosis and late catch-up phenomenon were 6.6% and 3.9%, respectively.

In the multivariate regression analyses, history of diabetes, hemodialysis and previous PCI were independent predictors of both early restenosis and late catch-up phenomenon. Also, some lesion characteristics such as chronic total occlusion, right coronary artery ostial lesion, small vessel (defined as reference diameter &lt;2.5mm), long lesion (defined as lesion length &gt;30mm) and treatment of ISR lesion were independent predictors of both early restenosis and late catch-up phenomenon.

Bifurcation lesion and heavily calcified lesion treated with rotablator were independent risk of early restenosis. Bypass graft lesion was an independent predictor of late catch-up phenomenon.

Early restenosis was observed less frequently in DP-DES than in BP-DES (6.3% versus 7.4%, P=0.012). On the contrary, late catch-up phenomenon was observed more frequently in DP-DES than in BP-DES (4.3% versus 2.9%, P=0.026).

Conclusions

Some lesion characteristics were independent predictors of early restenosis and late catch-up phenomenon after newer-generation DES implantation. The deployment of BP-DES resulted in more early restenosis and less late catch-up phenomenon compared to that of DP-DES.

Early Restenosis and Late Catch-Up

Funding Acknowledgement

Type of funding source: None

Clinical features and prognosis of acute myocardial infarction due to coronary artery embolism

Background

Coronary artery embolism (CE) is one of the important causes of acute coronary syndrome (ACS). The feature of CE is that angiographic evidence of coronary artery embolism and thrombosis without atherosclerotic components. However, the prevalence of CE remains unknown because of the diffifulty to diagnose in the acute settings. A recent retrospective analysis suggested that up to 3% of ACS cases may result from CE.

Purpose

The aim of this study was to elucidate the prevalence, clinical features and long-term outcomes including all-cause and cardiac death.

Methods

We analysed the consecutive 2695 patients with first AMI performed coronary intervention between January 2004 and July 2017. CE was diagnosed by clinical histories and angiographic findings. We retrospectively evaluated the clinical and lesion characteristics and outcomes including all-cause and cardiac death.

Results

The prevalence of CE was 2.0% (n=55; CE group and n=2640; non-CE group), including 8 (15%) patients with multivessel CE. The CE group had higher average age (70.8±14.9 vs. 68.4±12.6, p&lt;0.01), prevalence of female (54% vs. 27%, p&lt;0.01), lower prevalence of smoking (34% vs. 62%, p&lt;0.01). The common causes with CE were atrial fibrillation (47%), and malignant tumor (9%), and cardiomyopathy (5%), and patent foramen ovale (4%). Only 20% of patients with CE were treated with anti-coagulant therapy. The rate of distal infarction site (defined as #4, #8, #14–15) was significantly higher in CE group than non-CE group (54.0% vs. 4.9%, p&lt;0.01). During median follow-up of 53.6 [32.6–77.3] months, CE and thromboembolism recurred in 5 patients (CE: 1 patient, stroke 4 patients). The 4-year incidence of all-cause death was significantly higher in the CE group, but cardiac death was not significantly different between the groups (28.8% vs. 14.8%, p=0.03; 12.8% vs. 5.1%, p=0.11).

Conclusion

Compared with non-CE group, the prevalence of distal infarction site was significantly higher in the CE group, and the incidence of cardiac death is not significantly different.

Funding Acknowledgement

Type of funding source: None

Risk stratification based on academic research consortium high bleeding risk criteria for long-term bleeding event after everolimus-eluting stent implantation

Background

Recently, the Academic Research Consortium for High Bleeding Risk (ARC-HBR) criteria has been suggested as the standard definition of HBR.

Purpose

We aimed to investigate the risk stratification based on ARC-HBR Criteria for long-term bleeding event after everolimus-eluting stent implantation

Methods

The study population comprised 1193 patients treated with EES without in-hospital event between 2010 and 2011. Individual ARC-HBR criteria was retrospectively assessed. Major bleeding were defined as the occurrence of a Bleeding Academic Research Consortium type 3 or 5 bleeding event. The mean follow-up period was 2996±433 days.

Results

There were 656 patients (55.0%) in HBR-groups. Cumulative incidence of major bleeding was significantly higher in HBR-group (8.1% vs 3.4% at 4 year, and 16.2% vs 5.7% at 8 year, P&lt;0.001). Cumulative rate of major bleeding tend to be higher as the number of ARC-HBR criteria increased (≥2 Majors: 24.3%, 1 Major: 17.0%, ≥2 Minors:11.7%, and Non-HBR: 5.7%, P&lt;0.001).

Conclusion

ARC-HBR criteria successfully stratified the long-term bleeding risk after drug-eluting stent implantation in real-world practice.

Funding Acknowledgement

Type of funding source: None

Clinical usefulness of Lipoprotein(a) for the prevalence and severity of peripheral artery disease among patients with acute coronary syndrome

Background

Lipoprotein(a) [LP(a)] is known to be a robust lipid marker associated with cardiovascular events. Though coronary artery disease and peripheral artery disease (PAD) are often coexist, little is known about the relationship between LP(a) and PAD among patients with acute coronary syndrome (ACS).

Purpose

The purpose of this study is to examine if LP(a) is of predictive value for PAD among ACS patients in Japanese population.

Methods

Of consecutive 238 ACS patient who received successful primary PCI, a total of 175 patients were enrolled in the current study. We excluded the patients who received hemodialysis (n=10), required multidisciplinary treatment (n=36) and incomplete data (n=17). PAD was diagnosed as ankle brachial index &lt;0.9. Multiple lipid biomarkers [LP(a), low-density lipoprotein (LDL-C), high-density lipoprotein (HDL-C), malondialdehyde-modified LDL (MDA-LDL), docosahexaenoic acid and arachidonic acid] were compared between patients with PAD (n=21) and without PAD (n=154). Further, multivariable logistic regression models were used to assess if LP(a) was associated with PAD. In addition, serum LP(a) level were compared between 3 groups according to pattern of PAD [none (n=154), unilateral (n=10) and bilateral PAD (n=11), respectively].

