Sodium-glucose cotransporter 2 inhibitors versus dipeptidyl peptidase 4 inhibitors on new-onset overall cancer in Type 2 diabetes mellitus: A population-based study

BACKGROUND

Cancer is currently the second leading cause of death globally. There is much uncertainty regarding the comparative risks of new-onset overall cancer and pre-specified cancer for Type 2 diabetes mellitus (T2DM) patients on sodium-glucose cotransporter 2 inhibitors (SGLT2I) versus DPP4I.

METHODS

This population-based cohort study patients included patients who were diagnosed with T2DM and administered either SGLT2 or DPP4 inhibitors between 1 January 2015 and 31 December 2020 in public hospitals of Hong Kong.

RESULTS

This study included 60,112 T2DM patients (mean baseline age: 62.1 ± 12.4 years, male: 56.36%), of which 18,167 patients were SGLT2I users and 41,945 patients were dipeptidyl peptidase 4 inhibitor (DPP4I) users. Multivariable Cox regression found that SGLT2I use was associated with lower risks of all-cause mortality (HR: 0.92; 95% CI: 0.84-0.99; p= 0.04), cancer-related mortality (HR: 0.58; 95% CI: 0.42-0.80; p ≤ 0.001) and new diagnoses of any cancer (HR: 0.70; 95% CI: 0.59-0.84; p ≤ 0.001). SGLT2I use was associated with a lower risk of new-onset breast cancer (HR: 0.51; 95% CI: 0.32-0.80; p ≤ 0.001), but not of other malignancies. Subgroup analysis on the type of SGLT2I, dapagliflozin (HR: 0.78; 95% CI: 0.64-0.95; p = 0.01) and ertugliflozin (HR: 0.65; 95% CI: 0.43-0.98; p = 0.04) use was associated with lower risks of new cancer diagnosis. Dapagliflozin use was also linked to lower risks of breast cancer (HR: 0.48; 95% CI: 0.27-0.83; p = 0.001).

CONCLUSION

Sodium-glucose cotransporter 2 inhibitor use was associated with lower risks of all-cause mortality, cancer-related mortality and new-onset overall cancer compared to DPP4I use after propensity score matching and multivariable adjustment.

P-wave durations from automated electrocardiogram analysis to predict atrial fibrillation and mortality in heart failure

BACKGROUND

P-wave indices have been used to predict incident atrial fibrillation (AF), stroke, and mortality. However, such indices derived from automated ECG measurements have not been explored for their predictive values in heart failure (HF). We investigated whether automated P-wave indices can predict adverse outcomes in HF.

METHODS

This study included consecutive Chinese patients admitted to a single tertiary centre, presenting with HF but without prior AF, and with at least one baseline ECG, between 1 January 2010 and 31 December 2016, with last follow-up of 31 December 2019.

RESULTS

A total of 2718 patients were included [median age: 77.4, interquartile range (IQR): (66.9-84.3) years; 47.9 males]. After a median follow-up of 4.8 years (IQR: 1.9-9.0 years), 1150 patients developed AF (8.8/year), 339 developed stroke (2.6/year), 563 developed cardiovascular mortality (4.3/year), and 1972 had all-cause mortality (15.1/year). Compared with 101-120 ms as a reference, maximum P-wave durations predicted new-onset AF at ≤90 ms [HR: 1.17(1.11, 1.50), P < 0.01], 131-140 ms [HR: 1.29(1.09, 1.54), P < 0.001], and ≥141 ms [HR: 1.52(1.32, 1.75), P < 0.001]. Similarly, they predicted cardiovascular mortality at ≤90 ms [HR: 1.50(1.08, 2.06), P < 0.001] or ≥141 ms [HR: 1.18(1.15, 1.45), P < 0.001], and all-cause mortality at ≤90 ms [HR: 1.26(1.04, 1.51), P < 0.001], 131-140 ms [HR: 1.15(1.01, 1.32), P < 0.01], and ≥141 ms [HR: 1.31(1.18, 1.46), P < 0.001]. These remained significant after adjusting for significant demographics, past co-morbidities, P-wave dispersion, and maximum P-wave amplitude.

CONCLUSIONS

Extreme values of maximum P-wave durations (≤90 ms and ≥141 ms) were significant predictors of new-onset AF, cardiovascular mortality, and all-cause mortality.

Risk stratification of sudden cardiac death in asymptomatic female Brugada syndrome patients: A literature review

BACKGROUND AND OBJECTIVES

Risk stratification in Brugada syndrome remains a difficult problem. Given the male predominance of this disease and their elevated risks of arrhythmic events, affected females have received less attention. It is widely known that symptomatic patients are at increased risk of sudden cardiac death (SCD) than asymptomatic patients, while this might be true in the male population; recent studies have shown that this association might not be significant in females. Over the past few decades, numerous markers involving clinical symptoms, electrocardiographic (ECG) indices, and genetic tests have been explored, with several risk-scoring models developed so far. The objective of this study is to review the current evidence of clinical and ECG markers as well as risk scores on asymptomatic females with Brugada syndrome.

FINDINGS

Gender differences in ECG markers, the yield of genetic findings, and the applicability of risk scores are highlighted.

CONCLUSIONS

Various clinical, electrocardiographic, and genetic risk factors are available for assessing SCD risk amongst asymptomatic female BrS patients. However, due to the significant gender discrepancy in BrS, the SCD risk amongst females is often underestimated, and there is a lack of research on female-specific risk factors and multiparametric risk scores. Therefore, multinational studies pooling female BrS patients are needed for the development of a gender-specific risk stratification approach amongst asymptomatic BrS patients.

Risk of diabetes mellitus among users of immune checkpoint inhibitors: A population-based cohort study

BACKGROUND

Immune checkpoint inhibitors (ICIs) are increasingly established cancer therapeutics, but they are associated with new-onset diabetes mellitus (DM). Such risks have not been adequately quantified, and between-class and -sex differences remain unexplored.

METHODS

This was a prospective cohort study of cancer patients receiving any ICI in Hong Kong between 2013 and 2021. Patients with known DM were excluded. Due to few patients using other ICIs, only programmed cell death 1 inhibitors (PD-1i) and programmed death ligand 1 inhibitors (PD-L1i) were compared, alongside between-sex comparison. When comparing PD-1i against PD-L1i, patients with the use of other ICIs or both PD-1i and PD-L1 were further excluded. Inverse probability treatment weighting (IPTW) was used to minimize between-group covariate imbalances.

RESULTS

Altogether, 3375 patients were analyzed (65.2% males, median age 62.2 [interquartile range 53.8-69.5] years old). Over a median follow-up of 1.0 [0.4-2.4] years, new-onset DM occurred in 457 patients (13.5%), with a 3-year risk of 14.5% [95% confidence interval 13.3%, 15.8%]. IPTW achieve acceptable covariate balance between sexes, and between PD-1i (N = 622) and PD-L1i (N = 2426) users. Males had significantly higher risk of new-onset DM (hazard ratio 1.35 [1.09, 1.67], p = 0.006), while PD-1i and PD-L1i users did not have significantly different risks (hazard ratio vs PD-L1i 0.81 [0.59, 1.11], p = 0.182). These were consistent in those with at least 1 year of follow-up, and on competing risk regression.

