Association between high sensitivity C-reactive protein and coronary atherosclerosis in a general middle-aged population

Background

Despite abundant knowledge about the relationship between inflammation and coronary artery disease (CAD), it is still unknown whether high sensitivity C-reactive protein (hsCRP) is associated with coronary atherosclerosis in the general population.

Objectives

The project aimed to study the association between systemic inflammation, measured as hsCRP, and coronary artery atherosclerosis in a large population based cohort.

Methods

30,154 randomly selected men and women aged between 50 and 64 years were included in the SCAPIS (Swedish Cardiopulmonary Bioimage Study). After excluding those not undergoing coronary computed tomography angiography (CCTA), those with proximal segments not technically assessable and those with missing values of hsCRP, 25,408 individuals were analysed. Coronary artery atherosclerosis was defined as presence of plaque of any degree (1–49% or ≥50% diameter stenosis) or segments not assessable due to calcification in any of the 18 coronary segments. Analysis of severe atherosclerosis included participants with ≥50% diameter stenosis in any of the left main coronary artery (LMCA), the proximal left anterior descending artery (LAD) or three vessel disease including ≥50% diameter stenosis in any of the segments in each of the LAD, right coronary artery (RCA) and circumflex artery (CX). Participants with hsCRP above the lowest detection limit (≥0.7mg/L) were divided into tertiles and compared with hsCRP<0.7 mg/L as a reference.

Results

The highest tertile of measurable hsCRP (≥2.3 mg/L) was associated with coronary atherosclerosis in a multivariate analysis adjusted for classical cardiovascular risk factors (Table 1). HsCRP was also related to atherosclerosis with significant coronary artery diameter stenosis ≥50%, ≥4 segments involved, severe atherosclerosis and atherosclerosis with noncalcified plaques. Also, moderately elevated hsCRP (1.2–2.2 mg/L) was significant associated with noncalcified plaques. In a stratified analysis, coronary atherosclerosis was associated with the two highest tertiles of hsCRP (≥1.2 mg/L) in women, but not in men.

Conclusion

Elevated hsCRP was associated with the prevalence of coronary atherosclerosis in a population based cohort of middle-aged men and women. The relationships were more pronounced for atherosclerosis with noncalcified plaques and in women compared to men. This suggests that more attention should be given to hsCRP in risk assessment in middle-aged individuals without known disease, especially in women.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The Swedish Heart Lung FoundationKnut and Alice Wallenberg Foundation

Association of beta-blockers beyond 1 year after myocardial infarction for patients without heart failure or left ventricular systolic dysfunction and cardiovascular outcomes: nationwide cohort study

Background

Beta-blockers (BB) is an established treatment following presentation with myocardial infarction (MI). However, there is uncertainty as to whether BB use beyond the first year of MI has a secondary preventive role in patients without heart failure and/or left ventricular systolic dysfunction (LVSD).

Purpose

To investigate the association between BB treatment beyond one year after MI for patients without heart failure or LVSD and cardiovascular (CV) outcomes.

Methods

We used data from SWEDEHEART, the national Swedish register for coronary heart disease, to identify patients with MI who were hospitalised between 2005 and 2016. Deterministic linkage of individual patient data was performed with the National Patient Register, the Swedish Prescribed Drug Register, and the National Cause of Death Register. Patients with heart failure or LVSD with left ventricular ejection fraction <50% were excluded. Follow-up started at 1 year after hospitalisation with first MI (index date), when patients were allocated into two groups according to BB treatment. Information about BB treatment at index date and during follow-up was obtained from the Swedish National Prescribed Drug Register. The primary outcome was a composite of all-cause mortality, recurrent MI, unscheduled revascularisation or hospitalisation for heart failure. Secondary outcomes comprised the individual components of the composite outcome, CV death and stroke. Comparison of outcomes between the study groups was performed using Cox and Fine-Gray regression models adjusting for relevant clinical factors after propensity-score weighting. In the main intention-to-treat analysis, patients were censored at end of follow-up (31st December 2017), death or at pre-specified outcome, whichever came first. In supplementary per-protocol analysis, patients were, in addition, censored at the time of first BB discontinuation or switch between treatment arms.

Results

A total of 43,618 patients with MI were hospitalised between 2005 and 2016. Of these, 34,253 (78.5%) were prescribed BB and 9,365 (21.5%) were not on BB treatment at index date 1 year following MI. The median age of the population was 64 years, 25.5% were female, and 36.2% had a STEMI. Median follow-up was 4.5 years. In the intention-to-treat analysis, and after multivariable adjustments and propensity score weighting, BB treatment was associated with a similar rate of the composite CV outcome (hazard ratio [HR] 0.99; 95% confidence interval [CI] 0.93–1.04) compared with no BB treatment. A similar finding was observed when censoring for BB discontinuation or treatment switch during follow-up in a per-protocol analysis (HR 0.98; 95% CI 0.98–1.06). Similar associations were observed for all secondary outcomes (Figure 1).

Conclusions

BB treatment beyond one year after MI for patients without heart failure or LVSD is not associated with a different risk of cardiovascular outcomes compared with patients who do not receive BB.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The study was financed by grants from the Swedish state under the agreement between the Swedish government and the county councils, the ALF-agreement.

Investigation of type 1 collagen a1 chain in plasma as a potential novel biomarker for prediction of coronary heart disease

Background

Remodeling of the extracellular matrix (ECM) plays a crucial role in development and progression of atherosclerosis. Collagens, in particular type I collagen, are the most abundant ECM proteins in an atherosclerotic plaque. Recently, type I collagen α1 chain (COL1α1) in plasma was identified as a potential predictor of coronary heart disease (CHD).

Aim

The aim was to further confirm the predictive value of COL1α1 and also to investigate its correlates in a population-based cohort as well as changes over time in patients with manifest CHD in Sweden.

Methods

In a total of 1007 well-characterized individuals (50% women), 86 CHD cases and 184 sex- and age-matched controls were identified at 13 years follow-up. CHD at follow-up was defined as first-time event of myocardial infarction (MI) or invasive coronary intervention. Plasma levels of COL1α1 was quantified by the Luminex assay while PRO-C1 and C1M, two markers of type I collagen synthesis and degradation, respectively, were quantified by ELISA. In Cox proportional hazard analysis, log2 values of biomarker levels were used. In addition, temporal change of COL1α1 levels was also examined in a cohort of 125 patients with acute MI followed for 6 months.

Results

COL1α1 levels were significantly associated with incident CHD, both unadjusted (HR = 0.69, 95% CI 0.56–0.87, p=0.001) and after multiple adjustment (HR = 0.55, 95% CI 0.41–0.75, p<0.001). PRO-C1 was similarly associated with CHD, unadjusted (HR = 0.62, 95% CI 0.47–0.82, p=0.001) as well as adjusted (HR = 0.61, 95% CI 0.43–0.86, p=0.005), while C1M was not. In patients with acute MI, COL1α1 levels remained stable over 6 months. COL1α1 was significantly correlated to PRO-C1 (r=0.73, p<0.001), while there were no correlations to C1M, markers of inflammation (C-reactive protein, interleukin-6, matrix metalloproteinase-9) or myocardial injury (troponin T).