Results

Compared to patients without PAD, those with PAD were older (74.4 vs. 65.4 years, p=0.003), and had a higher prevalence of chronic kidney disease (CKD) (61.9% vs. 20.1%, p&lt;0.001), diabetes mellitus (DM) (66.7% vs. 27.3%, p&lt;0.001). Serum LP(a) level was significantly higher in patients with PAD (36.4 vs. 18.5 mg/dl, p&lt;0.001), whereas LDL-C and MDA-LDL were significantly lower in PAD (92.0 vs. 109.5 mg/dl, p=0.015 and 98.6 vs. 119.5 mg/dl, p=0.046, respectively). After adjusting for LDL-C and MDA-LDL, LP(a) &gt;30 mg/dl was independently associated with a presence of PAD (OR 5.67, 95% CI 2.09–15.4, p=0.0006). When adjusting for CKD and DM in a different model, LP(a) &gt;30 mg/dl was similarly associated with PAD (OR 4.98, 95% CI 1.66–14.9, p=0.004). Serum LP(a) levels were significantly higher in bilateral PAD group compared to none PAD group (Figure).

Conclusion

LP(a) was a useful lipid biomarker for the prevalence and severity of PAD among patients with ACS in Japanese population.

Funding Acknowledgement

Type of funding source: None

Clinical Usefulness of New R-R Interval Analysis Using the Wearable Heart Rate Sensor WHS-1 to Identify Obstructive Sleep Apnea: OSA and RRI Analysis Using a Wearable Heartbeat Sensor

Obstructive sleep apnea (OSA) is highly associated with cardiovascular diseases, but most patients remain undiagnosed. Cyclic variation of heart rate (CVHR) occurs during the night, and R-R interval (RRI) analysis using a Holter electrocardiogram has been reported to be useful in screening for OSA. We investigated the usefulness of RRI analysis to identify OSA using the wearable heart rate sensor WHS-1 and newly developed algorithm. WHS-1 and polysomnography simultaneously applied to 30 cases of OSA. By using the RRI averages calculated for each time series, tachycardia with CVHR was identified. The ratio of integrated RRIs determined by integrated RRIs during CVHR and over all sleep time were calculated by our newly developed method. The patient was diagnosed as OSA according to the predetermined criteria. It correlated with the apnea hypopnea index and 3% oxygen desaturation index. In the multivariate analysis, it was extracted as a factor defining the apnea hypopnea index (r = 0.663, p = 0.003) and 3% oxygen saturation index (r = 0.637, p = 0.008). Twenty-five patients could be identified as OSA. We developed the RRI analysis using the wearable heart rate sensor WHS-1 and a new algorithm, which may become an expeditious and cost-effective screening tool for identifying OSA.

Study of charged particle activation analysis (II): Determination of boron concentration in human blood samples

Boron Neutron Capture Therapy (BNCT) is a radiotherapy for the treatment of intractable cancer. In BNCT precise determination of ¹⁰B concentration in whole blood sample before neutron irradiation of the patient, as well as accurate neutron dosimetry, is crucial for control of the neutron irradiation time. For this purpose ICP-AES and neutron induced prompt γ-ray analysis are generally used. In Ibaraki Neutron Medical Research Center (iNMRC), an intense proton beam will be accelerated up to 8 MeV, which can also be used for Charged Particle Activation Analysis (CPAA). Thus, in this study, we apply the CPAA utilizing the proton beam to non-destructive and accurate determination of ¹⁰B concentration in whole blood sample. A CPAA experiment is performed by utilizing an 8 MeV proton beam from the tandem accelerator of Nuclear Science Research Institute in Japan Atomic Energy Agency. The 478 keV γ-ray of ⁷Be produced by the ¹⁰B(p, α)⁷Be reaction is used to quantify the ¹⁰B in human blood. The 478 keV γ-ray intensity is normalized by the intensities of the 847 keV and 1238 keV γ-rays of ⁵⁶Co originating from Fe in blood. The normalization methods were found to be linear in the range of 3.27 μg ¹⁰B/g to 322 μg ¹⁰B/g with correlation coefficients of better than 0.9999.

FRI0179 A STUDY ON THE ACHIEVEMENT OF LUPUS LOW DISEASE ACTIVITY STATE AND QUALITY OF LIFE IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS: FROM THE JUNTENDO UNIVERSITY SLE PROSPECTIVE REGISTRY STUDY

Background:

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease of unknown etiology that affects mostly young women. Multiorgan complications and prolonged treatment significantly cause physical and mental stress in patients. Improving patients’ quality of life (QOL) in SLE treatment is essential. We examined the treatment effects on disease activity and QOL of SLE patients.

Objectives:

In recent years, lupus low disease activity state (LLDAS) has been proposed as a treatment target for SLE. Patients who achieve LLDAS have a low recurrence rate for lupus and a low risk of serious complications (1). The aim of this study is to investigate whether achieving LLDAS reduces not only recurrence rate and complications of SLE but also improves patients’ QOL.

Methods:

A total of 104 SLE patients were enrolled in our prospective SLE registry study (Juntendo, Multi-center, Prospective cohort for investigation of clinical course and outcome in SLE: JUMP) conducted at our institution. SLE was diagnosed using the American College of Rheumatology (ACR) 1982 criteria (revised in 1997). QOL was evaluated using the standard version of the 36-item short form health survey version 2 (SF36v2). Participants were divided into the LLDAS achievement and non-achievement groups, and the characteristics of each group including results of SF36v2 were examined.

Results:

This study included 104 SLE patients, 94 female and 10 male, and the average age and disease duration were 46.4±13.8 and 14.5±11.3 years, respectively. The average corticosteroid dose was 8.0±17.4 mg/day in terms of prednisolone, and anti-dsDNA antibody titer was 16.8±38.5 IU/ml. Of the 104 patients, 57 achieved LLDAS. The subscale’s standard scoring using SF36v2 for role physical (RP) was 78.9±24.0 and 64.6±27.6 (P<0.01), general health (GH) was 50.0±17.0 and 42.0±19.3 (P<0.05), vitality (VT) was 55.8±15.8 and 38.0±24.1 (P<0.01), social functioning (SF) was 82.0±20.7 and 66.5±26.3 (P<0.01), role emotional (RE) was 89.0±16.1 and 73.4±28.1 (P<0.01), and mental health (MH) was 72.4±15.9 and 58.3±21.8 (P<0.01) in the LLDAS achievement and non-achievement groups, respectively. Furthermore, scoring based on the national standard value in the LLDAS achievement group showed that two categories were >50. However, in the LLDAS non-achievement group, all categories were <50. In particular, RP, GH, VT, SF, RE, and MH of the LLDAS achievement group had significantly higher scores than the LLDAS non-achievement group (RP and GH: p<0.05 and VT, SF, RE and MH: p<0.01).