CONCLUSION

Users of ICI may have a substantial risk of new-onset DM, which may be higher in males but did not differ between PD-1i and PD-L1i.

Cardiovascular outcomes and hospitalizations in Asian patients receiving immune checkpoint inhibitors: a population-based study

Immune checkpoint inhibitors (ICI) have known associations with cardiotoxicity. However, a representative quantification of the adverse cardiovascular events and cardiovascular attendances amongst Asian users of ICI has been lacking. This retrospective cohort study identified all ICI users in Hong Kong, China, between 2013-2021. All patients were followed up until the end of 2021 for the primary outcome of major adverse cardiovascular event (MACE; a composite of cardiovascular mortality, myocardial infarction, heart failure, and stroke). Patients with prior diagnosis of any component of MACE were excluded from all MACE analyses. In total, 4324 patients were analysed (2905 (67.2%) males; median age 63.5 years old (interquartile range 55.4-70.7 years old); median follow-up 1.0 year (interquartile range 0.4-2.3 years)), of whom 153 were excluded from MACE analyses due to prior events. MACE occurred in 116 (2.8%) with an incidence rate (IR) of 1.7 [95% confidence interval: 1.4, 2.0] events per 100 patient-years; IR was higher within the first year of follow-up (2.9 [2.3, 3.5] events per 100 patient-years). Cardiovascular hospitalization(s) occurred in 188 (4.4%) with 254 episodes (0.5% of all episodes) and 1555 days of hospitalization (1.3% of all hospitalized days), for whom the IR of cardiovascular hospitalization was 5.6 [4.6, 6.9] episodes per 100 person-years with 52.9 [39.8, 70.3] days' stay per 100 person-years. Amongst Asian users of ICI, MACE was uncommon, and a small proportion of hospitalizations was cardiovascular in nature. Most MACE and cardiovascular hospitalizations occurred during the first year after initiating ICI.

Clinical Characteristics, Genetic Findings and Arrhythmic Outcomes of Patients with Catecholaminergic Polymorphic Ventricular Tachycardia from China: A Systematic Review

INTRODUCTION

Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a rare inherited cardiac ion channelopathy. The present study aims to examine the clinical characteristics, genetic basis, and arrhythmic outcomes of CPVT patients from China to elucidate the difference between CPVT patients in Asia and Western countries.

METHODS

PubMed and Embase were systematically searched for case reports or series reporting on CPVT patients from China until 19 February 2022 using the keyword: "Catecholaminergic Polymorphic Ventricular Tachycardia" or "CPVT", with the location limited to: "China" or "Hong Kong" or "Macau" in Embase, with no language or publication-type restriction. Articles that did not state a definite diagnosis of CPVT and articles with duplicate cases found in larger cohorts were excluded. All the included publications in this review were critically appraised based on the Joanna Briggs Institute Critical Appraisal Checklist. Clinical characteristics, genetic findings, and the primary outcome of spontaneous ventricular tachycardia/ventricular fibrillation (VT/VF) were analyzed.

RESULTS

A total of 58 unique cases from 15 studies (median presentation age: 8 (5.0-11.8) years old) were included. All patients, except one, presented at or before 19 years of age. There were 56 patients (96.6%) who were initially symptomatic. Premature ventricular complexes (PVCs) were present in 44 out of 51 patients (86.3%) and VT in 52 out of 58 patients (89.7%). Genetic tests were performed on 54 patients (93.1%) with a yield of 87%. RyR2, CASQ2, TERCL, and SCN10A mutations were found in 35 (71.4%), 12 (24.5%), 1 (0.02%) patient, and 1 patient (0.02%), respectively. There were 54 patients who were treated with beta-blockers, 8 received flecainide, 5 received amiodarone, 2 received verapamil and 2 received propafenone. Sympathectomy (n = 10), implantable cardioverter-defibrillator implantation (n = 8) and ablation (n = 1) were performed. On follow-up, 13 patients developed VT/VF.

CONCLUSION

This was the first systematic review of CPVT patients from China. Most patients had symptoms on initial presentation, with syncope as the presenting complaint. RyR2 mutation accounts for more than half of the CPVT cases, followed by CASQ2, TERCL and SCN10A mutations.

Clinical characteristics, risk factors and outcomes of cancer patients with COVID-19: A population-based study

INTRODUCTION

Cancer patients may be susceptible to poorer outcomes in COVID-19 infection owing to the immunosuppressant effect of chemotherapy/radiotherapy and cancer growth, along with the potential for nosocomial transmission due to frequent hospital admissions.

METHODS

This was a population-based retrospective cohort study of COVID-19 patients who presented to Hong Kong public hospitals between 1 January 2020 and 8 December 2020. The primary outcome was a composite endpoint of requirement for intubation, ICU admission and 30-day mortality.

RESULTS

The following study consisted of 6089 COVID-19 patients (median age 45.9 [27.8.1-62.7] years; 50% male), of which 142 were cancer subjects. COVID-19 cancer patients were older at baseline and tended to present with a higher frequency of comorbidities, including diabetes mellitus, hypertension, chronic obstructive pulmonary disease, ischemic heart disease, ventricular tachycardia/fibrillation and gastrointestinal bleeding (p < 0.05). These subjects also likewise tended to present with higher serum levels of inflammatory markers, including D-dimer, lactate dehydrogenase, high sensitivity troponin-I and C-reactive protein. Multivariate Cox regression showed that any type of cancer presented with an almost four-fold increased risk of the primary outcome (HR: 3.77; 95% CI: 1.63-8.72; p < 0.002) after adjusting for significant demographics, Charlson comorbidity index, number of comorbidities, past comorbidities and medication history. This association remained significant when assessing those with colorectal (HR: 5.07; 95% CI: 1.50-17.17; p < 0.009) and gastrointestinal malignancies (HR: 3.79; 95% CI: 1.12-12.88; p < 0.03), but not with lung, genitourinary, or breast malignancies, relative to their respective cancer-free COVID-19 counterparts.

CONCLUSIONS

COVID-19 cancer patients are associated with a significantly higher risk of intubation, ICU admission and/or mortality.

Heart rate variability and meditation: a meta-analysis

Funding Acknowledgements

Type of funding sources: None.

Background

Meditation can induce changes in autonomic balance, which can benefit cardiovascular health. The present meta-analysis evaluated changes in heart rate variability (HRV) in meditators.

Methods

PubMed and Embase were searched for primary prospective studies using the search terms ‘heart rate variability’ and ‘meditation’ until January 18th, 2019. The statistical significance of the difference between subgroups is evaluated by the standardized mean difference (SMD), 95% confidence interval (CI), and P-value. I2 value was used to assess the statistical heterogeneity between the included studies.