Conclusions

Circulating COL1α1 in plasma was independently and inversely associated with incident CHD. Furthermore, COL1α1 levels appeared to be relatively stable after an acute MI. COL1α1 levels seem to reflect collagen synthesis rather than collagen degradation and inflammation. Future studies are needed to confirm whether COL1α1 is a clinically useful marker and/or predictor of CHD.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): This research was in part financed by a grant from the Region of Östergötland, Sweden, aimed towards scientists early in their career. We would like to thank the people behind this grant for contributing to this research.This research was also partly supported by Futurum - the academy for healthcare in Region Jönköping County.

Does the quality index of adherence to the evidence-based guidelines predict mortality in patients with myocardial infarction?

Background

The SWEDEHEART quality index of hospitals' adherence to the evidence-based (EB) guidelines for myocardial infarction (MI) patients has been continuously used for several decades in Sweden. The grading protocol is based on the consensus among hospitals. The hospitals are awarded points (0, 0.5, 1) for each of the 11 indicators depending on the proportion of patients who received EB treatment and achieved treatment goals. The 11 indicators at present are reperfusion treatment in STEMI (yes/no), time to-reperfusion treatment in STEMI, time to revascularisation in NSTEMI, P2Y12 antagonists at discharge, ACE-inhibitor/ARB at discharge, the proportion of patients at follow-up, smoking cessation at one-year, participation in a physical exercise program, target LDL-cholesterol and target blood pressure at one year.

Purpose

To evaluate whether the SWEDEHEART quality index predicts mortality in patients with MI.

Methods

We used data for all MI patients reported to the SWEDEHEART registry from 72 hospitals in Sweden between 2015–2021. We calculated the difference in quality index between 2021 and 2015. The hospitals were divided into quintiles based on the difference in the score. Logistic regression with log-time offset was used to adjust for confounders (age, gender, diabetes, hypertension, hyperlipidemia, STEMI/NSTEMI, cardiac arrest before admission, occupation status, history of heart failure, prior MI, prior PCI, prior CABG, cardiogenic shock).

Results

We identified 98,635 patients with MI, 32,608 (33.1%) were women and 34,198 (34.7%) had STEMI. The average age was 70.8±12.2 years. The median follow-up time was 2.7 years (IQR 1.06–4.63). The crude all-cause mortality rate was 5.5% at 30-days and 22.3% after long-term follow-up. Most hospitals (72.1%) improved their quality index on average by 3.4% per year (P<0.001). The increase in the quality index continued during COVID-19 pandemic (2020–2021) with average increase of 8.6%, 95% CI, 0.97–1.02; P<0.001. The median change in SWEDEHEART quality index score among the quintiles were −1.5 (Q1), 0,5 (Q2), 2,5 (Q3), 3 (Q4), and 4 (Q5). We found no difference in mortality between the quintiles at 30-days (OR 0.99; 95% CI 0.97–1.02; p=1.02) and long-term (OR 1.01; 95% CI 0,99–1.02; p=0.850).

Conclusion

The SWEDEHEART quality index provides valuable descriptive information about hospitals' adherence to the guidelines. However, the index, in its current form, does not predict mortality in patients with MI.

Funding Acknowledgement

Type of funding sources: None.

Association of ischemic and bleeding events with mortality in patients with a recent acute myocardial infarction

Background/Introduction

Duration and intensity of antithrombotic treatment after myocardial infarction should be individualized based on a patient's ischemic and bleeding risk [1,2]. While such strategies are typically based on calculations that give equal weight to both types of events, uncertainty remains regarding their relative importance.

Purpose

To describe the incidence of ischemic and bleeding events in patients with a recent myocardial infarction, to compare the association of an ischemic vs bleeding event with mortality and to assess whether this association had changed over the past two decades.

Methods

Patients with acute myocardial infarction enrolled in the SWEDEHEART registry and discharged alive with antithrombotic treatment (aspirin, P2Y12 inhibitor, or oral anticoagulant) from January 2012 to December 2017 were followed from discharge until an ischemic event (recurrent myocardial infarction or ischemic stroke) or bleeding event. Cox regression adjusted for demographic factors, comedications and comorbidities, was used to estimate hazard ratios (HR) for time to death after an ischemic and bleeding event as compared with no event (in a model using time-varying exposure definition) and for an ischemic vs bleeding event in a direct comparison. We then assessed whether the adjusted HR for mortality of an ischemic vs bleeding event had changed across three time-periods (1997–2000, 2001–2011 and 2012–2017) by using an interaction term between time period and type of event.

Results

From January 2012 until December 2017 86, 736 patients were discharged alive with antithrombotic treatment after a myocardial infarction. Of these, 4,039 patients experienced a first ischemic event (incidence rate 5.7 events per 100 person-years), and 3,399 a first bleeding event (incidence rate 4.8 events per 100 person-years). As compared with no event, both ischemic events (adjusted HR 4.16, 95% CI 3.91 to 4.43) and bleeding events (adjusted HR 3.43, 95% CI 3.17 to 3.71) were associated with an increased risk of death. In the direct comparison, ischemic events were associated with a higher risk of death than bleeding events (adjusted HR 1.27, 95% CI 1.15 to 1.40). There was no evidence of a change in the aHR across the three time periods (aHR; 1.17, 95% CI 1.02 to 1.35 in 1997–2000 and 1.18, 95% CI, 1.11 to 1.27 in 2001–2011, p for interaction between time period and type of event ≥0.646).

Conclusion

In this nationwide study of patients with a recent MI, post-discharge ischemic events were more common and associated with higher mortality risk as compared with bleeding events.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Swedish Heart and Lung FoundationSwedish Diabetes Foundation

Temporal trends, short- and long-term prognostic impact of pre-hospital delay times in ST elevation myocardial infarction – 20 years national data from the SWEDEHEART registry

Background

Previous studies have demonstrated that total ischaemic time during ST-elevation myocardial Infarction (STEMI) is associated with mortality. However, how duration from symptom onset to hospital admission affects outcomes and how pre-hospital delay times (PHDT) have evolved over time in STEMI in total, as well as in prespecified subgroups, remains unknown.

Aim

The aim was to explore temporal trends and prognostic impact of PHDT in STEMI patients during the last two decades in Sweden, including the fibrinolytic era as well as the primary percutaneous coronary intervention (PPCI) era. Temporal trends of PHDT was aimed to be studied in the total STEMI cohort as well as in subgroups according to age, sex and presence or absence of diabetes.

Method

This was an observational retrospective cohort study based on the SWEDEHEART registry including 89,155 STEMI patients between 1998 and 2017.

