Temporal evolution of liver function parameters predicts clinical outcome in chronic heart failure patients (Bio-SHiFT Study)

Background

Liver dysfunction contributes to worse clinical outcome in heart failure (HF) patients, and cholestatic enzymes are associated with mortality in the setting of chronic HF (CHF). However, the temporal evolutions of liver function parameters in stable CHF patients, and their associations with clinical outcome, have not yet been investigated.

Purpose

We aimed to investigate in detail the temporal patterns of alkaline phosphatase (ALP), gamma glutamyl transpeptidase (GGTP), total bilirubin (TBIL) and albumin (ALB), and their relation with clinical outcome, in patients with stable CHF with reduced ejection fraction (HFrEF).

Methods

During 2.2 (1.4–2.5) years of follow-up, we collected 1984 tri-monthly plasma samples in 263 patients. We selected 749 samples in the 250 HFrEF patients included in the study - all baseline samples, the last two samples before censoring in event-free patients, and the last two samples preceding the primary endpoint (PEP; composite of cardiac death, heart transplantation, LVAD implantation, and hospitalization for the management of acute or worsened HF). In these samples ALP, GGTP, and ALB were measured using colorimetric assays, TBIL using diazomethod, all by Roche/Hitachi Cobas c analyser. The relationship between repeatedly measured biomarker levels and the PEP was evaluated by joint models.

Results

Mean age was 68±18 years; 74% were men, 25% in NYHA class III or IV. 66 patients (26%) reached the PEP.

Repeatedly measured levels of TBIL, ALP, GGTP and ALB were associated with the PEP in a model adjusted for NT-proBNP and hs-TnT (hazard ratio (HR) [95% confidence interval] per doubling of biomarker level: 1.98 [1.32; 2.95], p=0.002; 1.84 [1.09; 3.05], p=0.018, 1.33 [1.08; 1.63], p=0.006 and 1.14 [1.09; 1.20], p<0.001, respectively). Serially measured ALP and GGTP remained significantly associated with the PEP after adjustment for clinical covariates (HR [95% CI]: 1.13 [1.07; 1.19], p=0.018; 1.03 [1.01; 1.06], p=0.006, respectively).

The levels of ALP and GGTP were higher in patients who experienced the PEP than in event-free patients long before the PEP occurred (>2 years), and as the PEP approached, levels diverged slightly between those with and without the PEP (Figure 1). Conversely, levels of ALB were higher in those with subsequent PEP, >2 years before the PEP, and subsequently fell; while TBIL levels rose less than 1 year before the PEP in those with subsequent PEP. The slopes of the temporal evolution of ALB and TBIL, adjusted for clinical variables, were also significantly associated with the PEP (HR [95% CI] per 20% decrease in the slope for albumin and increase in the slope of TBIL per year: 1.61 [1.43; 1.84], p<0.001 and 1.72 [1.28; 2.55], p<0.001, respectively).

Conclusions

Changes in serum levels of TBIL, ALP, GGTP and ALB precede adverse cardiovascular events in patients with CHF. These routine liver function parameters may provide additional prognostic information in HFrEF patients in clinical practice.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Jaap Schouten Foundation (Rotterdam, the Netherlands)Noordwest Academie (Alkmaar, the Netherlands)

Serially measured cytokines and cytokine receptors in relation to clinical outcome in patients with stable heart failure

Background

Activation of the inflammatory response in heart failure (HF) may initially serve as a compensatory mechanism. However, on the longer term, this physiological phenomenon can become disadvantageous. Temporal patterns of inflammatory proteins other than CRP have not yet been investigated in patients with stable HF.

Purpose

We aimed to evaluate the association of 17 serially measured cytokines and cytokine receptors with clinical outcome in patients with stable heart failure.

Methods

In 263 patients, 1984 serial, tri-monthly blood samples were collected during a median follow-up of 2.2 (IQR: 1.4–2.5) years. The primary endpoint (PE) composed of cardiovascular mortality, HF-hospitalization, heart transplantation, and LVAD. We selected baseline blood samples in all patients, as well as the two samples closest to the primary endpoint, and the last sample available in event-free patients. Thus, in 567 samples we measured 17 cytokines and cytokine receptors using the Olink Proteomics Cardiovascular III multiplex assay. Associations between biomarkers and PE were investigated by joint modelling.

Results

Median age was 68 (IQR: 59–76) years, with 72% men, 74% NYHA class I-II and a median ejection fraction of 30% (23–38%). 70 patients reached a PE. After adjustment for clinical characteristics (age, sex, diabetes, atrial fibrillation, NYHA class at baseline, diuretics and systolic blood pressure), 7 biomarkers were associated with the PE (Figure). Interleukin-1 receptor type 1 (IL1RT1) showed the strongest association: HR 2.65 [95% CI: 1.78–4.21]) per standard deviation change in level (NPX) at any point in time during follow-up, followed by Tumor necrosis factor receptor 1 (TNF-R1): 2.25 [1.66–3.08], and C-X-C motif chemokine 16 (CXCL16): 2.18 [1.59–3.04]. After adjustment for baseline N-terminal pro–B-type natriuretic peptide, high-sensitive troponin T and C-reactive protein however, only IL1RT1 and TNF-R1 remained significantly associated with the PE.