Results

Twenty-one studies involving 538 meditators (experienced= 209, beginners= 329) and 334 controls (mean age= 40.61, 35% male) were included. Regarding time-domain indices, no statistically significant differences were observed when assessing HRV between i) meditators versus controls (SMD= -0.17; 95% CI: [-0.50, 0.17]; p= 0.30; I2= 0%), ii) pre- versus post-meditation (SMD= -0.41; 95% CI: [-1.10, 0.28]; p= 0.25; I2= 80%) or iii) at baseline versus during meditation (SMD= -0.40; 95% CI: [-0.94, 0.14]; p= 0.14; I2= 72%). Pertaining to frequency-domain indices, analysis of low frequency (LF), normalized low frequency (LFnu) and high frequency (HF) between i) meditators versus controls, ii) at baseline versus post-meditation and iii) at baseline versus during meditation yet again did not show any variations. Seven studies assessed normalized high frequency (HFnu) at baseline versus during meditation collectively demonstrated a significantly higher HFnu during meditation in beginners with notable heterogeneity (SMD= 1.29; 95% CI: [0.09, 2.49]; p= 0.04; I2= 95). Moreover, LF/HF was evaluated by seven studies at baseline versus during meditation. Both meta-analysis (SMD= 0.76; 95% CI: [-0.17, 1.69]; p= 0.11; I2= 94%) as well as subset analysis of experienced meditators (SMD= -0.46; 95% CI: [-0.88, -0.03]; p= 0.03; I2= 0%) revealed a significantly lower LF/HF at baseline.

Conclusions

Short-term changes in HRV indices were observed during meditation, but there is limited evidence for significant long-term effects.

Adverse Cardiovascular Complications following prescription of programmed cell death 1 (PD-1) and programmed cell death ligand 1 (PD-L1) inhibitors: a propensity-score matched Cohort Study with competing risk analysis

Background

Programmed death-1 (PD-1) and programmed death- ligand 1 (PD-L1) inhibitors, such as pembrolizumab, nivolumab and atezolizumab, are major classes of immune checkpoint inhibitors that are increasingly used for cancer treatment. However, their use is associated with adverse cardiovascular events. We examined the incidence of new-onset cardiac complications in patients receiving PD-1 or PD-L1 inhibitors.

Methods

Patients receiving PD-1 or PD-L1 inhibitors since their launch up to 31st December 2019 at publicly funded hospitals of Hong Kong, China, without pre-existing cardiac complications were included. The primary outcome was a composite of incident heart failure, acute myocardial infarction, atrial fibrillation, or atrial flutter with the last follow-up date of 31st December 2020. Propensity score matching between PD-L1 inhibitor use and PD-1 inhibitor use with a 1:2 ratio for patient demographics, past comorbidities and non-PD-1/PD-L1 medications was performed with nearest neighbour search strategy (0.1 caliper). Univariable and multivariable Cox regression analysis models were conducted. Competing risks models and multiple propensity matching approaches were considered for sensitivity analysis.

Results

A total of 1959 patients were included. Over a median follow-up of 247 days (interquartile range [IQR]: 72-506), 320 (incidence rate [IR]: 16.31%) patients met the primary outcome after PD-1/PD-L1 treatment: 244 (IR: 12.57%) with heart failure, 38 (IR: 1.93%) with acute myocardial infarction, 54 (IR: 2.75%) with atrial fibrillation, 6 (IR: 0.31%) with atrial flutter. Compared with PD-1 inhibitor treatment, PD-L1 inhibitor treatment was significantly associated with lower risks of the composite outcome both before (hazard ratio [HR]: 0.32, 95% CI: [0.18-0.59], P value=0.0002) and after matching (HR: 0.34, 95% CI: [0.18-0.65], P value=0.001), and lower all-cause mortality risks before matching (HR: 0.77, 95% CI: [0.64-0.93], P value=0.0078) and after matching (HR: 0.80, 95% CI: [0.65-1.00], P value=0.0463). Patients who developed cardiac complications had shorter average readmission intervals and a higher number of hospitalizations after treatment with PD-1/PD-L1 inhibitors in both the unmatched and matched cohorts (P value<0.0001). Multivariable Cox regression models, competing risk analysis with cause-specific and subdistribution hazard models, and multiple propensity approaches confirmed these observations.

Conclusions

Compared with PD-1 treatment, PD-L1 treatment was significantly associated with lower risk of new onset cardiac complications and all-cause mortality both before and after propensity score matching.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40959-021-00128-5.

Programmed Cell Death 1 (PD-1) and Programmed Cell Death Ligand 1 (PD-L1) inhibitors and adverse cardiovascular events: a population-based study

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

Cardiovascular Analytics Group

Background

Programmed death-1 (PD-1) and programmed death-ligand 1 (PD-L1) inhibitors are major classes of immune checkpoint inhibitors that are increasingly used for cancer treatment. However, they are associated with adverse cardiovascular events.

Purpose

To evaluate the cardiotoxicity of PD-1 and PD-L1 inhibitors, the present study aims to examine the incidence of new-onset cardiac complications in patients receiving PD-1 or PD-L1 inhibitors.

Methods

Patients receiving PD-1 or PD-L1 inhibitors since their launch up to December 31st, 2019 without pre-existing cardiac complications were included. Patient data were obtained using a territory-wide electronic health record database. The primary outcome was a composite of incident heart failure (HF), acute myocardial infarction (AMI), atrial fibrillation (AF) or atrial flutter followed up to August 31st, 2020. Propensity score matching between PD-L1 and PD-1 inhibitor use with a 1:1 ratio for patient demographics and comorbidities was performed.

Results

A total of 1925 patients were included. Over a median follow-up of 136 days (interquartile range [IQR]: 42-279), 318 (16.51%) patients met the primary outcome after PD-1/PD-L1 treatment: 242 (incidence rate [IR]: 12.57%) with HF, 38 (IR: 1.97%) with AMI, 53 (IR: 2.75%) with AF, 6 (IR: 0.31%) with atrial flutter. Compared with PD-1 inhibitor treatment, PD-L1 inhibitor treatment was significantly associated with a lower risk of composite outcome after matching (HR: 0.78, 95% CI: [0.62-0.99], P value = 0.0417). Patients who developed cardiovascular complications had shorter average readmission intervals and more hospitalization episodes after treatment with PD-1/PD-L1 inhibitors both before and after matching (P value &lt; 0.0001).

Conclusions

Compared with PD-1 inhibitor users, PD-L1 inhibitor users had a significantly lower risk of new-onset composite cardiovascular complications. Abstract Figure. Kaplan-Meier survival curve

Predictions of arrhythmic, heart failure and mortality outcomes in pericarditis using automatic electrocardiogram analysis: a retrospective cohort study

Funding Acknowledgements

Type of funding sources: None.

Introduction

 Pericarditis is a relatively rare disease with a global burden. Despite its strong association with adverse cardiovascular outcomes, identification of patients at risk of future heart failure or arrhythmic events is difficult. In the following study, automated electrocardiogram (ECG) variables were used to predict new onset ventricular tachycardia/fibrillation (VT/VF), atrial fibrillation (AF) and heart failure with reduced ejection fraction (HF) in an Asian cohort of pericarditis patients.

Purpose

Assessing the use of automated ECG parameters to predict prognosis in pericarditis patients.

Methods

Consecutive patients admitted to a single tertiary center in China, for a diagnosis of pericarditis between 1st January 2005 and 31st December 2019, were included. Patients with existing AF or HF were excluded. The follow-up period was until the 31st December 2020, or death. Cox regression was applied to identify significant predictors of the incident VT/VF, AF or HFrEF.