Results

In total, the PHDT curve was hump-shaped without any significant trend. The median PHDT was 150 min (Q1 80; Q3 302), and the shortest PHDT of 140 (Q1 85; Q3 274) min was found during the last period. During the fibrinolytic era (1998–2004) there was a significant increase in PHDT while delay times decreased during the PPCI era (2005–2017). There were consistent differences within subgroups; women sought care 25 min later than men, older (&gt;70 years) delayed 30 min longer than younger and patients with diabetes 29 min longer than those without. Higher short- and long-term mortality was seen with increasing delay except for the group seeking care within 1 hour, which had higher short-term mortality. In five years follow up, mortality incrementally increased with delay, from 24.1% (0–1 hours) to 31.1% (&gt;12 hours) of PHDT, p&lt;0.01. When adjusting for confounders the risk of dying within 1 and 5 years was approximately 1% per hour of increase of PHDT (HR 1.011, 95% CI 1.006–1.016 and HR 1.008, 95% CI 1.004–1.013, respectively).

Conclusions

PHDT is an independent predictor of short- and long-term mortality and reducing PHDT will diminish the risk of heart failure and premature death. We found only a modest decrease in PHDT over time and the trend was hump shaped. Since the implementation of PPCI, with the diagnosis of STEMI made in the ambulances, these have been redirected in the pre-hospital setting, transporting the patient directly to cath lab. This may explain why the PHDT initially increased in the beginning of this era when new routines were being established. Although we did not find any significant trend during the total 20-year period it is reassuring that the PHDT decreased during the PPCI era. Anyhow, there are subgroups with consistently prolonged PHDT, such as women, the elderly, and patients with diabetes, who need to be targeted in future interventions.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): This study was funded with grants from the Medical Research Council of Southeast Sweden (FORSS), Region Östergötland and Linköping University Hospital Research Fund, Sweden.

Comparison between ticagrelor and clopidogrel in high bleeding risk patients with acute coronary syndrome

Background

Potent antiplatelet agents such as ticagrelor are associated with a lower risk of ischemic events than clopidogrel in patients with acute coronary syndrome (ACS). However, it is uncertain whether the benefits of more intensive anti-ischemic therapy outweigh the risks of major bleeding in individuals who have a high bleeding risk (HBR). This study aimed to assess treatment outcomes following dual antiplatelet therapy (DAPT) using either ticagrelor or clopidogrel in ACS patients with HBR.

Methods

All HBR patients enrolled in the SWEDEHEART registry who were discharged with DAPT using ticagrelor or clopidogrel following ACS between 2010 and 2017 were included in this study. Bleeding risk was assessed using the 4-item PRECISE-DAPT score, which consists of age, prior bleeding, haemoglobin concentration and creatinine clearance. HBR was defined as a PRECISE-DAPT score ≥25. Inverse-probability of treatment weighting was used to adjust for baseline differences between the treatment groups. The main analysis consisted of a doubly robust estimation of causal effect using Cox proportional hazards models. Data on major bleeding, recurrent myocardial infarction (MI), ischemic stroke and all-cause mortality was obtained from national registries, with 365 days of follow-up. Additional outcomes include major adverse cardiovascular events (MACE), a composite of MI, ischemic stroke and all-cause mortality, and net adverse clinical events (NACE), a composite of MACE and major bleeding.

Results

Of all ACS patients, 36% (n=25,042) had a PRECISE-DAPT score ≥25. Approximately half of the study participants were treated with ticagrelor (n=11,848). Ticagrelor reduced the risk of MI (hazard ratio [HR], 0.82 [95% CI 0.74–0.91]), ischemic stroke (HR, 0.73 [95% CI 0.60–0.88]) and MACE (HR, 0.90 [95% CI 0.84–0.97]), while also increasing the risk of major bleeding compared to clopidogrel (HR, 1.30 [95% CI 1.16–1.47]). We found no significant differences in all-cause mortality (HR 1.02 [95% CI 0.92–1.12]) and NACE (HR 0.98 [95% CI 0.92–1.05]).

Conclusions

Ticagrelor was associated with a lower risk of recurrent ischemic events, but a higher risk of major bleeding compared to clopidogrel. There were no significant differences in all-cause mortality and NACE between the treatment groups. These results suggest that more potent antiplatelet agents might not be superior to clopidogrel in ACS patients with HBR.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Stockholm county council

Poor long-term prognosis in patients admitted with strong suspicion of acute myocardial infarction but discharged with another diagnosis

BACKGROUND

Characteristics and prognosis of patients admitted with strong suspicion of myocardial infarction (MI) but discharged without an MI diagnosis are not well-described.

OBJECTIVES

To compare background characteristics and cardiovascular outcomes in patients discharged with or without MI diagnosis.

METHODS

The DETermination of the role of Oxygen in suspected Acute Myocardial Infarction (DETO2X-AMI) trial compared 6629 patients with strong suspicion of MI randomized to oxygen or ambient air. The main composite end-point of this subgroup analysis was the incidence of all-cause death, rehospitalization with MI, heart failure (HF) or stroke during a follow-up of 2.1 years (median; range: 1-3.7 years) irrespective of randomized treatment.

RESULTS

1619 (24%) received a non-MI discharge diagnosis, and 5010 patients (76%) were diagnosed with MI. Groups were similar in age, but non-MI patients were more commonly female and had more comorbidities. At thirty days, the incidence of the composite end-point was 2.8% (45 of 1619) in non-MI patients, compared to 5.0% (250 of 5010) in MI patients with lower incidences in all individual end-points. However, for the long-term follow-up, the incidence of the composite end-point increased in the non-MI patients to 17.7% (286 of 1619) as compared to 16.0% (804 of 5010) in MI patients, mainly driven by a higher incidence of all-cause death, stroke and HF.

CONCLUSIONS

Patients admitted with a strong suspicion of MI but discharged with another diagnosis had more favourable outcomes in the short-term perspective, but from one year onwards, cardiovascular outcomes and death deteriorated to a worse long-term prognosis.

The association of mode of location activity and mobility with acute coronary syndrome: a nationwide ecological study

BACKGROUND

We aimed to study the effect of social containment mandates on ACS presentation during COVID-19 pandemic using location activity and mobility data from mobile phone map services.

METHODS

We conducted a cross-sectional study using data from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR) including all ACS presentations during the pandemic until 7 May 2020. Using a count regression model, we adjusted for day of the week, daily weather and incidence of COVID-19.

RESULTS

A 10% increase in activity around areas of residence was associated with 38% lower rates of ACS hospitalizations, whereas increased activity relating to retail and recreation, grocery stores and pharmacies, workplaces and mode of mobility was associated with 10-20% higher rates of ACS hospitalizations.

CONCLUSION

Government policy regarding social containment mandates has important public health implications for medical emergencies such as ACS and may explain the decline in ACS presentations observed during COVID-19 pandemic.

Long term antithrombotic treatment in atrial fibrillation patients undergoing coronary surgery

Introduction

Current revascularisation guidelines from ESC recommend treatment with oral anticoagulants (OAC) alone in atrial fibrillation (AF) patients treated with coronary artery by-pass grafting (CABG), after one year of treatment with OAC and platelet inhibition (PI). Little is known about current treatment practice and there is a paucity of evidence to guide decision making.