Conclusion

Repeatedly measured levels of several cytokines and cytokine receptors are independently associated with clinical outcome in stable HF patients. These results suggest that repeated measurements of these biomarkers, in addition to established cardiac biomarkers, may contribute to personalized risk assessment and herewith better identify high-risk patients.

Figure 1. Associations between levels of cytokines and cytokine receptors and the primary endpoint.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): This work was supported by the Jaap Schouten Foundation and the Noordwest Academie.

Hospital@Home: a proof of concept

Background

Expenditure in healthcare in the Netherlands is so increasing that currently 1 in 7 employees are working in the health care/cure. Future expansion is under constrain given the 10% of GDP use and shortage of working force.Dutch healthcare consists of a cure section (mostly hospitals) and nursing care@home. Both entities have different national budgets (€25 + €20bln)

Methods

In a proof of concept, we explored a new Hospital@Home (H@H) model combining hospital cure and home-care budgets in a 800 mi2 district with 850,000 inhabitants. The objective comprises 4 proofs: (1)provide hospital care@home, (2) combine financial budgets (3) increasing working forces by combining teams, (4) increased satisfaction of pts and nursing staff.

Results

We proofed a joining budgets of the hospital and home-care group for cardiology. The homecare-budget was sufficient to hire 3 nurse practitioners who are trained by the cardiologists and work with 16 home-care cardiovascular nurses for H@H treatment. The hospital budget provided a virtual EHR cardiology ward and supplied the home care-nurses with a nursing app to assess the patients EHR. Budgets were sufficient to obtain the home-heartfailure monitoring application. The cardiology-group developed the H@H program for endocarditis treatment and heartfailure telemonitoring. Clinically, in the first 6 months, 50% of hospitalized endocarditis pts were treated with iv antibiotics@home with an average 16.5 days per pt shorter admission days without complications. 33% of eligible hospitalized heartfailure pts consented for telemonitoring@home while up-titrated on medication. Video-consulting reduced outpatient visits with 75%. Patient satisfaction was 75/100.

Conclusion

In this proof of concept, the H@H program provided hospital cure at home by merging hospital and home-care nursing staff and ICT budgets. Patient satisfaction score were driven by shorter admissions and less hospital visits. We call for further exploration of efforts to facilitate combined home-care and hospital-cure transmural budgets to confirm this proof of concept.

Funding Acknowledgement

Type of funding source: None

5948Circulating biomarkers of cell adhesion in relation to clinical outcomes in patients with chronic heart failure: the Bio-SHiFT study

Background

Cardiovascular inflammation and vascular endothelial dysfunction are present in chronic heart failure (CHF), and cellular adhesion molecules are considered to play a key role in these mechanisms. The temporal patterns of the blood biomarkers involved could provide further insights into these processes.

Purpose

We aimed to evaluate the prognostic value of the temporal patterns of blood biomarkers of cell adhesion in stable patients with CHF.

Methods

In 263 patients, a median of 9 (IQR: 5–10) serial, tri-monthly blood samples were collected during a median follow-up of 2.2 (IQR: 1.4–2.5) years. The composite primary endpoint (PE) of cardiovascular mortality, HF-hospitalization, heart transplantation and LVAD was reached in 70 patients. For efficiency, we selected all baseline samples, the two samples closest to a PE, and the last sample available for event-free patients. Thus, in 567 samples we measured twelve biomarkers of cell adhesion using the Olink Proteomics Cardiovascular III multiplex assay. Associations between biomarkers and first PE were investigated by combining linear mixed effect models and Cox regression (so-called joint model).

Results

Median age was 68 (IQR: 59–76) years, with 72% men and 74% NYHA class I-II. Levels of CD93 (Complement component C1q receptor), CDH5 (VE cadherin), CHI3L1 (Chitinase-3-like protein 1), EPHB4 (Ephrin type-B receptor 4) and JAM-A (Junctional adhesion molecule A) differed at baseline already. The average biomarker evolutions of these markers, and additionally of ICAM-2 (Intercellular adhesion molecule-2), showed different patterns in patients approaching the PE versus those who remained event-free (Figure 1). Repeatedly measured levels of these biomarkers were independently associated with the PE. Corresponding HRs [95% CI] per 1SD increase in log2 level (arbitrary unit) were: CD93: 1.85 [1.29–2.70], CDH5: 1.72 [1.23–2.44], CHI3L1: 2.45 [1.73–3.56], EPHB4: 1.83 [1.33–2.55], ICAM2: 1.74 [1.24–2.46] and JAM-A: 2.07 [1.39–3.18], adjusted for clinical characteristics (age, sex, diabetes, atrial fibrillation, baseline NYHA class, diuretics, systolic blood pressure and eGFR).