Results

A total of 874 patients were included. The cohort was 57% male and had a median age of 59 (IQR: 50-70) years old. During follow-up, 57 patients (6.5%), 156 (17.8%) and 168 (19.2%) suffered from VT/VF, AF and HF, respectively. Cox regression identified baseline VT/VF, terminal angle of the QRS vector in the transverse plane, mean QRS duration and mean QTc intervals as significant predictors of incident VT/VF events, with only the foremost maintaining significance in multivariate analysis. In contrast, baseline age, prior diagnoses of hypertension, malignancy and atrial flutter, initial angle and magnitude of the QRS vector in the transverse plane, P-wave and QRS axis in the frontal plane, ST segment axis in the frontal and horizontal planes, mean PT interval, mean PR segment duration and QTc intervals were all univariate predictors of incident AF, albeit only baseline age and initial angle of the QRS vector in the transverse plane retained significance after multivariate adjustment. As it pertains to new-onset HFrEF, several clinical and electrocardiographic parameters demonstrated an association in univariate analysis, with history of hypertension, history of sudden cardiac death (SCD), initial QRS angle in transverse plane, initial 40ms QRS complex axis, ST-segment axis in the horizontal plane, T-wave frontal axis and atrial rate all showcasing significant relationships in multivariate analysis.

Conclusions

AF and HFrEF are relatively common complications, whilst VT/VF occurs less frequently in the context of pericarditis. Different clinical and ECG predictors of these outcomes were identified. Future studies are still needed to evaluate their use for risk stratification in the clinical setting.

A territory-wide study of arrhythmogenic right ventricular cardiomyopathy patients from Hong Kong

Background

Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) is a hereditary disease characterised by fibrofatty infiltration of the right ventricular myocardium that predisposes affected patients to malignant ventricular arrhythmias, dual-chamber cardiac failure and sudden cardiac death (SCD).

Methods

This was a territory-wide retrospective cohort study of patients diagnosed with ARVC/D between 1997 and 2019. The primary outcome was incident ventricular tachycardia/ventricular fibrillation (VT/VF). The secondary outcomes were new-onset heart failure with reduced ejection fraction (HFrEF) and all-cause mortality.

Results

This study consisted of 115 ARVC/D patients (median age: 60 [44.1–70.2] years; 58% male). Of these, 51 and 24 patients developed incident VT/VF and new-onset HFrEF, respectively. Five patients underwent cardiac transplantation, and 14 died during follow-up. Multivariate Cox regression identified prolonged QRS duration as a predictor of VT/VF (P&lt;0.05). Female gender, prolonged QTc duration, the presence of epsilon waves and T-wave inversion (TWI) in any lead except aVR/V1 predicted new-onset HFrEF (P&lt;0.05). Female gender, prolonged QTc duration and the presence of epsilon waves, in addition to the parameters of older age at diagnosis of ARVC/D, prolonged QRS duration and worsening ejection fraction predicted all-cause mortality (p&lt;0.05). Clinical scores were also developed to predict new-onset HFrEF (Table 1a-c) and all-cause mortality (Table 2a-c). This was followed by the application of a non-parametric machine learning survival analysis models for outcome prediction. These machine learning algorithms better capture nonlinear and interactive patterns within survival data compared to traditionally used Cox regression models, which assume the existence of a hazard function between survival data and censored outcomes. The present study introduced weighted random survival forests models for the prediction of incident VT/VF, HFrEF and all-cause mortality. Findings indicate that these machine learning wRSF models performed the best in the prediction of all three aforementioned outcomes compared to other analytical methods.

Conclusion

Clinical and electrocardiographic parameters are important for assessing prognosis in ARVC/D patients. Machine learning algorithms appear to be the most optimal tools for event prediction, and as such should potentially be used to aid risk stratification and decision-making in the clinical setting.

Funding Acknowledgement

Type of funding sources: None.

Brugada syndrome in Hong Kong: long term outcome prediction through machine learning

Funding Acknowledgements

Type of funding sources: None.

Introduction

 Brugada syndrome (BrS) is an ion channelopathy that predisposes affected patients to spontaneous ventricular tachycardia/fibrillation (VT/VF) and sudden cardiac death (SCD). Despite its greater prevalence in Asia and epidemiological heterogeneity in disease manifestation, the majority of the conducted cohort studies available in current literature are based in Western countries. 

Purpose

The aim of this study is to examine the clinical and electrocardiographic predictive factors of spontaneous VT/VF for Asian BrS patients.

Methods

This was a territory-wide retrospective cohort study of patients diagnosed with BrS between 1997 and 2019. The primary outcome was spontaneous VT/VF detected either during hospital admission or by implantable-cardioverter defibrillator (ICD) data. Cox regression was used to identify significant clinical and electrocardiographic risk predictors. Non-linear interactions between variables (latent patterns) were extracted using non-negative matrix factorization (NMF) and used as inputs into the random survival forest (RSF) model.

Results

This study included 516 consecutive BrS patients (mean age of initial presentation= 50 ± 16 years, male= 92%) with a median follow-up of 86 (interquartile range: 45-118) months. The cohort was divided into subgroups based on initial disease manifestation: asymptomatic (n = 314), syncope (n = 159) or VT/VF (n = 41). Annualized event rates per person-year were 1.70%, 0.05% and 0.01% for the VT/VF, syncope and asymptomatic subgroups, respectively. Multivariate Cox regression analysis revealed initial presentation of VT/VF (HR = 24.0, 95% CI = [1.21, 479] , P= 0.037) and standard deviation of P-wave duration (HR = 1.07, 95% CI = [1.00, 1.13], P = 0.044) were significant predictors. The NMF-RSF showed the best predictive performance compared to RSF and Cox regression models (precision: 0.87 v.s. 0.83 v.s. 0.76, recall: 0.89 v.s. 0.85 v.s. 0.73, F1-score: 0.88 v.s. 0.84 v.s. 0.74).

Conclusions

This is one of the largest territory-wide cohort studies on BrS and the largest study in Asia published to date, with an extensive median follow-up duration of 7 years. Clinical history, electrocardiographic markers and investigation results provide important information for risk stratification. Machine learning techniques using NMF and RSF significantly improves overall risk stratification performance.

Prostaglandin E receptor subtype 4 protects against diabetic cardiomyopathy by modulating cardiac fatty acid metabolism via FOXO1/CD36 signalling

BACKGROUND

Cardiac fatty acid metabolism is essential for maintaining normal cardiac function at baseline and in response to various disease stress, like diabetes. EP4 is widely expressed in cardiomyocytes and has been demonstrated to play a role in cardio function. However, its function in regulating cardiac fatty acid metabolism is remained unknown.

METHODS

Mice were fed with standard chow or high-fat for eight weeks. The effects of EP4 deficiency on cardiac function, cardiomyocytes hypertrophy and myocardial fibrosis were studied. The possible regulatory mechanisms were further investigated.

RESULTS

EP4^-/- mice exhibited concentric hypertrophy and myocardial fibrosis with cardiac energy deprivation due to reduction of fatty acid uptake and inhibition of ATP generation mediated by FOXO1/CD36 signalling. Moreover, pharmacologically activated EP4 alleviated impaired fatty acid transport and insufficient ATP generation in cardiomyocytes.