Conclusion:

Results of examining the association between LLDAS and QOL using SF36v2 in SLE patients showed that patients who achieved LLDAS had significantly better standard statistical scores in many subscale categories. Thus, LLDAS achievement as a treatment target for SLE patients greatly contributes to improving patients’ QOL.

References:

[1]Franklyn K, et al. Definition and initial validation of a Lupus Low Disease Activity State (LLDAS).Ann Rheum Dis. 2016 Sep;75(9):1615-21.

Disclosure of Interests:

None declared

P177 Left atrial strain in patients with cardiac amyloidosis. Relationship to left atrial amyloid deposition focusing on prognosis

Background

 In cardiac amyloidosis (CA), the left atrium (LA) is frequently infiltrated by the amyloid fibrils. It is currently known that LA strain is a marker of LA function and prognosis in many cardiac diseases, however its significance in CA remains unknown. 

Purpose

 Our aim was to investigate correlation between LA strain measured by Cardiovascular Magnetic Resonance (CMR) and amyloid deposit in LA, and also evaluate the LA strain on the prognostic significance. 

Methods and results

 Of 74 consecutive patients with biopsy-proven CA, we analyzed 42 patients (age 72 ± 10 years; 76 % males) with contrast-enhanced CMR, and examined LA late gadolinium enhancement (LGE) and CMR derived LA strain using feature tracking method. Of the 42 patients, 29 patients (69 %) was transthyretin cardiac amyloidosis (ATTR-CA) in the majority. We divided these 42 patients into two groups according to the CMR measured peak atrial longitudinal strain (PALS) (&gt; = or &lt; median); high-strain (&gt; = 6.67 %, n = 21) and low-strain (＜ 6.67 %, n = 21) and compared the patient’s characteristics, blood test data, echocardiography and CMR parameters. There were no significant differences between two groups in these parameters but in the extent of LA-LGE (54 % vs 80 %, p = 0.008). The PALS correlated with the extent of LA-LGE (ρ= 0.50, p = 0.001). In multivariate analysis including LVEF, E/e’ and BNP, LA-LGE was an independent determinant of PALS. During three-year follow up, the LA strain significantly related to heart failure hospitalization in the ATTR-CA patients (p = 0.036)(Figure). 

Conclusions

 In CA patients, CMR measured LA longitudinal strain correlates with the LA-LGE. It also provides useful information for poor prognosis of patients with ATTR-CA.

Abstract P177 Figure. Heart failure hospitalization in ATTR-CA

P5593The association of recurrence and bleeding events with mortality after venous thromboembolism: from the COMMAND VTE Registry

Background/Introduction

Venous thromboembolism (VTE), including pulmonary embolism (PE) and deep vein thrombosis (DVT), has a long-term risk for recurrence, which can be prevented by anticoagulation therapy. The duration of anticoagulation therapy after VTE should be based on the balance between risks of recurrent VTE and bleeding. However, there is uncertainty about the impact of these events on subsequent mortality.

Purpose

We sought to evaluate the impact of recurrent VTE events and bleeding events on subsequent mortality in patients with VTE in a large retrospective observational database in Japan.

Methods

We evaluated the association of recurrent VTE and major bleeding with mortality among 3026 patients in the COMMAND VTE Registry. We estimated the risks of recurrent VTE events and major bleeding events for subsequent all-cause death with the multivariable Cox proportional hazard model. We incorporated the recurrent VTE events and major bleeding events during follow-up into the multivariable Cox model as time-updated covariates together with the clinically-relevant 16 risk-adjusting factors. We expressed the adjusted risks of each covariate as hazard ratios (HR) and their 95%confidence intervals (CI). Furthermore, to assess the risks of recurrent PE and recurrent DVT events for subsequent all-cause death respectively, we divided recurrent VTE events into recurrent PE (PE with or without DVT) and recurrent DVT (DVT only), and incorporated these events as well as major bleeding events into the multivariable Cox model as time-updated covariates.

Results

In the current study population, the mean age was 67 years, 61% were women, and mean body weight and body mass index were 57.9 kg and 23.2 kg/m2, respectively. During the median follow-up period of 1,218 days, 763 patients died, 225 patients developed recurrent VTE events, and 274 patients developed major bleeding events. The time-updated multivariable Cox proportional hazard model revealed that both the recurrent VTE events and the major bleeding events were strongly associated with subsequent mortality risk (recurrent VTE events: HR 3.24, 95% CI 2.57–4.08, P<0.001; major bleeding events: HR 3.53, 95% CI 2.88–4.31, P<0.001). Both the recurrent PE events and the recurrent DVT events were associated with subsequent mortality risk with the numerically greater magnitude of effect with the recurrent PE events than with the recurrent DVT events (recurrent PE events: HR 4.42, 95% CI 3.28–5.95, P<0.001; recurrent DVT events: HR 2.42, 95% CI 1.75–3.36, P<0.001).

Conclusions

In the real-world patients with VTE, both recurrent VTE events and major bleeding events were strongly associated with subsequent mortality risk with the comparable effect size. Recurrent PE and recurrent DVT events were also associated with increased risks for mortality, although the magnitude of the effect on mortality was numerically greater with the recurrent PE events than with the recurrent DVT events.

Acknowledgement/Funding

Research Institute for Production Development, Mitsubishi Tanabe Pharma Corporation

P2693Late catch-up phenomenon and late-term target lesion revascularization of two-stenting for coronary bifurcation lesions between first and second generation drug-eluting stents

Background

The second generation drug-eluting stent (G2-DES) has been reported as superior to the first generation drug-eluting stent (G1-DES) in mid-term outcomes. However, the late-term outcomes between G1-DES and G2-DES in two-stenting for coronary bifurcation lesions are not well studied.

Purpose

To evaluate the late catch-up phenomenon and late-term target lesion revascularization (TLR) of two-stenting for coronary bifurcation lesions between G1-DES and G2-DES.