Purpose

To assess treatment patterns and clinical outcome of OAC as sole antithrombotic treatment one year after CABG in patients with a history of AF, in comparison to PI only and OAC+PI.

Method

We included 2 112 patients (out of 32908 who underwent isolated CABG) from 2006 to 2014 with a history of atrial fibrillation, alive one year after surgery and a CHA2DS2-VASC-score ≥2. Based on data on individual dispensed prescriptions 1 to 1.5 years after surgery, patients were assigned to one of three treatment arms: PI alone (n=931), OAC alone (n=814) or combination of OAC+PI (n=367). Differences in MACE (death, myocardial infarction [MI] and stroke) between the three groups were assessed using a Cox regression model. Data are presented as hazard ratios (HR) with 95% confidence intervals [CI], adjusted for CHA2DS2-VASC-score (which include age, sex, hypertension [HT], congestive heart failure [CHF], stroke, vascular disease and diabetes) for MACE and the individual components of MACE; and CHA2DS2-VASC+history of bleeding regarding readmission for bleeding. Median follow-up was 3 years, range (0.5–3).

Results

Patients treated with PI only were younger (71, 72 and 73 years) and less often had HT (62%, 72 and 70%), and CHF (30, 40 and 40%) in the PI, PI+OAC and OAC groups respectively. Patients treated with PI only, more often had a history of MI (54%) compared to OAC (42%) but not to PI+OAC (53%). The cumulative incidence of MACE at three years was 18.9, 14.0 and 14.9% in the PI, PI+OAC and OAC groups, respectively. The corresponding numbers were for death 9.9, 9.0 and 11.2%, MI 4.6, 3.5 and 1.9%, stroke 6.0, 2.7 and 2.7% and readmission for bleeding 5.9, 11.3 and 7.0%, respectively. After adjustment, PI only was associated with significantly higher risk for MACE (HR 1.36, 95% CI: 1.06–1.75), MI (HR 2.82, 95% CI: 1.47–5.40), and stroke (HR 2.34, 95% CI: 1.36–4.02); while PI+OAC was associated with higher risk for MI (HR 2.43, 95% CI: 1.09–5.34) and bleeding complications (HR 1.58, 95% CI: 1.01–2.46), compared to OAC only.

Conclusions

In CABG patients with a history of AF and an indication for OAC, one year after surgery, treatment with OAC alone was associated with lower MACE rate than PI alone, driven by lower rates of MI and stroke. In addition, OAC only was associated with less bleeding complications than PI+OAC. These real-world data provide support to current ESC guidelines recommending OAC alone one year after CABG surgery.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): County council of Östergötland, Sweden

Characteristics and outcome in foreign-born vs Sweden-born patients with myocardial infarction

Introduction

Immigration is increasing in most European countries. Little is known about differences in baseline characteristics and outcome between foreign-born and native patients with myocardial infarction (MI).

Purpose

To investigate differences in baseline characteristics and one-year mortality after an MI, based on region of birth.

Methods

We included 194 498 MI patients (36% women) between 2005 and 2016 from the SWEDEHEART registry and compared them according to region of birth: Sweden (Sw, n=166020), Other Nordic countries (No, n=10856), EU countries except Nordic (EU, (n=6301), Non-EU Europe (non EU, n=4779), Asia (n=4927), Africa (n=669), S America (n=567) and N America (n=379). One-year mortality was assessed using a Cox regression model (pairwise with Swedish-born as reference) and in a second model adjusting for age and sex. Data are presented as hazard ratios (HR) with 95% confidence intervals (CI).

Results

There was an increased proportion of foreign-born patients over time (12.8 to 16.7%).

We observed substantial differences in risk factors and comorbidity according to region of birth (lowest vs highest value) in age (mean) (58 vs 72 year, African vs Sw. born), smoking (19 vs 39%, Sw. vs Asian born), history of diabetes (20 vs 36%, African vs Sw. born), hypertension (40 vs 59%, born in African vs No.), MI (17 vs 23%, S America vs EU born) stroke (9 vs 20%, born in S American vs No.), low income (28% vs 56%, Sw. vs Asian born) and low level of education (27 vs 49%, born in Africa vs No.). One-year mortality according to region of birth was 15.4% for patients born in Sweden, 14.0% for patients born in other Nordic countries, 12.8% in EU, 9.6% for non-EU Europe, 6.3% for Asia, 8.4% for Africa, 6.7% for S America and 15.0% for N America. After adjustment for age and sex, the only significant differences were higher mortality in patients born in other Nordic countries (HR 1.1, 95% CI: 1.01–1.12), non-EU Europe (HR=1.12, 95% CI: 1.02–1.23) and Africa (HR=1.68, 95% CI: 1.29–2.19) compared to patients born in Sweden.

Conclusions

We observed increased rate of foreign-born MI patients, with differences in risk profile, comorbidity, education and financial resources according to region of birth, which may impact on observed differences in outcome. Equal access to care pose a challenge which may merit a more comprehensive and individualised approach to cardiac care. Future analyses should explore differences in treatment based on region of birth and potential association with outcome.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): The Kamprad Family for Entrepeneurship, Research and Charity; The County Council of Östergötland, Sweden; Medical Research Council of Southeast Sweden

Collagen remodeling markers show differentiated expression in patients with ST- and non-ST elevation myocardial infarction

Background

Following acute myocardial infarction (MI), the left ventricle undergoes molecular and extracellular matrix (ECM) changes. The ECM is a dynamic structure with a potential role in cardiac remodeling post-MI. Collagens are the major components of both cardiac and arterial ECM.

Purpose

We evaluated circulating levels of type I, IV and VI collagen fragments in two cohorts of patients with acute MI to investigate collagen turnover post-MI. The cohorts were Malmö AMI in elderly (MAMI-Y) and Assessing Platelet Activity in Coronary Heart Disease (APACHE).

Methods

Serum was collected from 190 patients from the discovery cohort (MAMI-Y: mean age 74, SD 10.8) at four timepoints: admission when MI, after 3–6 days, 6 weeks, 12 months; citrate plasma was collected from 142 patients from the validation cohort (APACHE: mean age 65, SD 11.6) at four timepoints: hospitalization, 3 days, 7–9 days, 6 months. The biomarkers of matrix metalloproteinase (MMP)-mediated degradation of type I collagen (C1M), MMP-mediated degradation of type IV collagen (C4M) and formation of type VI collagen (PRO-C6) were measured at all timepoints (immunosorbent assays). Differences in the markers at the different timepoints were calculated using repeated measures ANOVA.