CONCLUSION

EP4 tightly coordinates the rates of cardiac fatty acid uptake and ATP generation via FOXO1/CD36 signalling axis. Our study provides evidences for the link between EP4 and cardiac fatty acid transport and further pointed out that EP4 could be a potential target for modulating fatty acid metabolism and curbing cardiac tissue-specific impairment of function following diabetes.

Territory-wide cohort study of Brugada syndrome in Hong Kong: predictors of long-term outcomes using random survival forests and non-negative matrix factorisation

OBJECTIVES

Brugada syndrome (BrS) is an ion channelopathy that predisposes affected patients to spontaneous ventricular tachycardia/fibrillation (VT/VF) and sudden cardiac death. The aim of this study is to examine the predictive factors of spontaneous VT/VF.

METHODS

This was a territory-wide retrospective cohort study of patients diagnosed with BrS between 1997 and 2019. The primary outcome was spontaneous VT/VF. Cox regression was used to identify significant risk predictors. Non-linear interactions between variables (latent patterns) were extracted using non-negative matrix factorisation (NMF) and used as inputs into the random survival forest (RSF) model.

RESULTS

This study included 516 consecutive BrS patients (mean age of initial presentation=50±16 years, male=92%) with a median follow-up of 86 (IQR: 45-118) months. The cohort was divided into subgroups based on initial disease manifestation: asymptomatic (n=314), syncope (n=159) or VT/VF (n=41). Annualised event rates per person-year were 1.70%, 0.05% and 0.01% for the VT/VF, syncope and asymptomatic subgroups, respectively. Multivariate Cox regression analysis revealed initial presentation of VT/VF (HR=24.0, 95% CI=1.21 to 479, p=0.037) and SD of P-wave duration (HR=1.07, 95% CI=1.00 to 1.13, p=0.044) were significant predictors. The NMF-RSF showed the best predictive performance compared with RSF and Cox regression models (precision: 0.87 vs 0.83 vs. 0.76, recall: 0.89 vs. 0.85 vs 0.73, F1-score: 0.88 vs 0.84 vs 0.74).

CONCLUSIONS

Clinical history, electrocardiographic markers and investigation results provide important information for risk stratification. Machine learning techniques using NMF and RSF significantly improves overall risk stratification performance.

Acacetin exerts antioxidant potential against atherosclerosis through Nrf2 pathway in apoE-/- Mice

Oxidative stress has a considerable influence on endothelial cell dysfunction and atherosclerosis. Acacetin, an anti-inflammatory and antiarrhythmic, is frequently used in the treatment of myocarditis, albeit its role in managing atherosclerosis is currently unclear. Thus, we evaluated the regulatory effects of acacetin in maintaining endothelial cell function and further investigated whether the flavonoid could attenuate atherosclerosis in apolipoprotein E deficiency (apoE^-/- ) mice. Different concentrations of acacetin were tested on EA.hy926 cells, either induced or non-induced by human oxidized low-density lipoprotein (oxLDL), to clarify its influence on cell viability, cellular reactive oxidative stress (ROS) level, apoptotic ratios and other regulatory effects. In vivo, apoE^-/- mice were fed either a Western diet or a chow diet. Acacetin pro-drug (15 mg/kg) was injected subcutaneously two times a day for 12 weeks. The effects of acacetin on the atherosclerotic process, plasma inflammatory factors and lipid metabolism were also investigated. Acacetin significantly increased EA.hy926 cell viability by reducing the ratios of apoptotic and necrotic cells at 3 μmol/L. Moreover, 3 μmol/L acacetin clearly decreased ROS levels and enhanced reductase protein expression through MsrA and Nrf2 pathway through phosphorylation of Nrf2 and degradation of Keap1. In vivo, acacetin treatment remarkably attenuated atherosclerosis by increasing reductase levels in circulation and aortic roots, decreasing plasma inflammatory factor levels as well as accelerating lipid metabolism in Western diet-fed apoE^-/- mice. Our findings demonstrate the anti-oxidative and anti-atherosclerotic effects of acacetin, in turn suggesting its potential therapeutic value in atherosclerotic-related cardiovascular diseases (CVD).

Multi-parametric system for risk stratification in mitral regurgitation: A multi-task Gaussian prediction approach

BACKGROUND

We hypothesized that a multi-parametric approach incorporating medical comorbidity information, electrocardiographic P-wave indices, echocardiographic assessment, neutrophil-to-lymphocyte ratio (NLR) and prognostic nutritional index (PNI) calculated from laboratory data can improve risk stratification in mitral regurgitation (MR).

METHODS

Patients diagnosed with mitral regurgitation between 1 March 2005 and 30 October 2018 from a single centre were retrospectively analysed. Outcomes analysed were incident atrial fibrillation (AF), transient ischemic attack (TIA)/stroke and mortality.

RESULTS

This study cohort included 706 patients, of whom 171 had normal inter-atrial conduction, 257 had inter-atrial block (IAB) and 266 had AF at baseline. Logistic regression analysis showed that age, hypertension and mean P-wave duration (PWD) were significant predictors of new-onset AF. Low left ventricular ejection fraction (LVEF), abnormal P-wave terminal force in V1 (PTFV1) predicted TIA/stroke. Age, smoking, hypertension, diabetes mellitus, hypercholesterolaemia, ischemic heart disease, secondary mitral regurgitation, urea, creatinine, NLR, PNI, left atrial diameter (LAD), left ventricular end-diastolic dimension, LVEF, pulmonary arterial systolic pressure, IAB, baseline AF and heart failure predicted all-cause mortality. A multi-task Gaussian process learning model demonstrated significant improvement in risk stratification compared to logistic regression and a decision tree method.

CONCLUSIONS

A multi-parametric approach incorporating multi-modality clinical data improves risk stratification in mitral regurgitation. Multi-task machine learning can significantly improve overall risk stratification performance.

Multi-modality machine learning approach for risk stratification in heart failure with left ventricular ejection fraction ≤ 45

AIMS

Heart failure (HF) involves complex remodelling leading to electrical and mechanical dysfunction. We hypothesized that machine learning approaches incorporating data obtained from different investigative modalities including atrial and ventricular measurements from electrocardiography and echocardiography, blood inflammatory marker [neutrophil-to-lymphocyte ratio (NLR)], and prognostic nutritional index (PNI) will improve risk stratification for adverse outcomes in HF compared to logistic regression.

METHODS AND RESULTS

Consecutive Chinese patients referred to our centre for transthoracic echocardiography and subsequently diagnosed with HF, between 1 January 2010 and 31 December 2016, were included in this study. Two machine learning techniques, multilayer perceptron and multi-task learning, were compared with logistic regression for their ability to predict incident atrial fibrillation (AF), transient ischaemic attack (TIA)/stroke, and all-cause mortality. This study included 312 HF patients [mean age: 64 (55-73) years, 75% male]. There were 76 cases of new-onset AF, 62 cases of incident TIA/stroke, and 117 deaths during follow-up. Univariate analysis revealed that age, left atrial reservoir strain (LARS) and contractile strain (LACS) were significant predictors of new-onset AF. Age and smoking predicted incident stroke. Age, hypertension, type 2 diabetes mellitus, chronic kidney disease, mitral or aortic regurgitation, P-wave terminal force in V1, the presence of partial inter-atrial block, left atrial diameter, ejection fraction, global longitudinal strain, serum creatinine and albumin, high NLR, low PNI, and LARS and LACS predicted all-cause mortality. Machine learning techniques achieved better prediction performance than logistic regression.