Methods

This study included 1133 lesions in 1089 patients undergoing drug eluting stent implantation with two stenting from 2004 to 2016. These consisted of 496 G1-DES implanted lesions and 637 G2-DES implanted lesions. Late-term follow-up angiography was performed without in-stent restenosis (ISR) and TLR at mid-term follow-up in 582 lesions (242 G1-DES lesions and 340 G2-DES lesions). ISR was defined as more than 50% restenosis. Late catch-up phenomenon was defined as ISR without ISR within 1 year following index stent implantation. Late-term TLR was defined as from 1 to 5 year TLR. Bifurcation lesions were defined as the main branch ranging from the proximal stem to the distal main branch with boundaries defined by 5 mm proximal and distal to the stent-implanted area, and the side branch ranging from the bifurcation carina to the distal side branch with boundaries defined by the carina and 5 mm distal to the stent-implanted area.

Results

The median follow-up duration was 5.1 years (the first and third quarters, 3.2 and 7.1 years). The late-catch up phenomenon rate significantly differed between the G1-DES and G2-DES groups (16.9% vs 8.4%, p=0.001). A significant difference in late catch-up between the same two groups was also observed in bifurcation lesions of the main branch (5.0% vs 0.6%, p=0.001) and side branch (10.3% vs 5.6%, p=0.033), respectively. The 5-year cumulative rates also differed between the two groups in TLR (8.2% vs 3.7% log-rank p=0.001), and late-term TLR (7.0% vs 3.6% log-rank p=0.001).

Conclusion

Two-stenting using G2-DES, compared with G1-DES, significantly reduced late-term restenosis and TLR. The restenosis rate in bifurcation area may be associated with differences between two groups in late-term outcome.

P5614The association between tissue morphology assessed with optical coherence tomography and mid and late-term results after percutaneous coronary intervention for in-stent restenosis lesions

Background

It was reported that tissue morphology of in-stent restenosis (ISR) lesions assessed with optical coherence tomography (OCT) had an effect on midterm results including ISR and target lesion revascularization (TLR) rates after percutaneous coronary intervention (PCI). However, little was known about the association between tissue morphology assessed with OCT and late-term results.

Methods

We performed PCI treated with paclitaxel coated balloon (PCB) or drug-eluting stent (DES) for 452 ISR lesions (260 lesions with fibrous plaque and 192 lesions with lipid-laden plaque) using OCT between May 2008 and July 2016. Six- to eight-month (midterm) angiographic follow-up was performed on 422 of the 452 ISR lesions (follow-up rate: 93.4%). Furthermore, eighteen- to twenty-month (late-term) angiographic follow-up was performed on 337 of the 361 ISR lesions (follow-up rate: 93.4%) which were free from midterm TLR. We examined the association between tissue morphology, midterm-results and late-term results including ISR and TLR rates. Fibrous plaque was defined as homogeneous, signal-rich regions with low attenuation. Lipid-laden plaque was defined as diffuse border, signal poor regions with high attenuation.

Results

The patients were 353 men and 69 women, and the mean age was 68.8±9.6 years. PCI were performed with PCB in 285 lesions (PCB group) and DES in 137 lesions (DES group). The figure shows the angiographic midterm results of the 422 lesions and late-term results of the 337 lesions with respect to each tissue morphology and each PCI device. There was no difference in ISR and TLR rates of lesions with both fibrous and lipid-laden plaque at midterm between the two groups. ISR and TLR rates of lesions with lipid-laden plaque at late-term were significantly higher in the PCB group than in the DES group, while there was no difference in ISR and TLR rates of lesions with fibrous plaque at late-term between two groups.

Figure 1

Conclusion

Tissue morphology of ISR lesions might have an impact on outcomes after PCI. Morphological assessment of ISR tissue using OCT might suggest favorable types of PCI for ISR lesions.

P3847Deep vein thrombosis in upper extremities: clinical characteristics, management strategies and long-term outcomes from the COMMAND VTE Registry

Background/Introduction

Pulmonary embolism (PE) is caused by blockage of pulmonary arteries by thrombus. The sources of thrombus are thought to be mostly veins in lower extremities, whereas deep vein thrombosis (DVT) in upper extremities rarely occurs spontaneously. Recent studies reported that DVT in upper extremities might have significant complications, and DVT in upper extremities could be increasing. However, there is a paucity of data on patients with DVT in upper extremities, leading to uncertainty in optimal treatment strategies including anticoagulation therapy.

Purpose

We sought to evaluate the clinical characteristics, management strategies, and long-term outcomes of patients with DVT in upper extremities in a large observational database in Japan.

Methods

The COMMAND VTE Registry is a multicenter registry enrolling 3027 consecutive patients with acute symptomatic venous thromboembolism (VTE) objectively confirmed by imaging examination or by autopsy among 29 centers in Japan between January 2010 and August 2014. The current study population consisted of 2498 patients with DVT in upper or lower extremities, after excluding 381 patients with PE only, 144 patients who had thrombus in locations other than upper or lower extremities, and 4 patients with DVT in both upper and lower extremities. The study patients were divided into 2 groups: patients with DVT in upper extremities and patients with DVT in lower extremities. We compared the clinical characteristics, management strategies and long-term outcomes between the 2 groups.

Results

There were 74 patients (3.0%) with upper extremities DVT and 2498 patients (97%) with lower extremities DVT. Patients with upper extremities DVT more often had active cancer at diagnosis (58%) and central venous catheter use (22%). The proportion of concomitant PE at diagnosis was lower in patients with upper extremities DVT than in those with lower extremities DVT (14% and 51%, P<0.001). Discontinuation of anticoagulation therapy was more frequent in patients with upper extremities DVT (63.8% and 29.8% at 1-year, P<0.001). The cumulative 3-year incidence of recurrent VTE was not different between the 2 groups (9.8% and 7.4%, P=0.43) (Figure). After adjusting confounders, the risks of upper extremities DVT relative to lower extremities DVT for recurrent VTE remained insignificant (HR 0.94, 95% CI 0.36–2.01, P=0.89).

Kaplan-Meier event curves for recurrence

Conclusions

The prevalence of patients with DVT in upper extremities was 3.0% in the current large-scale real-world registry. Patients with DVT in upper extremities more often had active cancer at diagnosis and central venous catheter use as a transient risk factor for VTE, and less often had concomitant PE. Patients with DVT in upper extremities had similar long-term risk for recurrent VTE as those with DVT in lower extremities despite shorter duration of anticoagulation.

Acknowledgement/Funding

Research Institute for Production Development, Mitsubishi Tanabe Pharma Corporation

P3846The association between statin prescription, recurrent venous thromboembolism and bleeding events: from the COMMAND VTE Registry

Background

Statin prevents occurrence and recurrence of atherosclerotic events. With regard to venous thromboembolism (VTE), a randomized controlled trial suggested that statin reduced occurrence of VTE, whereas its usefulness as secondary prevention of VTE remains to be elucidated.