Results

Circulating levels of the formation biomarker PRO-C6 significantly increased from baseline and remained high at all three following timepoints in both MAMI-Y and APACHE studies (all p&lt;0.001). In contrast, the degradation biomarkers C1M and C4M showed a similar pattern of an initial increase 3 days post-MI followed by a decrease over time, with C1M in MAMI-Y and both C1M and C4M in APACHE having returned to baseline level by the final timepoint. Circulating baseline levels of PRO-C6 correlated with age (r=0.397, p&lt;0.0001 in MAMI-Y, r=0.427, p&lt;0.0001 in APACHE). Categorizing the subjects into ST elevation MI (STEMI; MAMI-Y: N=67, APACHE: N=71) or non-ST elevation MI (NSTEMI; MAMI-Y: N=130, APACHE: N=52) revealed that a correlation with age remained in both subgroups (r=0.443, p&lt;0.0001 and r=0.325, p&lt;0.0001, respectively, in MAMI-Y, and r=0.516, p&lt;0.0001 and r=0.316, p=0.023, respectively, in APACHE). Moreover, PRO-C6 was elevated in STEMI patients that had previously experienced an MI in both cohorts (MAMI-Y: p=0.017, APACHE: p=0.016). C1M and C4M levels were not different in patients with prior MI in any of the cohorts. No association was found between any biomarker and gender or diabetes. Echocardiography showed a correlation between baseline levels of C1M and ejection fraction (r=0.228, p=0.023) in the whole MAMI-Y cohort and among NSTEMI, but not among STEMI, subjects (r=0.337, p=0.004).

Conclusions

We observed changes in circulating fragments reflecting collagen turnover in the acute phase post-MI, more pronounced in STEMI patients. This may indicate that STEMI patients have more active collagen remodeling than NSTEMI patients and may have more altered left ventricle function and remodeling.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): This work was supported by the Danish Research Foundation “den danske forskningsfond”, the Innovation foundation (Innovationsfonden), Swedish Research Council, Swedish Heart and Lung Foundation, Swedish Society for Medical Research, Swedish Society of Medicine, the Crafoord Foundation, the Åke Wiberg foundation and the Stroke foundation.

Uninterrupted oral anticoagulant therapy in patients undergoing unplanned percutaneous coronary intervention

Background

To investigate the optimal periprocedural antithrombotic strategy in patients on oral anticoagulants (OAC) who undergoing unplanned percutaneous coronary intervention (PCI).

Methods

Using data from the SWEDEHEART registry, we identified all patients on OAC who underwent an unplanned PCI, from 2005 to 2017. We compared uninterrupted OAC (U-OAC) vs interrupted OAC (I-OAC) therapy, defined as any discontinuation of OAC at least 24 hours prior to PCI. Outcomes were major adverse cardiac and cerebrovascular events (MACCE), including death, MI or stroke and net adverse cardiac and cerebrovascular events (NACCE), including MACCE or major bleeds, up to 120 days after the index procedure.

Results

We included 6485 patients, 3163 in U-OAC and 3322 in I-OAC group. The U-OAC strategy increased over time, by 13% per year. Almost 80% of patients in both groups had an acute coronary syndrome. We found no major differences in terms of medical history, clinical characteristics and the CRUSADE bleeding score on admission. The proportion of patients on warfarin was higher in the I-OAC group (85 vs 81%). Patients in the I-OAC were more likely to receive low-molecular weight heparin (29 vs 12%) and glycoprotein IIb/IIIa inhibitors (6 vs 3%) during the index hospitalisation. In the I-OAC group, dual antiplatelet therapy without OAC was more often prescribed (22 vs 8%) and OAC plus single antiplatelet therapy was less often prescribed (8 vs 22%) at discharge.

At 120 days, the cumulative rate of MACCE was 8.2 vs 8.2% and the rate of NACCE was 12.6 vs 12.9% in I-OAC vs U-OAC, respectively. We found no significant difference in the risk for MACCE and NACCE between the two groups (table). The risk for major or minor in-hospital bleeds was similar. I-OAC was associated with significantly longer time-delay to PCI and length of hospitalisation (table).

Conclusion

Uninterrupted OAC was safe and was associated with significantly shorter length of hospitalisation. Our data support U-OAC as the preferable strategy in patients on OAC undergoing PCI.

Funding Acknowledgement

Type of funding source: None

Utilization and outcomes of rotational atherectomy in Sweden

Aim

To evaluate utilization and outcomes of rotational atherectomy (RA) using data from the Swedish Coronary and Angioplasty Registry (SCAAR)

Methods

We included 1476 patients with 2218 lesions who underwent RA from 2005 to 2016. To study temporal changes, the study period was divided into three equal time-periods, period A, B and C.

Results

Although the number of RA procedures increased 3-fold from 2005 to 2016, the rate of RA (of all PCI procedures) remained low (0.5% vs 1.2% in 2005 vs 2016). RA patients consisted a high-risk group, with advanced age and clustering of comorbidities. Over time, included patients were older and had a higher risk profile. Trans-radial access, drug eluting stent (DES) use and use of intravascular imaging significantly increased from period A to C whereas positioning of a temporary pacemaker or intra-aortic balloon pump declined. Unfractionated heparin became the main anticoagulant (52 vs 87%) and use of glycoprotein IIb/IIIa inhibitors declined (31 vs 12%, in period A vs C). Following RA, 11% of lesions were treated without stent (15 vs 15 vs 8%, in period A, B and C) (Rota-only). In lesions treated with a stent, a bare metal stent (BMS) was implanted in 39% vs 12% vs 2% and a new generation DES (N-DES) in 5 vs 75 vs 97% (period A vs B vs C) of lesions.

The 3-year cumulative rate of restenosis was 6.7% (122 events), (11.1 vs 7.1 vs 4.1% in period A vs B vs C). As compared to DES, rota-only (adjusted HR 2.71; 95% CI 1.69- 4.36) and BMS (adjusted HR 3.63; 95% CI 2.27- 5.81) were associated with significantly higher risk for restenosis. First generation DES were associated with numerically higher but not significantly different risk for restenosis as compared to N-DES (adjusted HR 1.31; 95% CI 0.74- 2.31).

The 3 year cumulative rate of major adverse cardiac events (MACE), including death, myocardial infarction (MI) or any restenosis was 30.6% (34.2 vs 31.4 vs 28.2%, in period A vs B vs C) and the corresponding numbers for all-cause mortality were 18.1% (18.9 vs 18.4 vs 17.0%). After adjustment for baseline characteristics and angiographic findings, RA in period A was associated with higher risk for MACE as compared to period C (adjusted HR 1.40; 95% CI 1.09- 1.79), due to higher risk for MI and restenosis. The difference disappeared when procedural characteristics, including DES use, were added to the model.

The rate of major in-hospital complications was 7.0%, including in-hospital death 1.3%, periprocedural MI 2.8%, perforation 1.1%, cardiac tamponade 0.7%, stroke 0.2% and major bleedings 2.1%. We found no significant differences over time.

Conclusion

During the studied period, RA remained a rare procedure, utilised in a highly selected population. Over time a declining rate of restenosis and MI after RA was observed, a finding that appeared to be mainly driven by an increased use of DES. The rate of major in-hospital complication remained low.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Boston Scientific International

P1726A gender perspective on incidence, management, short- and long term outcome of cardiogenic shock complicating ST-elevation myocardial infarction - A report from the SWEDEHEART register

Background

Cardiogenic shock [CS] is a severe complication of ST-elevation myocardial infarction [STEMI]. An increased use of primary percutaneous coronary intervention [PPCI] has been associated with a decline in CS incidence, and a better prognosis. Female gender has been associated with a worse prognosis in STEMI, but whether there is a gender difference in incidence and outcome of CS complicating STEMI is not known.