CONCLUSIONS

Multi-modality assessment is important for risk stratification in HF. A machine learning approach provides additional value for improving outcome prediction.

Takotsubo cardiomyopathy with low ventricular ejection fraction and apical ballooning predicts mortality: a systematic review and meta-analysis

Takotsubo cardiomyopathy (TCM) is characterized by temporary wall motion abnormality of the left ventricle. There is much debate upon the prognostic parameters. We conducted a systematic review and meta-analysis to investigate whether LVEF and the presence of apical ballooning predict long-term mortality in TCM. PubMed and Embase were searched through to October 30, 2017 without language restrictions, followed by an additional search through to February 2, 2020. Our search identified 18 studies that met the inclusion criteria, with a total of 5168 patients. Reduced LVEF as a categorical variable was associated with more than threefold increase in mortality risk in TCM patients (HR 3.10; 95% CI 1.78-5.42; P < 0.0001; I² = 57%). Further subset analyses with the exclusion of studies consisting of patients with coronary artery disease revealed another significant relationship between LVEF and mortality (HR 3.13; 95% CI 1.392-7.031; P < 0.006; I² = 58%). LVEF as a continuous variable was also found to be associated with increased mortality risk. However, this relationship only retained significance when computing odds ratios instead of hazard ratios (OR 0.95; 95% CI 0.93-0.98; P < 0.001; I² = 0%). Finally, the existence of apical ballooning failed to demonstrate any link with an increased risk of mortality (HR 1.26; 95% CI 0.97-1.64; P = 0.09; I² = 34%). LVEF and apical ballooning are both potential prognostic markers for mortality.

Does Minimizing Ventricular Pacing Reduce the Incidence of Atrial Fibrillation? A Systematic Review and Meta-analysis of Randomized Controlled Trials

Background: Right ventricular pacing disrupts atrioventricular synchrony and increases the risk of atrial fibrillation (AF). However, whether algorithms for minimizing ventricular pacing reduce the incidence of AF remains controversial. Therefore, we conducted a systematic review and meta-analysis to compare the incidence of AF between minimizing ventricular pacing and conventional pacing protocols in patients with pacemakers implanted.Methods: The PubMed, Embase, and Cochrane Library databases were searched up to August 1, 2017, for randomized controlled trials that reported the incidence of AF in patients with and without the use of algorithms for minimizing ventricular pacing.Results: Eleven studies comprising 5705 participants (61% males, mean age 71 years [standard deviation 11 years]) were finally included in the analysis. The mean follow-up duration was 24 months. Use of algorithms for minimizing ventricular pacing significantly reduced the incidence of AF, with an odds ratio of 0.74 (95% confidence interval 0.55‐1.00; P<0.05). There was moderate heterogeneity among studies (I2=63%).Conclusions: The incidence of AF was reduced by 26% with use of algorithms for minimizing ventricular pacing. The incorporation of such algorithms in routine clinical practice should in theory lead to a decrease in AF-related morbidity and mortality.

Effects of ticagrelor pretreatment on electrophysiological properties of stellate ganglion neurons following myocardial infarction

Higher sympathetic activity predisposes to malignant ventricular arrhythmias in the context of myocardial infarction (MI). This is, in part, mediated by the electrical activity of the stellate ganglion (SG). The aim of this study is to examine the effects of ticagrelor pretreatment on the electrophysiological properties of SG neurons following MI in rabbits. MI was induced by isoproterenol (ISO) of 150 mg kg^-1 d^-1 (twice at an interval of 24 hours). Ticagrelor pretreatment was administered at low- (10 mg kg^-1 d^-1) or high-dose (20 mg kg^-1 d^-1). Protein and RNA expression were determined by immunohistochemical analysis and real-time PCR, respectively. The activity of sodium channel current (I_Na), delayed rectifier potassium current (I_KDR), M-type potassium current (I_KM) as well as action potentials (APs) from SG neurons were measured by whole-cell patch-clamp. Intracellular calcium concentrations were measured by confocal microscopy. Compared with the control group, the MI group exhibited a greater amplitude of I_Na, I_KDR and I_KM, significantly altered activation and inactivation characteristics of I_Na, no significant alterations in protein or mRNA expression of sodium and M-type potassium channels, along with higher AP amplitude and frequency and intracellular calcium concentrations. Most of these abnormalities were prevented by pretreatment with low- or high-dose ticagrelor. Our data suggest that ticagrelor exerts cardioprotective effects, potentially through modulating the activity of different ion channels in SG neurons.

In-Hospital Prognostic Value of Electrocardiographic Parameters Other Than ST-Segment Changes in Acute Myocardial Infarction: Literature Review and Future Perspectives

Electrocardiography (ECG) remains an irreplaceable tool in the management of the patients with myocardial infarction, with evaluation of the QRS and ST segment being the present major focus. Several ECG parameters have already been proposed to have prognostic value with regard to both in-hospital and long-term follow-up of patients. In this review, we discuss various ECG parameters other than ST segment changes, particularly with regard to their in-hospital prognostic importance. Our review not only evaluates the prognostic segments and parts of ECG, but also highlights the need for an integrative approach in big data to re-assess the parameters reported to predict in-hospital prognosis. The evolving importance of artificial intelligence in evaluation of ECG, particularly with regard to predicting prognosis, and the potential integration with other patient characteristics to predict prognosis, are discussed.

P-Wave Area Predicts New Onset Atrial Fibrillation in Mitral Stenosis: A Machine Learning Approach

Introduction: Mitral stenosis is associated with an atrial cardiomyopathic process, leading to abnormal atrial electrophysiology, manifesting as prolonged P-wave duration (PWD), larger P-wave area, increased P-wave dispersion (PWD_max—PWD_min), and/or higher P-wave terminal force on lead V1 (PTFV1) on the electrocardiogram.

Methods: This was a single-center retrospective study of Chinese patients, diagnosed with mitral stenosis in sinus rhythm at baseline, between November 2009 and October 2016. Automated ECG measurements from raw data were determined. The primary outcome was incident atrial fibrillation (AF).

Results: A total 59 mitral stenosis patients were included (age 59 [54–65] years, 13 (22%) males). New onset AF was observed in 27 patients. Age (odds ratio [OR]: 1.08 [1.01–1.16], P = 0.017), systolic blood pressure (OR: 1.03 [1.00–1.07]; P = 0.046), mean P-wave area in V3 (odds ratio: 3.97 [1.32–11.96], P = 0.014) were significant predictors of incident AF. On multivariate analysis, age (OR: 1.08 [1.00–1.16], P = 0.037) and P-wave area in V3 (OR: 3.64 [1.10–12.00], P = 0.034) remained significant predictors of AF. Receiver-operating characteristic (ROC) analysis showed that the optimum cut-off for P-wave area in V3 was 1.45 Ashman units (area under the curve: 0.65) for classification of new onset AF. A decision tree learning model with individual and non-linear interaction variables with age achieved the best performance for outcome prediction (accuracy = 0.84, precision = 0.84, recall = 0.83, F-measure = 0.84).