Purpose

This study aimed to assess the association between statin prescription, recurrent VTE and bleeding events in patients with VTE.

Methods

The COMMAND VTE Registry is a multicentre registry enrolling consecutive 3027 patients with acute symptomatic VTE among 29 centres in Japan. We divided the cohort into the patients who were prescribed statin (N=437) and those not (N=2590), and compared the two groups. We assessed hazard ratios (HRs) of those with statin relative to those without for long-term clinical outcomes (recurrent symptomatic VTE and International Society of Thrombosis and Hemostasis [ISTH] major bleeding). Because the durations of anticoagulation therapy were widely different between the two groups, we constructed Cox's proportional hazard model incorporating status of anticoagulation during the follow-up period as a time-varying covariate. Also, because the incidences of death were strikingly different between the two groups due to the difference in the prevalence of active cancer, we used Fine-Gray's subdistribution hazard model in the presence of competing risks. We incorporated clinically relevant factors into these two models as covariates (10 factors for recurrent VTE and 11 for major bleeding).

Results

The statin group was significantly older than the non-statin group (statin 71.2±11.8 vs. non-statin 66.5±15.8, P<0.001). The prevalence of active cancer in the statin group was less than one-half of that in the non-statin group (12% vs. 25%, P<0.001), and the cumulative 3-year incidence of death was significantly lower in the statin group than in the non-statin group (12.8% vs. 26.1%, log-rank P<0.001). The table shows the adjusted HRs of the statin group relative to the non-statin group. The HRs of the statin group relative to non-statin group for recurrent VTE were significantly low, but those for major bleeding were insignificant.

Adjusted hazard ratios Outcome measures Model 1 P value Model 2 P value Adjusted HR [95% CI] Adjusted HR [95% CI] Recurrent VTE 0.59 [0.36–0.98] 0.042 0.53 [0.32–0.89] 0.02 Major bleeding 0.87 [0.60–1.24] 0.43 0.997 [0.69–1.43] 0.99 Model 1 derived from Cox's model with time-varying covariate of anticoagulation status. Model 2 derived from Fine-Gray's model.

Study flowchart

Conclusions

Prescription of satin was associated with significantly low risks for recurrent VTE, whereas that was not for major bleeding events. Statin could be a potential treatment option for secondary prevention of VTE.

P5623Plaque characteristics, slow flow during percutaneous coronary intervention, and clinical outcomes of irregular protrusion by optical coherence tomography

Introduction

In pathological studies, penetration of the lipid core into the stent strut is associated with neointimal growth and stent thrombosis. Irregular protrusion on optical coherence tomography (OCT) is associated with clinical events and target lesion revascularization. However, there are few reports about the relationship among irregular protrusion, plaque characteristics, and slow flow during percutaneous coronary intervention. We investigated clinical and procedure characteristics, plaque characteristics, slow flow after stent implantation, and clinical outcomes with irregular protrusion by using OCT.

Methods

Eighty-four lesions in 76 patients undergoing OCT before percutaneous coronary intervention were evaluated. Irregular protrusion was defined as protrusion of material with an irregular surface into the lumen between stent struts with a maximum height of ≥100 μm. Major adverse clinical outcomes were defined as death, acute myocardial infarction, acute coronary syndrome, or target lesion revascularization.

Results

Lesions with irregular protrusion were found in 56% (47/84). Compared with lesions without irregular protrusion, those with irregular protrusion had significantly higher low-density lipoprotein cholesterol (LDL-C) levels (108±31 mg/dL vs. 95±25 mg/dL, P=0.044); a tendency toward decreased use of statins (44% [19/43] vs. 67% [22/33], P=0.065); significantly larger reference vessel diameter (3.12±0.53 mm vs. 2.74±0.63 mm, P=0.004); significantly larger stent diameter (3.23±0.43 mm vs. 3.00±0.49 mm, P=0.025); a tendency toward longer total stent length (29.3±14.2 mm vs. 23.7±11.4 mm, P=0.056); significantly larger maximum balloon diameter (3.56±0.55 mm vs. 3.22±0.63 mm, P=0.010); significantly higher incidence of slow flow after stent implantation (38% [18/47] vs. 11% [4/37], P=0.006); significantly higher ΔTIMI flow from pre-stenting to post-stenting (0.4±0.6 vs. 0.1±0.3, P=0.009); significantly higher incidence of lipid-rich plaque (70% [33/47] vs. 35% [13/37], P=0.002); thin-cap fibroatheromas (TCFAs: 49% [23/47] vs. 5% [2/37], P<0.001); plaque rupture (40% [19/47] vs. 16% [6/37], P=0.018); macrophage accumulation (51% [24/47] vs. 24% [9/37], P=0.015); internal running vasa vasorum (51% [24/47] vs. 11% [4/37], P<0.001); thrombus (32% [15/47] vs. 3% [1/37], P<0.001); and a tendency higher incidence of one-year adverse clinical outcomes (12% [5/43] vs. 0% [0/33], P=0.075: log rank). The multivariable analysis showed that TCFA was an independent predictor of irregular protrusion (odds ratio 9.00, 95% CI 1.32–61.36, P=0.025).

Conclusions

Irregular protrusion on OCT was associated with high plaque vulnerability, higher LDL-C, less frequent use of statin, larger vessel diameter, longer total stent length, slow flow after stent implantation, and one-year adverse clinical outcomes.

P5592Thrombolysis with tissue plasminogen activator for patients with acute pulmonary embolisms in the real world: from the COMMAND VTE Registry

Background/Introduction

There is still uncertainty about the optimal usage of thrombolysis for acute pulmonary embolisms (PEs), leading to widely varying usage of thrombolysis in the real world. However, these have not been fully evaluated yet.

Purpose

We sought to evaluate the management strategies and clinical outcomes of thrombolysis for acute PEs in the real world.

Methods

The COMMAND VTE Registry is a multicenter registry enrolling 3,027 consecutive patients with acute symptomatic venous thromboembolisms in Japan between January 2010 and August 2014. The present study population consisted of 1,549 patients with PEs who received tissue plasminogen activator (t-PA) thrombolysis (N=180, 12%), or those who did not (N=1,369). The effectiveness outcome was all-cause death. The safety outcome was major bleeding. We used a multivariable logistic regression analysis to estimate the odds ratio (OR) and 95% confidence intervals (CI), to adjust clinically relevant confounders (age, sex, history of major bleeding, active cancer, and anemia). Additionally, we conducted stratified analysis by clinical severity, and we also evaluated clinical outcomes according to dosages of t-PA.