Figure 1. Average temporal patterns of cell adhesion biomarkers during follow-up.

Conclusion

CD93, CDH5, CHI3L1, EPHB4, ICAM2 and JAM-A show different patterns as adverse events approach in CHF patients, and their temporal patterns strongly predict clinical outcome. These findings demonstrate the incremental value of repeated measurements of biomarkers of cell adhesion in stable patients with CHF.

Acknowledgement/Funding

This work was supported by the Jaap Schouten Foundation and the Noordwest Academie.

P1644Personalized screening intervals for measurement of n-terminal pro-b-type natriuretic peptide improve efficiency of prognostication in patients with chronic heart failure

Background

Predefined screening intervals and target levels do not account for variations in temporal patterns of biomarkers between individuals, which may hamper their potential use for therapy guidance. Conversely, a personalized screening approach with screening intervals and target levels based on the evolution of biomarkers in individual patients may further improve risk assessment and therapy guidance.

Purpose

We hypothesize that personalized screening intervals for N-terminal pro-B-type natriuretic peptide (NT-proBNP) measurements in patients with chronic heart failure (CHF) maximize information gain on the individual patient's disease progression, while minimizing the number of necessary measurements. We aim to compare such personalized scheduling of NT-proBNP measurements to a predefined fixed scheduling approach.

Methods

In 263 CHF patients from the Bio-SHiFT study, NT-proBNP was measured trimonthly according to a prespecified, fixed schedule [median: 9 (IQR: 5–10) measurements per patient].The primary composite endpoint (PE) comprised cardiac death, cardiac transplantation, left ventricular assist device implantation or heart failure hospitalization, and occurred in 70 patients (26.6%). Using joint models for time-to-event and longitudinal data, we modelled the association between repeated NT-proBNP measurements and the PE. Using the fitted joint model, for each patient at each follow-up visit, we determined the optimal time point of the next NT-proBNP measurement based on the patient's individual risk profile and the maximum information gain on the patient's prognosis as assessed by the Kullback-Leibler divergence. Personalized scheduling was compared to fixed (trimonthly) scheduling by means of a realistic simulation study, based on a replica of the study population included in the Bio-SHiFT study. In this simulation study, we stopped monitoring NT-proBNP to potentially enable appropriate timely intervention if the cumulative risk of PE exceeded an arbitrary risk threshold of 7.5% within 3-months. We compared personalized scheduling with fixed scheduling in terms of capability of identification of high-risk intervals (whether timely intervention was enabled before occurrence of PE), number of measurements needed, and costs.

Results

Compared to fixed scheduling, personalized scheduling saved on average 2 measurements [personalized; median: 7 (IQR: 7–8) vs. fixed; 9 (IQR: 8–10) measurements], while the start of the time-window identified for therapeutic intervention to avoid the occurrence of PE was similar in both approaches [personalized; median: 6.6 (IQR: 4.5–11.3) vs. fixed; 6.3 (IQR: 4.2–10.3) months before occurrence of PE]. Costs saved were €165 per patient per year.

Figure 1

Conclusion

Personalized scheduling of NT-proBNP measurements in CHF patients shows similar prognostic performance as fixed scheduling, but requires fewer NT-proBNP measurements. This may improve efficiency of natriuretic guided therapy, if the latter were to be installed.

Acknowledgement/Funding

Funding for this study was provided by the Jaap Schouten Foundation and Erasmus MC Efficiency Research grant

Alterations in plasma lipoproteins and heparin-releasable lipase activities in mice bearing the GRSL ascites tumor

The lipoproteins in GR mice bearing the transplanted GRSL ascites tumor were characterized by density gradient ultracentrifugation and SDS-polyacrylamide gel electrophoresis. In control mice the major proportion of the lipoproteins was found in the HDL density range, but on days 4 and 5 following tumor transplantation a gradual shift into the LDL density range was observed. At the same time the apolipoprotein E content increased at the expense of apolipoprotein A-I. VLDL became moderately elevated. On days 6 and 7 all lipoproteins except VLDL reached extremely low values. The C-apolipoproteins showed a remarkable shift in their relative proportions. Plasma lecithin:cholesterol acyltransferase activity showed no significant alteration in the course of tumor growth, but the triacylglycerol lipases in postheparin plasma were strongly decreased. Lipoprotein lipase had already started to decline on day 2 following tumor transplantation. However, when assayed in the presence of heat-inactivated control plasma, a decrease was not observed before day 5. This is suggestive of a depletion of a plasma cofactor preceding the final disappearance of the enzyme itself, and is compatible with the changing apolipoprotein C pattern. Hepatic lipase showed a 50% reduction between days 3 and 4. The lipoprotein alterations in tumor-bearing mice are explained as a direct consequence of the decreased lipase activities.