Conclusion: Atrial electrophysiological alterations in mitral stenosis can detected on the electrocardiogram. Age, systolic blood pressure, and P-wave area in V3 predicted new onset AF. A decision tree learning model significantly improved outcome prediction.

Association of NPAC score with survival after acute myocardial infarction

BACKGROUND AND AIMS

Risk stratification in acute myocardial infarction (AMI) is important for guiding clinical management. Current risk scores are mostly derived from clinical trials with stringent patient selection. We aimed to establish and evaluate a composite scoring system to improve short-term mortality classification after index episodes of AMI, independent of electrocardiography (ECG) pattern, in a large real-world cohort.

METHODS

Using electronic health records, patients admitted to our regional teaching hospital (derivation cohort, n = 1747) and an independent tertiary care center (validation cohort, n = 1276), with index acute myocardial infarction between January 2013 and December 2017, as confirmed by principal diagnosis and laboratory findings, were identified retrospectively.

RESULTS

Univariate logistic regression was used as the primary model to identify potential contributors to mortality. Stepwise forward likelihood ratio logistic regression revealed that neutrophil-to-lymphocyte ratio, peripheral vascular disease, age, and serum creatinine (NPAC) were significant for 90-day mortality (Hosmer- Lemeshow test, p = 0.21). Each component of the NPAC score was weighted by beta-coefficients in multivariate analysis. The C-statistic of the NPAC score was 0.75, which was higher than the conventional Charlson's score (C-statistic = 0.63). Judicious application of a deep learning model to our dataset improved the accuracy of classification with a C-statistic of 0.81.

CONCLUSIONS

The NPAC score comprises four items from routine laboratory parameters to basic clinical information and can facilitate early identification of cases at risk of short-term mortality following index myocardial infarction. Deep learning model can serve as a gatekeeper to facilitate clinical decision-making.

Management of acute type A intramural hematoma: upfront surgery or individualized approach? A retrospective analysis and meta-analysis

Background

Management of acute type A intramural hematoma (IMH) is a controversial topic. In our study, we aim to analyze the survival outcomes in local patients with acute type A IMH and a meta-analysis on survival in type A IMH treated medically versus surgically was performed.

Methods

From 2014 to 2019, 65 patients with acute type A IMH were selected for analysis. Primary outcome of interest was 1 year all cause survival. The rate of aortic-related events in the medical group was evaluated. PubMed and Embase were searched for meta-analysis.

Results

The mean age of our cohort was 61.7±9.7 years. Of the 65 patients, 40% had emergency operation. Overall 1-year survival was 96.9%. The 1-year survival was 94.9% for the medical group. 46.2% of the medical group required aortic intervention at a mean duration of 191±168 days. Maximal aortic diameter (MAD) ≥45 mm was predictive of aortic-related events in the medical group (OR: 7.0; 95% CI, 1.7-29.4; P=0.008). For the meta-analysis, 21 studies were identified, and 900 patients were included. Emergent surgery was associated with improved survival in type A IMH (OR: 0.76; 95% CI, 0.29-1.97, P=0.58; I²=27%).

Conclusions

The 1-year survival after type A IMH was promising, regardless of approach. The conservative-first approach was found to be safe & feasible, and upfront surgery remained the management of choice in general. Patients with MAD ≥45 mm was associated with subsequent aortic intervention in the medical-first group.

Diagnostic and prognostic value of serum C-reactive protein in heart failure with preserved ejection fraction: a systematic review and meta-analysis

Heart failure (HF) is a major epidemic with rising morbidity and mortality rates that encumber global healthcare systems. While some studies have demonstrated the value of CRP in predicting (i) the development of HFpEF and (ii) long-term clinical outcomes in HFpEF patients, others have shown no such correlation. As a result, we conducted the following systematic review and meta-analysis to assess both the diagnostic and prognostic role of CRP in HFpEF. PubMed and Embase were searched for studies that assess the relationship between CRP and HFpEF using the following search terms: (((C-reactive protein) AND ((preserved ejection fraction) OR (diastolic heart failure))). The search period was from the start of database to August 6, 2019, with no language restrictions. A total of 312 and 233 studies were obtained from PubMed and Embase respectively, from which 19 studies were included. Our meta-analysis demonstrated the value of a high CRP in predicting the development of not only new onset HFpEF (HR: 1.08; 95% CI: 1.00-1.16; P = 0.04; I² = 22%), but also an increased risk of cardiovascular mortality when used as a categorical (HR: 2.52; 95% CI: 1.61-3.96; P < 0.0001; I² = 19%) or a continuous variable (HR: 1.24; 95% CI: 1.04-1.47; P = 0.01; I² = 28%), as well as all-cause mortality when used as a categorical (HR: 1.78; 95% CI: 1.53-2.06; P < 0.00001; I² = 0%) or a continuous variable: (HR: 1.06; 95% CI: 1.02-1.06; P = 0.003; I² = 61%) in HFpEF patients. CRP can be used as a biomarker to predict the development of HFpEF and long-term clinical outcomes in HFpEF patients, in turn justifying its use as a simple, accessible parameter to guide clinical management in this patient population. However, more prospective studies are still required to not only explore the utility and dynamicity of CRP in HFpEF but also to determine whether risk stratification algorithms incorporating CRP actually provide a material benefit in improving patient prognosis.

P5014The NPAC score for predicting survival after incident acute myocardial infarction

Background

Risk stratification in acute myocardial infarction (AMI) is important for guiding clinical management. Current risk scores are mostly derived from clinical trials with stringent patient selection. We aimed to establish and evaluate a composite scoring system to predict short-term mortality after index episodes of AMI, independent of electrocardiography (ECG) pattern, in a large real-world cohort.

Methods

Using electronic health records, patients admitted to our regional teaching hospital (derivation cohort, n=2127) and an independent tertiary care center (validation cohort, n=1276) with index acute myocardial infarction between January 2013 and December 2017 as confirmed by principal diagnosis and laboratory findings, were identified retrospectively.

Results

Univariate logistic regression was used as the primary model to identify potential contributors to mortality. Stepwise forward likelihood ratio logistic regression revealed that neutrophil-to-lymphocyte ratio, peripheral vascular disease, age, and serum creatinine (NPAC) were significant predictors for 90-day mortality (Hosmer-Lemeshow test, P=0.21). Each component of the NPAC score was weighted by beta-coefficients in multivariate analysis. The C-statistic of the NPAC score was 0.75, which was higher than the conventional Charlson's score (C-statistic=0.63). Application of a deep learning model to our dataset improved the accuracy of classification with a C-statistic of 0.81.