Results

Patients with t-PA thrombolysis were younger, and more frequently had higher body weight, but less frequently had active cancer, history of major bleeding, and anemia. More than half of patients with t-PA thrombolysis were patients with mild PEs, and the proportions of t-PA thrombolysis varied widely across the participating centers. More than half of patients received low-dose of t-PA (<20,000 IU/kg). As for the effectiveness, 9 (5.0%) patients in the t-PA thrombolysis group and 95 (6.9%) patients in the non t-PA thrombolysis group died at 30 days (Crude OR, 0.71; 95% CI 0.35–1.42, P=0.33). As for the safety, 7 (3.9%) patients in the t-PA thrombolysis group and 22 (1.6%) patients in the non t-PA thrombolysis group experienced major bleeding events at 10 days (Crude OR, 2.48; 95% CI 1.04–5.88, P=0.04). T-PA thrombolysis group had a significantly higher risk for 10-day major bleeding (Adjusted OR, 4.01; 95% CI 1.57–10.2, P=0.004), but not a lower risk for 30-day mortality (Adjusted OR, 1.10; 95% CI 0.53–2.28, P=0.79), although the risk for 30-day mortality was significantly lower in those with severe PEs (Adjusted OR, 0.36; 95% CI 0.15–0.88, P=0.02). After adjusting confounders, the 10-day major bleeding risk of the low-dose of t-PA group relative to the standard-dose of t-PA group tended to be lower (Adjusted OR, 0.07; 95% CI 0.004–1.05, P=0.05).

Conclusions

In the present real-world registry, relatively large number of patients received t-PA thrombolysis with wide variation across the participating centers. T-PA thrombolysis was significantly associated with a higher risk for major bleeding, but not a lower risk for mortality, although there appeared to be a benefit of t-PA thrombolysis in decreasing the risk for mortality in patients with severe PEs.

Acknowledgement/Funding

Research Institute for Production Development, Mitsubishi Tanabe Pharma Corporation

P6461The long-term clinical comparisons of symptomatic patients of pulmonary embolism with and those without deep vein thrombosis: from the COMMAND VTE Registry

Background

Venous thromboembolism (VTE), including pulmonary embolism (PE) and deep vein thrombosis (DVT), has significant morbidity and mortality. Acute PE, in particular, is fatal if we miss it, and symptomatic patients of PE sometimes have concomitant DVT.

Purpose

This study compared the risk of mortality in symptomatic patients of PE with and those without DVT in the long term.

Methods

The COMMAND VTE Registry is a multicenter registry enrolling consecutive 3027 patients with acute symptomatic VTE objectively confirmed by imaging examination or by autopsy among 29 centers in Japan between January 2010 and August 2014. Patients with both PE and DVT (N=1334) were regarded as PE patients, and the current study population consisted of 1715 PE patients and 1312 DVT patients.

Results

There were 1203 symptomatic patients of PE, including 381 without and 822 with DVT. In our cohort, the mean age was 67.9±14.9 years, 63% was female, 44% had hypertension, 12% diabetes mellitus, 5% history of VTE. There were 20% of active cancer. Baseline characteristics were well matched except for dyslipidemia (18% vs. 23%, p=0.021) and atrial fibrillation (8% vs. 5%, p=0.045). Patients without DVT had a more severe clinical presentation compared to those with DVT, including hypoxemia, shock and arrest. Moreover, Initial parenteral anticoagulation therapy in the acute phase was administered less frequently in patients without DVT (89% vs. 96%, P=0.0001). Two groups received thrombolysis (20% vs. 26%, P=0.18) and mechanical supports (Ventilator 14% vs. 5%, p<0.001, PCPS 5% vs. 3%, p<0.001, respectively). During follow-up, 93 (8%) patients experienced recurrent VTE events and 98 (8%) major bleeding events, and 323 (27%) patients died. The most frequent cause of death was cancer (11%). There were a significant differences in the cumulative incidences of all-cause death between the groups (32% vs. 24%, P=0.006), whereas there was significant difference in VTE-related death (13% vs. 4%, p<0.001). Estimated freedom rates from death for patients of PE without and those with DVT were as follows: 88% vs 99% at 10-day, 86% vs 95% at 1-month, 75% vs 83% at 1-year, and 64% vs 71% at 5-year, respectively.

Landmark analysis

Conclusions

In symptomatic patients of PE, there was a difference in mortality between groups, but no difference in recurrent VTE. Patients without DVT had a more severe clinical presentation compared to those with DVT, and many VTE-related deaths in the acute phase. The one-month mortality rate differed statistically between groups, but there was no significant difference in long-term survival beyond one month. Most of deaths were due to underlying diseases, mainly cancer, and less commonly due to VTE in the long term.

Acknowledgement/Funding

Research Institute for Production Development, Mitsubishi Tanabe Pharma Corporation

P2770Clinical characteristics and outcomes of venous thromboembolism according to patients with versus without atrial fibrillation: from the COMMAND VTE Registry

Background/Introduction

Oral anticoagulants are widely used for the treatment and second prevention of venous thromboembolism (VTE) and stroke prevention in atrial fibrillation (AF). VTE and AF are common diseases and these sometimes might coexist. However, there are few reports about the relationship between VTE and AF.

Purpose

We sought to evaluate the clinical characteristics and outcomes in VTE patients with AF.

Methods

The COMMAND VTE Registry is a multicenter registry enrolling consecutive 3027 patients with acute symptomatic VTE objectively confirmed by imaging examination or by autopsy among 29 centers in Japan between January 2010 and August 2014. The current study population consisted of 129 patients with AF (AF group) and 2898 patients without AF (non-AF group). We compared the clinical characteristics, management strategies and long-term outcomes between the 2 groups.