Purpose

The objectives of this study were to compare the genders regarding incidence, management, and prognosis of CS complicating STEMI.

Methods

Patients with STEMI and CS were identified in SWEDEHEART 2005–2014. Cardiogenic shock was defined as any of; 1) systolic blood pressure [BP] <90 mm Hg ≥30 min, 2) signs of tissue hypoperfusion, 3) cardiac index <1,8 l/min/m2, 4) ionotropic drugs and/or need of intra-aortic balloon pump. Multiple logistic and cox regression analyses were done with reperfusion therapy, in-hospital and 1-year mortality as dependent variables.

Results

Among 56072 STEMI patients 3134 CS cases were identified. Women more often than men developed CS (6.3 vs 5.2%, p<0.001). The age-adjusted incidence of CS did not change in women, whereas in men the incidence increased by 2.7% yearly. Women had a less chance of receiving reperfusion therapy, OR 0.77 (95% CI 0.65–0.92), but had neither higher in-hospital mortality (OR 1.01, 95% CI 0.85–1.19), nor higher 1-year mortality (OR 0.97, 95% CI 0.70–1.33). Upon age stratification the gender difference in reperfusion was only evident among the oldest (>80 years).

Conclusion

Women had higher risk of CS than men when stricken by STEMI, but whereas CS incidence increased in men it was stable in women. Although women had less likelihood of receiving reperfusion therapy, adjusted in-hospital, and 1-year mortality was without any gender difference. The rate of reperfusion was especially low in elderly women, where there seems to be room for improvement.

3333Contemporary mortality rates in myocardial infarction patients in Sweden: a tale of two registries

Background

Sweden has contributed to the understanding of the long-term prognosis after myocardial infarction (MI) utilising the quality registry SWEDEHEART, including patients admitted to heart intensive care, and the National Patient Registry (PAR), based on administrative records for Swedish hospitals. As registration procedures differ between the registries, and not all MI patients are admitted to heart intensive care, MI patients identified in SWEDEHEART and PAR, respectively, will yield different cohorts of patients. This may result in different epidemiological research findings regarding prognosis after MI.

Purpose

To study MI populations identified in SWEDEHEART and PAR, respectively, and investigate potential differences in mortality outcome.

Methods

Patients hospitalised with an MI primary diagnosis (ICD-10 I21) between 2002 and 2015 were identified using SWEDEHEART and PAR. The analysis time started at the date of hospital admission and survivors were followed for 365 days. Kaplan-Meier analysis was used to estimate survival by cohort category controlling for age and gender.

Results

Excluding cases with invalid data (n=1,905), 225,612 and 282,118 SWEDEHEART and PAR patients, respectively, were identified. We found 213,367 patients in both SWEDEHEART and PAR, whereas 12,245 and 68,751 patients were unique to SWEDEHEART and PAR, respectively. The one-year survival probability after MI in the SWEDEHEART population was 0.841, compared to 0.788 in PAR (Figure). This discrepancy can be explained by high mortality among patients not covered by SWEDEHEART and persists after controlling for age and gender (Table). To what extent differences in registration procedures and other patient characteristics can explain the mortality difference is an area for further research.

One-year survival by age and gender Age ± 1 year Male Female PAR S.H. Diff. PAR S.H. Diff. 65 0.922 0.936 0.015 0.919 0.936 0.017 70 0.893 0.909 0.016 0.889 0.908 0.019 75 0.829 0.858 0.029 0.834 0.860 0.026 80 0.743 0.783 0.040 0.768 0.800 0.033 85 0.625 0.677 0.052 0.662 0.705 0.042

One-year survival after MI

Conclusion

Estimated one-year survival for MI patients differs by up to 5 percentage points depending on the registry used. Although further research is needed to fully understand these differences, epidemiological findings regarding MI prognosis should be interpreted in light of registry type used and population represented.

Acknowledgement/Funding

Region Östergötland

P4635Long term risk and costs of bleeding in men and women treated with triple antithrombotic therapy

Background

Triple antithrombotic therapy (TAT) is known to increase bleeds and its relevance is questioned. No study has observed the long-term risk of bleeding and health care costs from a sex perspective, in a total TAT population. We investigated the rate of all bleeds in patients receiving TAT at index hospitalization and within one year. We explored early discontinuation of TAT and potential sex disparities. We also assessed health care costs related to bleeding complications.

Methods

All patients discharged with TAT registered in SWEDEHEART in the County of Östergötland 2009–2015 were included. Information about bleeds during one-year follow-up were retrieved from the medical records. All bleeds receiving medical attention were included. Resource use associated with bleeds were assigned unit cost to estimate the health care costs associated with bleeding episodes.

Results

Among 272 identified patients, 156 bleeds occurred post-discharge, of which 28.8% were gastrointestinal. In total 54.4% had at least one bleed during or after the index event and 40.1% bled post discharge of whom 28.7% experienced a TIMI major or minor bleeding. Women discontinued TAT prematurely more often than men (52.9 vs 36.1%, p=0.01) and bled more (48.6 vs. 37.1%, p=0.09). One-year mean health care costs were EUR 575 and EUR 5787 in non-bleeding and bleeding patients, respectively.

Conclusion

The very high bleeding incidence in patients with TAT is a cause of concern, especially in women. There is a need for an adequately sized randomized, controlled trial to determine a safe but still effective treatment for these patients.

Activated platelet aggregation is transiently impaired also by a reduced dose of protamine

Objectives: Protamine reduces platelet aggregation after cardiopulmonary bypass (CPB). We studied the inhibitory effect of a reduced protamine dose, the duration of impaired platelet function and the possible correlation to postoperative bleeding. Design: Platelet function was assessed by impedance aggregometry in 30 patients undergoing cardiac surgery with CPB at baseline, before protamine administration, after 70% and 100% of the calculated protamine dose, after 20 minutes and at arrival to the intensive care unit. Adenosine diphosphate (ADP), thrombin receptor activating peptide-6 (TRAP), arachidonic acid (AA) and collagen (COL) were used as activators. Blood loss was measured during operation and three hours after surgery. Results are presented as median (25th-75th percentile). Results: Platelet aggregation decreased markedly after the initial dose of protamine (70%) with all activators; ADP 89 (71-110) to 54 (35-78), TRAP 143 (116-167) to 109 (77-136), both p < .01; AA 25 (16-49) to 17 (12-24) and COL 92 (47-103) to 60 (38-81) U, both p < .05. No further decrease was seen after 100% protamine. The effect was transient and after twenty minutes platelet aggregation had started to recover; ADP 76 (54-106), TRAP 138 (95-158), AA 20 (10-35), COL 70 (51-93) U. Blood loss during operation correlated to aggregometry measured at baseline and after protaminization. Conclusions: Protamine after CPB induces a marked decrease in platelet aggregation already at a protamine-heparin ratio of 0.7:1. The impairment seems to be transient and recovery had started after 20 minutes.