Multivariate binary logistic regression Variable β Adjusted Odds ratio (95% CI) P-value Points Age ≥65 years 1.304 3.68 (2.63–5.17) <0.001 2 Peripheral vascular disease 1.109 3.03 (1.52–6.04) 0.002 2 NLRt ≥9.51 1.100 2.73 (2.12–3.51) <0.001 1 Creatinine≥109 μmol/L 1.003 3.00 (2.35–3.85) <0.001 2

NPAC deep learning model

Conclusions

The NPAC score comprised of four items from routine laboratory parameters and basic clinical information and can facilitate early identification of cases at risk of short-term mortality following index myocardial infarction. Deep learning model can serve as a gate-keeper to provide more accurate prediction to facilitate clinical decision making.

Fibroblast growth factor 21 in cardio-metabolic disorders: a systematic review and meta-analysis

BACKGROUND

Fibroblast growth factor 21 is a signalling protein involved in cell differentiation, morphogenesis, proliferation and metabolism. Recent studies have associated increased levels of FGF21 in the development of cardiovascular diseases, whereas others have reported no significant associations. Therefore, this systematic review and meta-analysis evaluated the value in predicting the risk of cardio-metabolic disorders and mortality.

METHODS

PubMed and EMBASE were searched until 5th September 2017 for studies that evaluated the roles of FGF21 levels in cardio-metabolic disorders.

RESULTS

A total of 183 and 301 entries were retrieved; 24 studies met the inclusion criteria. Four studies were identified by an additional search. Therefore, 28 studies were included in the final meta-analysis. High FGF21 levels significantly predicted the incidence of coronary artery disease (hazard ratio [HR]: 1.29; 95% confidence interval [CI]: 1.06-1.55; P < 0. 01; I² = 48%) and the risk of metabolic syndrome (HR: 1.70, 95% CI: 1.35-2.15; P < 0.0001 I² = 24%). In diabetes mellitus, FGF21 predicted disease incidence or progression (HR: 1.35, 95% CI: 1.06-1.72, P < 0.05, I² = 69%) and worsening renal failure (HR: 1.06, 95% CI: 1.03-1.09, P < 0.0001, I² = 47%). FGF21 also predicted all-cause mortality (HR: 3.00, 95% CI: 1.23-7.33; P < 0.05; I² = 51%), and cardiovascular mortality (HR: 2.33, 95% CI: 1.08-4.99, P < 0.05, I² = 75%).

CONCLUSION

FGF21 significantly predicts the incidence of coronary artery disease, the risks of metabolic syndrome, diabetes mellitus and renal progression in diabetes. It also predicted all-cause and cardiovascular mortality.

Atrial Fibrillation Recurrence and Peri-Procedural Complication Rates in nMARQ vs. Conventional Ablation Techniques: A Systematic Review and Meta-Analysis

Background and Objectives: Atrial fibrillation is a common abnormal cardiac rhythm caused by disorganized electrical impulses. AF which is refractory to antiarrhythmic management is often treated with catheter ablation. Recently a novel ablation system (nMARQ) was introduced for PV isolation. However, there has not been a systematic review of its efficacy or safety compared to traditional ablation techniques. Therefore, we conducted this meta-analysis on the nMARQ ablation system.

Methods: PubMed and EMBASE were searched up until 1st of September 2017 for articles on nMARQ. A total of 136 studies were found, and after screening, 12 studies were included in this meta-analysis.

Results: Our meta-analysis shows that the use of nMARQ was associated with higher odds of AF non-recurrence (n = 1123, odds ratio = 6.79, 95% confidence interval 4.01–11.50; P < 0.05; I² took a value of 83%). Moreover, the recurrence rate of AF using nMARQ was not significantly different from that of traditional ablation procedures (n = 158 vs. 196; OR = 0.97, 95% confidence interval:0.59–1.61). No significant difference in complication rates was observed between these groups (RR: 0.86; 95% CI: 0.37–1.99; P > 0.05). There were four reported mortalities in the nMARQ group compared to none in the conventional ablation group (relative risk: 1.58; 95% CI: 0.09–29.24; P > 0.05).

Conclusions: AF recurrence rates are comparable between nMARQ and conventional ablation techniques. Although general complication rates are similar for both groups, the higher mortality with nMARQ suggests that conventional techniques should be used for resistant AF until improved safety profiles of nMARQ can be demonstrated.

Association between preoperative serum insulin levels and lymph node metastasis in endometrial cancer-a prospective cohort study

Endometrial cancer is a common gynecological malignancy in developed countries. Insulin has been identified as a risk factor for endometrial cancer. However, whether insulin levels are related to the risk of lymph node metastasis (LNM) in endometrial cancer is unknown. We conducted a prospective cohort study in a regional hospital to examine the relationships between insulin levels and risk of LNM in premenopausal and postmenopausal women. A total of 668 patients were recruited. Of these, 206 were premenopausal (mean age: 42.01 ± 10.17) and 462 were postmenopausal (mean age: 62.13 ± 13.85). The incidence of LNM in both premenopausal and postmenopausal groups was comparable at 7% and 8%, respectively. In premenopausal women, multivariate logistic regression demonstrated that insulin levels (OR: 2.11, 95% CI: 1.48–2.85, P < 0.05) were significant predictors of LNM risk. In the same group, insulin levels remained significant predictors of LNM risk (cut‐off: 10.48 μIU/mL) when adjusted for body mass index (BMI) (OR: 3.51, 95% CI: 1.42–5.98; P < 0.05) or for waist‐to‐hip ratio (WHR) (OR: 1.87, 95% CI: 1.08–2.66; P < 0.05). Similarly, in postmenopausal women, multivariate logistic regression showed that insulin levels (OR: 1.99, 95% CI: 1.30–2.89; P < 0.05) also significantly predicted LNM risk. This relationship was maintained even after adjustment for BMI (cut‐off: 7.40 μIU/mL, OR: 1.99, 95% CI: 1.01–3.12, P < 0.05) or for WHR (cut‐off: 10.15 μIU/mL, OR: 1.61, 95% CI: 1.04–2.35; P < 0.05). Insulin levels are significantly associated with LNM risk in both premenopausal and postmenopausal women with endometrial cancer. Further prospective studies are needed to examine a potential causal relationship and determine whether its use can offer incremental value for risk stratification in this patient population.

Prognostic value of soluble ST2 postaortic valve replacement: a meta-analysis

Objectives

Soluble suppression of tumorigenicity 2 (sST2) is a member of the interleukin-1 receptor family and a modulator of hypertrophic and fibrotic responses. Its prognostic value for patients undergoing aortic valve replacement (AVR) has been examined in prospective studies but to date, there has been no systematic evaluation or meta-analysis on this issue.

Methods

PubMed and Embase were searched until 1 October 2017 for studies that evaluated the relationship between sST2 levels and mortality after AVR.

Results

A total of 18 and 37 entries were retrieved from both databases, from which four studies were included in the final meta-analysis. In a total of 1154 subjects (50% male, mean age 80±10 years old, mean follow-up 14 months), elevated sST2 levels were significantly associated with a 44% increase in the risk of all-cause mortality (HR 1.44, 95% CI 1.30 to 1.60, p<0.0001; I²: 44%).

Conclusions

sST2 significantly predicts all-cause mortality in patients who have undergone AVR, but this conclusion is limited by the small number of patients. Larger prospective studies are required to better elucidate its value for risk stratification in this patient population.