Results

The AF group was older (mean age: 75.3 vs. 66.8 years, P<0.001), and more often had co-morbidities such as hypertension (54.3% vs. 37.7%, P<0.001), diabetes mellitus (20.2% vs. 12.4%, P=0.01), chronic kidney disease (28.7% vs. 18.5%, P=0.004), heart failure (28.7% vs. 18.5%, P=0.004), history of stroke (20.2% vs. 8.4%, P<0.001), and history of major bleeding (12.4% vs. 7.4%, P=0.04) compared with the non-AF group, whereas there were no significant differences in the proportions of active cancer at diagnosis (18.6% vs. 23.2%, P=0.23) and pulmonary embolism at presentation (64.3% vs. 56.3%, P=0.07). The proportion of anticoagulation therapy beyond acute phase was not significantly different (94% vs. 93%, P=0.60), while the cumulative discontinuation rates of anticoagulation therapy was significantly lower in the AF group (26.9% vs. 43.4% at 3 years, Log-rank P=0.03). The cumulative 5-year incidences of recurrent VTE and major bleeding were not significantly different (Recurrent VTE: 7.6% vs. 10.6%, Log-rank P=0.89; Major bleeding: 18.6% vs. 11.8%, Log-rank P=0.07). After adjusting for potential confounders, the risks of the AF group relative to the non-AF group for recurrent VTE and major bleeding remained insignificant (HR 1.19, 95% CI 0.54–2.28, P=0.64; HR 1.28, 95% CI 0.73–2.06, P=0.37). The cumulative 5-year incidence of all-cause death was significantly higher in the AF-group (49.1% vs. 28.6%, Log-rank P<0.001). After adjusting for potential confounders, the risks of the AF group relative to the non-AF group for all-cause death remained significant (HR 1.63, 95% CI 1.23–2.15, P<0.001). The proportion of deaths due to cancer was lower in the AF group (30% vs. 55%, P<0.001), while the proportion of cardiac deaths was higher in the AF group (16.1% vs. 4.0%, P<0.001).

The outcomes of VTE patients with AF

Conclusions

The risks for recurrent VTE between patients with AF and those without AF were not significantly different, although patients with AF received longer-term anticoagulation therapy, whereas the risks for major bleeding tended to be higher in patients with AF.

Acknowledgement/Funding

Research Institute for Production Development, Mitsubishi Tanabe Pharma Corporation

Score-Based and Nutrient-Derived Dietary Patterns Are Associated with Depressive Symptoms in Community-Dwelling Older Japanese: A Cross-Sectional Study

OBJECTIVES

This study evaluated associations of score-based and nutrient-derived dietary patterns with depressive symptoms in community-dwelling older Japanese.

DESIGN

Cross-sectional study.

SETTING

Community-based.

PARTICIPANTS

982 community-dwelling adults aged 65 years or older.

MEASUREMENTS

Score-based pattern was assessed by using dietary variety score (DVS), which covers 10 food group items in Japanese meals. Nutrient-derived dietary patterns were identified by using reduced rank regression (RRR), with folate, vitamin C, magnesium, calcium, iron, and zinc intakes as response variables. Depressive symptoms were assessed with the Geriatric Depression Scale. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for these dietary patterns in multivariate logistic regression analyses with potential confounders. The lowest consumption category was used as the reference group.

RESULTS

The prevalence of depressive symptoms was 13.5%. Higher DVS was associated with fewer depressive symptoms (OR=0.52, 95% CI=0.27-1.03 for the highest vs the lowest DVS; P for trend=0.031). The first RRR dietary pattern score was characterized by high intakes of fish, soybean products, potatoes, most vegetables, mushrooms, seaweeds, fruits, and green tea and a low intake of rice and was inversely associated with the prevalence of depressive symptoms (OR=0.53, 95% CI=0.30-0.92; P for trend=0.030).

CONCLUSION

Greater dietary variety and a dietary pattern characterized by high intakes of fish, soybean products, potatoes, most vegetables, mushrooms, seaweeds, fruit, and green tea and a low intake of rice were consistently associated with lower prevalence of depressive symptoms in community-dwelling older Japanese. Therefore, both patterns identified the components of dietary habits essential to depression prevention.

Localization and transient emission properties in InGaN/GaN quantum wells of different polarities within core-shell nanorods

Transient photoluminescence (PL) characteristics and localization phenomena in InGaN/GaN core-shell nanorods (NRs) were investigated from 6 K up to 285 K. The NRs exhibit three well-defined PL bands in the near-UV, blue, and green range ascribed to the emission of quantum well (QW) areas situated at the (1.00) sidewalls, (10.1) top facets, and (00.1) tip, respectively. At low temperature, time-resolved PL shows a fast decay time of about 0.5 ns for the semi- and non-polar QWs, while the polar QWs exhibit at least a twice-longer time. Rapid delocalization of carriers above 50 K indicates shallow potential fluctuations in the QWs. At room temperature, the characteristic fast PL decay time of the three QW bands stabilizes around 300 ps. The slow decaying PL components have different characteristic decay times that are explained by additional localization at basal stacking faults (BSFs), taking into account the quantum confined Stark effect. In addition, narrow excitonic luminescence lines are observed in the BSF-enriched polar QWs, providing direct evidence of the impact of the BSF/QW crossings on the optical properties of the NRs. A PL rise time of about 100 ps does not show any deviation between bands. These findings are suggestive of similar transport mechanisms in temperature equilibrium without inter-facet transport between different QWs. We believe that predictable transient characteristics can play a key role in creating uniform NR ensembles for device applications.

Albumin, Hemoglobin, and the Trajectory of Cognitive Function in Community-Dwelling Older Japanese: A 13-Year Longitudinal Study

BACKGROUND

Cognitive function can substantially decline over a long period, and understanding the trajectory of cognitive function is important. However, little is known about the linkage between nutritional biomarkers and long-term cognitive change.

OBJECTIVES

We analyzed 13-year longitudinal data for older Japanese to examine the associations of serum albumin and hemoglobin levels with the trajectory of cognitive function.

DESIGN

Longitudinal study.

SETTING

Community-based.

PARTICIPANTS

A total of 1,744 community-dwelling adults aged 65 years or older who participated in annual health examinations in Kusatsu town, Gunma Prefecture, Japan, from 2002-2014.

MEASUREMENTS

Cognitive function was assessed annually by the Mini-Mental State Examination (MMSE). Albumin and hemoglobin levels at baseline (the year when a respondent first participated in the health examination) were divided into quartiles. Hierarchical linear modeling was used to analyze intrapersonal and interpersonal differences in cognitive function.