Sex-related response to bivalirudin and unfractionated heparin in patients with acute myocardial infarction undergoing percutaneous coronary intervention: A subgroup analysis of the VALIDATE-SWEDEHEART trial

Aims:

Our aim was to study the impact of sex on anticoagulant treatment outcomes during percutaneous coronary intervention in acute myocardial infarction patients.

Methods:

This study was a prespecified analysis of the Bivalirudin versus Heparin in ST-Segment and Non ST-Segment Elevation Myocardial Infarction in Patients on Modern Antiplatelet Therapy in the Swedish Web System for Enhancement and Development of Evidence-based Care in Heart Disease Evaluated according to Recommended Therapies Registry Trial (VALIDATE-SWEDEHEART) trial, in which patients with myocardial infarction were randomised to bivalirudin or unfractionated heparin during percutaneous coronary intervention. The primary outcome was the composite of death, myocardial infarction or major bleeding at 180 days.

Results:

There was a lower risk of the primary outcome in women assigned to bivalirudin than to unfractionated heparin (13.6% vs 17.1%, hazard ratio 0.78, 95% confidence interval (0.60–1.00)) with no significant difference in men (11.8% vs 11.2%, hazard ratio 1.06 (0.89–1.26), p for interaction 0.05). The observed difference was primarily due to lower risk of major bleeding (Bleeding Academic Research Consortium definition 2, 3 or 5) associated with bivalirudin in women (8.9% vs 11.8%, hazard ratio 0.74 (0.54–1.01)) but not in men (8.5% vs 7.3%, hazard ratio 1.16 (0.94–1.43) in men, p for interaction 0.02). Conversely, no significant difference in the risk of Bleeding Academic Research Consortium 3 or 5 bleeding, associated with bivalirudin, was found in women 4.5% vs 5.4% (hazard ratio 0.84 (0.54–1.31)) or men 2.9% vs 2.1% (hazard ratio 1.36 (0.93–1.99)). Bleeding Academic Research Consortium 2 bleeding occurred significantly less often in women assigned to bivalirudin than to unfractionated heparin. The risk of death or myocardial infarction did not significantly differ between randomised treatments in men or women.

Conclusion:

In women, bivalirudin was associated with a lower risk of adverse outcomes, compared to unfractionated heparin, primarily due to a significant reduction in Bleeding Academic Research Consortium 2 bleeds.

Supplemental oxygen therapy does not affect the systemic inflammatory response to acute myocardial infarction

BACKGROUND

Oxygen therapy has been used routinely in normoxemic patients with suspected acute myocardial infarction (AMI) despite limited evidence supporting a beneficial effect. AMI is associated with a systemic inflammation. Here, we hypothesized that the inflammatory response to AMI is potentiated by oxygen therapy.

METHODS

The DETermination of the role of Oxygen in suspected Acute Myocardial Infarction (DETO2X-AMI) multicentre trial randomized patients with suspected AMI to receive oxygen at 6 L min^-1 for 6-12 h or ambient air. For this prespecified subgroup analysis, we recruited patients with confirmed AMI from two sites for evaluation of inflammatory biomarkers at randomization and 5-7 h later. Ninety-two inflammatory biomarkers were analysed using proximity extension assay technology, to evaluate the effect of oxygen on the systemic inflammatory response to AMI.

RESULTS

Plasma from 144 AMI patients was analysed whereof 76 (53%) were randomized to oxygen and 68 (47%) to air. Eight biomarkers showed a significant increase, whereas 13 were decreased 5-7 h after randomization. The inflammatory response did not differ between the two treatment groups neither did plasma troponin T levels. After adjustment for increase in troponin T over time, age and sex, the release of inflammation-related biomarkers was still similar in the groups.

CONCLUSIONS

In a randomized controlled setting of normoxemic patients with AMI, the use of supplemental oxygen did not have any significant impact on the early release of systemic inflammatory markers.

APR-246 overcomes resistance to cisplatin and doxorubicin in ovarian cancer cells

Two main causes of platinum resistance are mutation in the tumor suppressor gene TP53 and drug-induced increase in intracellular glutathione concentration. Mutations in TP53 occur in about 50% of human tumors. APR-246 (PRIMA-1(MET)) is the first clinical-stage compound that reactivates mutant p53 and induces apoptosis. APR-246 is a prodrug that is converted to the active compound methylene quinuclidinone (MQ), a Michael acceptor that binds to cysteine residues in mutant p53 and restores its wild-type conformation. Here, we show that MQ also binds to cysteine in glutathione, thus decreasing intracellular free glutathione concentration. We also show that treatment with APR-246 completely restores the cisplatin and doxorubicin sensitivity to p53-mutant drug-resistant ovarian cancer cells. We propose that this unique ability of APR-246/MQ to bind to cysteines in both mutant p53 and glutathione has a key role in the resensitization as well as in the outstanding synergistic effects observed with APR-246 in combination with platinum compounds in ovarian cancer cell lines and primary cancer cells. However, MQ binding to cysteines in other targets, for example, thioredoxin reductase, may contribute as well. Strong synergy was also observed with the DNA-damaging drugs doxorubicin and gemcitabine, while additive effects were found with the taxane docetaxel. Our results provide a strong rationale for the ongoing clinical study with APR-246 in combination with platinum-based therapy in patients with p53-mutant recurrent high-grade serous (HGS) ovarian cancer. More than 96% of these patients carry TP53 mutations. Combined treatment with APR-246 and platinum or other DNA-damaging drugs could allow dramatically improved therapy of a wide range of therapy refractory p53 mutant tumors.

APR-246 overcomes resistance to cisplatin and doxorubicin in ovarian cancer cells

Two main causes of platinum resistance are mutation in the tumor suppressor gene TP53 and drug-induced increase in intracellular glutathione concentration. Mutations in TP53 occur in about 50% of human tumors. APR-246 (PRIMA-1(MET)) is the first clinical-stage compound that reactivates mutant p53 and induces apoptosis. APR-246 is a prodrug that is converted to the active compound methylene quinuclidinone (MQ), a Michael acceptor that binds to cysteine residues in mutant p53 and restores its wild-type conformation. Here, we show that MQ also binds to cysteine in glutathione, thus decreasing intracellular free glutathione concentration. We also show that treatment with APR-246 completely restores the cisplatin and doxorubicin sensitivity to p53-mutant drug-resistant ovarian cancer cells. We propose that this unique ability of APR-246/MQ to bind to cysteines in both mutant p53 and glutathione has a key role in the resensitization as well as in the outstanding synergistic effects observed with APR-246 in combination with platinum compounds in ovarian cancer cell lines and primary cancer cells. However, MQ binding to cysteines in other targets, for example, thioredoxin reductase, may contribute as well. Strong synergy was also observed with the DNA-damaging drugs doxorubicin and gemcitabine, while additive effects were found with the taxane docetaxel. Our results provide a strong rationale for the ongoing clinical study with APR-246 in combination with platinum-based therapy in patients with p53-mutant recurrent high-grade serous (HGS) ovarian cancer. More than 96% of these patients carry TP53 mutations. Combined treatment with APR-246 and platinum or other DNA-damaging drugs could allow dramatically improved therapy of a wide range of therapy refractory p53 mutant tumors.

