Exercise testing soon after myocardial infarction

Forty-six men under age 70, without clinical congestive heart failure or unstable angina pectoris, performed treadmill tests 3, 5, 7, 9 and 11 weeks after myocardial infarction. Patients were more frequently able to perform moderate exertion (2 mph, 14% grade) at 7 and 11 weeks than at 3 weeks following infarction. Ischemic ST-segment depression, usually unaccompained by angina pectoris, occurred in 45% of patients and was associated with a significantly increased incidence of subsequent coronary events. The presence of exercise-induced ventricular ectopic activity provided little independent prognostic information. No serious complications occurred in 210 tests. Exercise testing soon after myocardial infarction provides objective information concerning the capacity to resume physical activity, including return to work. Two tests, at 3-5 weeks and at 7-11 weeks, appear to provide most of the information contined in five tests performed during this time.

A new method for evaluating antiarrhythmic drug efficacy

To develop standards for distinguishing antiarrhythmic drug effect from spontaneous variability of premature ventricular complexes (PVCs), 21 males (mean age 56 +/- 8 years) with chronic ischemic heart disease and PVCs underwent symptom-limited treadmill exercise testing and 24-hour ambulatory monitoring before and after 2 weeks of placebo medication. Linear regression analysis was used to describe the relationship between baseline and placebo PVC frequency for various indexes of ventricular ectopic activity and to establish 95% and 99% one-tailed confidence intervals for this relationship within the group of 21 patients. The lower limit of baseline PVC frequency for which the procedure could distinguish a placebo from a true drug response, termed the "sensitivity threshold," was an average frequency of 2.2 PVCs/hour for ambulatory electrocardiographic monitoring and 1.2 PVCs/min for treadmill exercise testing. All patients exceeded the sensitivity threshold on baseline ambulatory ECGs, but only 38% of patients did so on baseline treadmill exercise tests. To establish antiarrhythmic efficacy with 95% confidence, the minimal percent reduction of PVCs between baseline and placebo visits was 68% for treadmill exercise testing and 65% for ambulatory electrocardiography. Although these standards were developed in patients with chronic ischemic heart disease, the model can be used to establish antiarrhythmic drug efficacy in any patient group.

Cardiovascular responses to dynamic and static effort soon after myocardial infarction. Application to occupational work assessment

Static and dynamic work involving the arms and the legs was performed by 40 men seven weeks after myocardial infarction. Leg ergometry produced a significantly higher peak work load, systolic blood pressure (BPs), heart rate (HR), and HR X BPs X 10(-2) product (DP) than did arm ergometry: 842 +/- 178 vs 546 +/- 135 kg-m/min, 176 +/- 24 vs 154 +/- 19 mm Hg and 256 +/- 54 vs 219 +/- 48 (SD). Peak heart rates were 145 and 142. Endpoints were primarily muscular and generalized fatigue and dyspnea. Ischemic abnormalities and ventricular ectopy were more frequent with leg ergometry. Sustained forearm lifting elicited higher HR, PBs and DP responses than sustained handgrip contraction: 95 +/- 16 vs 91 +/- 16 beats/min, 162 +/- 18 vs 152 +/- 17 mm Hg and 154 +/- 33 vs 139 +/- 33 (SD). Ischemic ST segment depression and significant ventricuar arrhythmias were infrequent with static effort. Dynamic leg testing is superior to dynamic or static arm testing in assessing the capacity of patients to perform physical work tasks after myocardial infarction.

Deleterious BRCA1/2 mutation is an independent risk factor for carboplatin hypersensitivity reactions

Background:

We tested the hypothesis that BRCA1/2 mutation carriers with ovarian cancer are at higher risk of carboplatin hypersensitivity reactions (HSRs).

Methods:

Medical records of women enrolled in two carboplatin+olaparib clinical trials (NCT01237067/NCT01445418) were reviewed. A maximum of eight cycles containing carboplatin were administered.

Results:

All women (N=87) had good performance status and end-organ function. Incidences of carboplatin HSR before enrolment and on study were 17% and 21%, respectively. Most patients who developed carboplatin HSR had a deleterious BRCA1/2 mutation (93%) vs 50% in patients without HSR (P<0.0001). Multivariable analysis accounting for potential confounding variables including age, history of allergies, and cumulative prior carboplatin cycles confirmed deleterious BRCA1/2 mutation as an independent risk factor for carboplatin HSR (odds ratio 13.1 (95% confidence interval 2.6–65.4), P=0.0017). Mutation carriers had onset of carboplatin HSR at lower cumulative exposure (P=0.003). No significant difference in outcome was observed on our study between patients with and without a history of HSR.

Conclusion:

Deleterious BRCA1/2 mutation increased susceptibility and shortened time to carboplatin HSR, independently of other reported factors. These data suggest that at-risk women should be counselled regarding likelihood, symptoms, and potential earlier onset of carboplatin HSRs.