RESULTS

Participants' MMSE scores decreased at an accelerated rate over the 13-year period. Participants with the lowest baseline albumin level (below the first quartile line) showed a greater accelerated decline in MMSE scores over time, compared with those with the highest level (above the third quartile line). Moreover, MMSE scores in participants with a lower hemoglobin level and lower MMSE score at baseline tended to decline faster over time at an accelerated rate.

CONCLUSIONS

These findings yield new insights about the complex and diverse roles of these nutritional biomarkers on the trajectory of cognitive function in old age.

Echocardiographic surrogates of right atrial pressure in pulmonary hypertension

Right atrial pressure (RAP), a representative parameter of right heart failure, is very important for prognostic evaluation and risk assessment in pulmonary hypertension. However, its measurement requires invasive cardiac catheterization. In this study, we determined the most accurate echocardiographic surrogate of catheterization-based RAP. In 23 patients with pulmonary hypertension, a total of 66 cardiac catheterization procedures were performed along with 2-dimensional echocardiography. We evaluated tricuspid E/A, E', A' and E/E', and estimated RAP by the respirophasic variation of the inferior vena cava diameter (eRAP-IVCd) as possible surrogates of catheterization-based RAP. In simple linear regression analysis, E/A (R = 0.452, P = 0.0001) and eRAP-IVCd (R = 0.505, P < 0.0001) were positively correlated with catheterization-based RAP, whereas A' (R = - 0.512, P < 0.0001) was negatively correlated with RAP. In multiple regression analysis, A' was the most significant independent predictor of catheterization-based RAP (R = - 0.375, P = 0.0007). In 16 patients who had multiple measurements, there were a total of 43 measurements before and after medication changes. The absolute change in catheterization-based RAP was negatively correlated with the percent change in A'. Receiver operating characteristic curve analysis indicated that the optimal cut-off value of A' to predict a catheterization-based RAP > 10 mmHg was 11.3 cm/s (area under the curve = 0.782, sensitivity = 0.70, specificity = 0.78). In 20 measurements of 20 patients with left heart failure, catheterization-based RAP was not correlated with any of 5 echocardiographic parameters. However, it was closely correlated with catheterization-based pulmonary capillary wedge pressure. The echocardiographic parameter, A', was the best surrogate of catheterization-based RAP in patients with pulmonary hypertension.

Association of serum concentrations of irisin and the adipokines adiponectin and leptin with epicardial fat in cardiovascular surgery patients

Epicardial fat located adjacent to the heart and coronary arteries is associated with increased cardiovascular risk. Irisin is a myokine produced by skeletal muscle after physical exercise, and originally described as a molecule able to promote the browning of white adipose tissue and energy expenditure. In order to decrease cardiovascular risk, it has been proposed as a promising therapeutic target in obesity and type 2 diabetes. We investigated the relationships between serum concentrations of irisin and the adipokines adiponectin and leptin and body fat including epicardial fat in patients undergoing cardiovascular surgery. We obtained serum samples from 93 patients undergoing cardiovascular surgery (age 69.6 (SD 12.8) years, BMI 24.1 ± 4.8 kg/m²). Computed tomography (CT) and echocardiographic data were obtained from the routine preoperative examination. Subcutaneous fat area (SFA, cm²) and visceral fat area (VFA, cm²) near the umbilicus were automatically measured using the standard fat attenuation range. Epicardial fat area (EFA, cm²) was measured at the position where the heart became a long axis image with respect to the apex of the heart in the coronal section image. Total body fat mass, body fat percentage, and skeletal muscle volume (SMV) were estimated using bioelectrical impedance analysis (BIA). Serum irisin concentration was measured by enzyme-linked immunosorbent assay, and compared with adiponectin and leptin concentrations. The data were also compared with the clinical biochemical data. EFA was strongly correlated with BMI (P = 0.0001), non-HDL-C (P = 0.029), TG (P = 0.004), body fat mass (P = 0.0001), and body fat percentage (P = 0.0001). Serum leptin concentration showed a significant positive correlation with BMI (P = 0.0001) and TG (P = 0.001). Adiponectin, but not irisin, showed a significant negative correlation with BMI (P = 0.006) and TG (P = 0.001). Serum leptin level had a significant positive correlation with EFA, VFA, and SFA. In contrast, the serum adiponectin level was significantly negatively correlated with EFA, VFA, and SFA. The serum irisin level was also negatively correlated with EFA (r = -0.249, P = 0.015), and SFA (r = -0.223, P = 0.039), and tended to correlate with VFA (r = -0.198, P = 0.067). The serum level of adiponectin was negatively correlated with that of leptin (r = -0.296, P = 0.012), but there were no significant correlations between irisin and either adiponectin or leptin. Multivariate linear regression demonstrated that EFA showed a positive association with serum leptin level (β = 0.438, P = 0.0001) and a negative correlation with serum irisin level (β = -0.204, P = 0.038) and serum adiponectin level (β = -0.260, P = 0.015) after adjusting for age, sex, and BMI. The present study provided the first evidence of associations of the serum irisin and adipokines (adiponectin and leptin) concentrations with epicardial fat in cardiovascular surgery patients. Irisin may play a role in preventing excess adiposity including epicardial fat, and consequently cardiovascular risk in patients.

Cardiac paraganglioma with a novel germline mutation of succinate dehydrogenase gene D

A 58-year-old woman with a past medical history of a carotid body tumor, resected 4 months prior to presentation, was admitted to our hospital for treatment of a cardiac tumor that was identified on post-operative echocardiography and chest computed tomography. The cardiac tumor was surgically removed and identified pathologically as a paraganglioma, similarly to the carotid body tumor. Genetic analysis of both tumors identified a non-synonymous mutation in the succinate dehydrogenase (SDH) gene D, Exon4, c.320T>C, p.Leu107Pro showing co-segregation with paternal transmission and maternal imprinting among family members. This novel mutation appears to be the cause of familial paraganglioma in this patient.

Radiation-Induced Coronary Artery Disease Manifested at Very Late Phase

We report the case of a 51-year-old female, in whom coronary artery disease such as occlusion of septal perforators was manifested, on the occasion of hospitalization with congestive heart failure. The patient had a history of radiation therapy for a mediastinal tumor 19 years previously. As she had no conventional coronary risk factors, the cause of the coronary artery disease is thought to have been related to the radiation therapy. As survival rates of cancer patients improve as a consequence of therapeutic advances, we should be aware of the possibility of coronary artery disease as a very late complication of radiation therapy, even in patients who have no coronary risk factors.