APR-246 overcomes resistance to cisplatin and doxorubicin in ovarian cancer cells

Two main causes of platinum resistance are mutation in the tumor suppressor gene TP53 and drug-induced increase in intracellular glutathione concentration. Mutations in TP53 occur in about 50% of human tumors. APR-246 (PRIMA-1^MET) is the first clinical-stage compound that reactivates mutant p53 and induces apoptosis. APR-246 is a prodrug that is converted to the active compound methylene quinuclidinone (MQ), a Michael acceptor that binds to cysteine residues in mutant p53 and restores its wild-type conformation. Here, we show that MQ also binds to cysteine in glutathione, thus decreasing intracellular free glutathione concentration. We also show that treatment with APR-246 completely restores the cisplatin and doxorubicin sensitivity to p53-mutant drug-resistant ovarian cancer cells. We propose that this unique ability of APR-246/MQ to bind to cysteines in both mutant p53 and glutathione has a key role in the resensitization as well as in the outstanding synergistic effects observed with APR-246 in combination with platinum compounds in ovarian cancer cell lines and primary cancer cells. However, MQ binding to cysteines in other targets, for example, thioredoxin reductase, may contribute as well. Strong synergy was also observed with the DNA-damaging drugs doxorubicin and gemcitabine, while additive effects were found with the taxane docetaxel. Our results provide a strong rationale for the ongoing clinical study with APR-246 in combination with platinum-based therapy in patients with p53-mutant recurrent high-grade serous (HGS) ovarian cancer. More than 96% of these patients carry TP53 mutations. Combined treatment with APR-246 and platinum or other DNA-damaging drugs could allow dramatically improved therapy of a wide range of therapy refractory p53 mutant tumors.

IgE-receptor Activation of Mast Cells Regulates Phosphorylation and Expression of Forkhead and Bcl-2 Family Members

Activation of the high-affinity IgE-receptor, FcepsilonRI, expressed on mast cells can result in either enhanced survival or apoptosis depending on the circumstances. In this study, we have analysed signalling pathways involved in the regulation of mast cell survival and apoptosis. FcepsilonRI cross-linking induces phosphorylation of Akt and its downstream target forkhead transcription factors. In addition, Bad, GSK-3beta and IkappaB-alpha also become phosphorylated. A1, a prosurvival Bcl-2 homologue transcriptionally controlled by NFkappaB transcription factors, is upregulated upon FcepsilonRI activation. These events have prosurvival effects on the mast cells. Moreover, FcepsilonRI activation upregulates the levels of the proapoptotic protein Bim and induces a rapid, but transient, phosphorylation of Bim. Thus, FcepsilonRI activation of mast cells leads to both prosurvival and proapoptotic signalling events where the outcome most likely depends on the balance between these signals.

Proapoptotic Bcl-2 family member Bim is involved in the control of mast cell survival and is induced together with Bcl-XL upon IgE-receptor activation

Mast cells play critical roles in the regulation of acute and chronic inflammations. Apoptosis is one of the mechanisms that limit and resolve inflammatory responses. Mast cell survival can be controlled by growth factors and activation of the IgE-receptor FcvarepsilonRI. Members of the Bcl-2 protein family are critical regulators of apoptosis and our study provides evidence that the proapoptotic BH3-only family member Bim is essential for growth factor deprivation-induced mast cell apoptosis and that Bim levels increase upon FcvarepsilonRI activation. Bim deficiency or Bcl-2 overexpression delayed or even prevented cytokine withdrawal-induced mast cell apoptosis in culture. The prosurvival protein Bcl-XL and the proapoptotic Bim were both induced upon FcvarepsilonRI activation. These results suggest that Bim and possibly also other BH3-only proteins control growth factor withdrawal-induced mast cell apoptosis and that the fate of mast cells upon FcvarepsilonRI activation depends on the relative levels of pro- and antiapoptotic Bcl-2 family members.

Stem cell factor-induced migration of mast cells requires p38 mitogen-activated protein kinase activity

Stem cell factor (SCF) can be considered a cardinal cytokine in mast cell biology as it affects mast cell differentiation, survival, and migration. The objective of this study was to investigate the role of two mitogen-activated protein (MAP) kinases, extracellular signal-regulated kinase (ERK) and p38, in SCF-induced cell migration. This was examined in mouse mast cells by using PD 098059 and SB203580, which are specific inhibitors of mitogen-induced extracellular kinase (MEK) and p38 MAP kinase, respectively. SCF induced a rapid and transient activation of ERK and p38 in a dose-dependent manner. Inhibition of p38 activity by SB203580 was paralleled with a marked reduction of migration toward SCF, whereas the effect of the MEK inhibitor was less pronounced. This is the first report of a physiological function of SCF-dependent activation of p38. Whether p38-mediated mast cell migration is a possible target for suppression of mast cell hyperplasia remains to be determined.

A polymorphic region in the human transcription factor AP-2beta gene is associated with specific personality traits

Transcription factor AP-2beta is implicated in playing an important role during embryonic development of different parts of the brain, eg, midbrain, hindbrain, spinal cord, dorsal and cranial root ganglia.1,2 The gene encoding AP-2beta contains a polymorphic region which includes a tetranucleotide repeat of [CAAA] four or five times, located in intron 2 between nucleotides 12593 and 12612.3 Since the midbrain contains structures important for variables such as mood and personality, we have investigated if the AP-2beta genotype is associated with personality traits estimated by the Karolinska Scales of Personality (KSP). Identification of transcription factor genes as candidate genes in psychiatric disorders is a novel approach to further elucidate the genetic factors that, together with environmental factors, are involved in the expression of specific psychiatric phenotypes. The AP-2beta genotype and KSP scores were determined for 137 Caucasian volunteers (73 females and 64 males). The personality traits muscular tension, guilt, somatic anxiety, psychastenia and indirect aggression were significantly associated with the specific AP-2beta genotype, albeit with significant difference between genders. Based on this result the human AP-2beta gene seems to be an important candidate gene for personality disorders. Moreover, the present results suggest that the structure of the intron 2 region of the AP-2beta gene is one factor that contributes to development of the constitutional component of specific personality traits.

Incidence of spontaneous abortion following artificial insemination by donor

This study examines the frequency of spontaneous abortions in pregnancies achieved by artificial inseminations with donor semen (AID), with special respect to the use of cryopreserved semen and ovulation induction with clomiphene citrate. The abortion rate was found to be similar in AID series using frozen semen to those using fresh semen, nor was the rate increased in composite AID series (both fresh and frozen semen) when compared with the rate of spontaneous abortions in the general population. When clomiphene was used, the abortion rate was increased only in groups of anovulatory and irregularly ovulating women. Those AID series where all women treated are given clomiphene show no increase in abortion rates. The discussion is focused on factors that influence the abortion rate and on possible etiological factors.