Changes in rest and exercise myocardial perfusion and left ventricular function 3 to 26 weeks after clinically uncomplicated acute myocardial infarction: effects of exercise training

The effects of exercise training on exercise myocardial perfusion and left ventricular (LV) function in the first 6 months after clinically uncomplicated acute myocardial infarction (AMI) were assessed in 53 consecutive men aged 55 +/- 9 years. Symptom-limited treadmill exercise with thallium myocardial perfusion scintigraphy and symptom-limited upright bicycle ergometry with equilibrium gated radionuclide ventriculography were performed 3, 11 and 26 weeks after AMI by 23 men randomized to training and 30 randomized to no training. Peak cycle capacity increased in both groups between 3 and 26 weeks (p less than 0.01), but reached higher levels in trained than in untrained patients (803 +/- 149 vs 648 +/- 182 kg-m/min, p less than 0.01). Reversible thallium perfusion defects were significantly more frequent at 3 than at 26 weeks: 59% and 36% of patients, respectively (p less than 0.05), without significant inter-group differences. Values of LV ejection fraction at rest, submaximal and peak exercise did not change significantly in either group. The increase in functional capacity, i.e., peak treadmill or bicycle workload, that occurred 3 to 26 weeks after infarction was significantly correlated with the increase in peak exercise heart rate (p less than 0.001), but not with changes in myocardial perfusion or LV function determined by radionuclide techniques. Changes in myocardial perfusion or LV function do not appear to account for the improvement in peak functional capacity that occurs within the first 6 months after clinically uncomplicated AMI.

Comparison of cardiovascular responses to static-dynamic effort and dynamic effort alone in patients with chronic ischemic heart disease

Thirty men, mean age 55 years, known to have treadmill-induced ischemic ST-segment depression, performed static and dynamic effort, i.e., forearm lifting and treadmill exercise, separately and combined. Static effort was sustained at 20%, 25% or 30% of maximal forearm lifting capacity. Two symptom-limited treadmill tests, one with and one without added static effort, were performed on each of two visits. Compared with dynamic effort alone, combined static-dynamic effort decreased treadmill work load and increased heart rate, systolic blood pressure and rate-pressure product at the onset of ischemic ST-segment depression or angina pectoris: 7.1 +/- 0.4 vs 8.0 +/- 0.5 (SEM) multiples of resting oxygen consumption (mets), estimated; 141 +/- 3 vs 134 +/- 3 beats/min; 170 +/- 4 vs. 162 +/- 4 mm Hg and 239 +/- 8 vs 218 +/- 9 (p less than 0.001). The prevalence of angina pectoris was significantly less with combined static-dynamic effort than with dynamic effort alone. Static effort causes a resetting of the threshold at which ischemic abnormalities appear during dynamic effort.

Comparison of cardiovascular response to combined static-dynamic effort, postprandial dynamic effort and dynamic effort alone in patients with chronic ischemic heart disease

The cardiovascular responses to combined static-dynamic effort, postprandial dynamic effort and dynamic effort alone were evaluated by upright bicycle ergometry during equilibrium-gated blood pool scintigraphy in 24 men, mean age 59 +/- 8 years, with chronic ischemic heart disease. Combined static-dynamic effort and the postprandial state elicited a peak cardiovascular response similar to that of dynamic effort alone; work load 643 +/- 156 and 638 +/- 161 vs 650 +/- 153 kg-m/min, respectively; heart rate 147 +/- 14 and 145 +/- 14 vs 143 +/- 17 beats/min; systolic pressure 195 +/- 26 and 200 +/- 25 vs 197 +/- 25 mm Hg; and rate-pressure product 286 +/- 48 and 292 +/- 55 vs 282 +/- 52. Heart rate, intraarterial systolic and diastolic pressures, rate-pressure product and ejection fraction were similar for the three test conditions at the onset of ischemia and at peak effort. The prevalence and extent of exercise-induced ischemic left ventricular dysfunction, ST-segment depression, angina pectoris and ventricular ectopic activity were also similar during the three test conditions. Direct and indirect measurements of systolic and diastolic blood pressure were highly correlated. The onset of ischemic ST-segment depression and angina pectoris correlated as strongly with heart rate alone as with the rate-pressure product during all three test conditions. The cardiovascular response to combined static-dynamic effort and to postprandial dynamic effort becomes more similar to that of dynamic effort alone as dynamic effort reaches a symptom limit. If significant ischemic and arrhythmic abnormalities are absent during symptom-limited dynamic exercise testing, they are unlikely to appear during combined static-dynamic or postprandial dynamic effort. This simplifies, the task of formulating guidelines for physical effort in patients with chronic ischemic heart disease, especially in providing "clearance" to perform avocational and vocational tasks involving combined static-dynamic and postprandial dynamic effort.

The effect of a standardized psychological stressor on the cardiovascular response to physical effort soon after uncomplicated myocardial infarction

To determine whether a standardized psychological stressor combined with physical stress might disclose ischemic abnormalities not evident with physical stress alone, 30 men, mean age 54, were evaluated seven weeks after clinically uncomplicated myocardial infarction. In the first 20 patients, two symptom-limited treadmill tests (TM) were performed on the same day, with and without superimposed psychological quiz (Q). In the next 10 consecutive patients, the Q was administered at a submaximal level (4 METs). When TM and TM + Q responses were compared, no significant differences were noted in the maximal levels of heart rate (HR), systolic blood pressure (SBP), rate pressure product, or in the prevalence of ischemic ST segment depression or angina pectoris. The HR and double product at which ischemic ST segment depression and angina pectoris appeared were similar for the two types of testing. The psychological stress of a psychological quiz may not, of course, approximate the effect of the more severe stressors individuals may encounter in their daily routines.

Acceptability, facilitators, and barriers to a hypothetical HIV vaccine in the pre-exposure prophylaxis era

Little is known about the pre-implementation context for a preventive HIV vaccine. We conducted interviews of individuals in Philadelphia recruited at Penn clinics and community-based organizations serving LGBTQ-identifying persons of color who 1) were cisgender men who had sex with men, or were transgender-identified, 2) had a sexually transmitted infection in the last 12 months, or sex with multiple partners within the last two weeks. We assessed acceptability, facilitators, and barriers to a hypothetical HIV vaccine using an integrated analysis approach. We interviewed 30 individuals between 2/2023-9/2023. Participants were supportive of an HIV vaccine and reported that they would strongly consider receiving one if one became available. Participants contextualized a hypothetical vaccine with the current HIV prevention context, primarily pre-exposure prophylaxis (PrEP), indicating that they would evaluate any future vaccine in comparison to their experience within the PrEP landscape.Reported facilitators for a hypothetical HIV vaccine included vaccine access, knowledge, and understanding; their risk for HIV exposure; and perceived benefits of the vaccine. Barriers included lack of understanding of the purpose of a vaccine, stigma surrounding HIV and sexual practices that may surface towards people who seek vaccination, and potential issues with effectiveness, side effects, or lack of availability.

Abstract OT2-06-01: Phase I/II study of T-DM1 alone versus T-DM1 and metronomic temozolomide in secondary prevention of HER2-Positive breast cancer brain metastases following stereotactic radiosurgery

Background: Brain metastases occur in up to 25-40% of HER2+ breast cancer patients. Standard treatment is limited to surgery or stereotactic radiosurgery (SRS) and/or whole brain radiation therapy (WBRT), with high levels of recurrence or progression, limiting survival and quality of life in most patients. Our group has demonstrated that low doses of temozolomide (TMZ) administered in a prophylactic, metronomic fashion can significantly prevent development of brain metastases in murine models of breast cancer. Based on these findings, we propose a secondary-prevention clinical trial.

Trial Design: Phase I/II open label study. Phase I will follow a standard 3+3 design: T-DM1 3.6 mg/kg IV every 21 days plus TMZ 30, 40 or 50 mg/m2 daily. Phase II: randomization T-DM1 3.6 mg/kg versus T-DM1 3.6mg/kg plus TMZ at recommended phase 2 dose (RP2D). Patients will undergo radiology guided lumbar puncture at baseline and after 6 weeks of treatment (C3D1) for correlative studies, brain MRI, systemic restaging CTs, and questionnaires for evaluation of symptoms and quality of life (MDASI-BT and PROMIS®) every 6 weeks.

Eligibility: HER2+ breast cancer with ≤3 brain metastases, treated with SRS and/or resection ≤6 weeks before enrollment, no leptomeningeal metastases, no previous WBRT, able to complete brain MRI with contrast evaluations, willing to undergo lumbar puncture, ECOG ≤2 and adequate organ and marrow function. HBV, HCV or HIV-positive patients are ineligible.

Specific Aims: Phase I: to identify the maximum tolerated dose (MTD) of TMZ combined with T-DM1. Phase II: to determine if the combination regimen of T-DM1 and TMZ improves the recurrence-free incidence from distant new brain metastases at one year as compared to T-DM1 alone. Biomarkers, including cell free DNA sequencing from CSF, serum and tumor block, serum markers for neuroinflammation, and patient reported outcomes, will be analyzed in an exploratory fashion.

Statistical Methods: Phase I, MTD will be identified based on the dose level at which 0 or 1 patient in 6 has a DLT. Phase II, to test whether TMZ will increase RFS from 50% to 65% at 12 months. RFS Kaplan-Meier curves will be created for each of the randomized arms and compared using a one-tailed log-rank test, with a one-sided 0.10 significance level of interest to be detected. Patients will be stratified for number of brain lesions and status of systemic metastases (controlled or not).

Target Accrual: 49 evaluable patients per arm (total 98), plus 9 to 18 patients during phase I. Trial will open in Summer 2017, at NIH in Bethesda, MD.

Contact Information: Principal Investigator: Alexandra S Zimmer, MD alexandra.zimmer@nih.gov

Citation Format: Zimmer AS, Gril B, Steinberg S, Smart D, Gilbert M, Armstrong T, Xiao L, Houston N, Biassou N, Brastianos P, Carter S, Lyden DC, Lipkowitz S, Steeg P. Phase I/II study of T-DM1 alone versus T-DM1 and metronomic temozolomide in secondary prevention of HER2-Positive breast cancer brain metastases following stereotactic radiosurgery [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr OT2-06-01.