Reprogramming the Intrahepatic Cholangiocarcinoma Immune Microenvironment by Chemotherapy and CTLA-4 Blockade Enhances Anti-PD-1 Therapy

Intrahepatic cholangiocarcinoma (ICC) has limited therapeutic options and a dismal prognosis. Adding blockade of the anti-programmed cell death protein (PD)-1 pathway to gemcitabine/cisplatin chemotherapy has recently shown efficacy in biliary tract cancers but with low response rates. Here, we studied the effects of anti-cytotoxic T lymphocyte antigen (CTLA)-4 when combined with anti-PD-1 and gemcitabine/cisplatin in orthotopic murine models of ICC. This combination therapy led to substantial survival benefits and reduction of morbidity in two aggressive ICC models that were resistant to immunotherapy alone. Gemcitabine/cisplatin treatment increased tumor-infiltrating lymphocytes and normalized the ICC vessels and, when combined with dual CTLA-4/PD-1 blockade, increased the number of activated CD8+Cxcr3+IFNγ+ T cells. CD8+ T cells were necessary for the therapeutic benefit because the efficacy was compromised when CD8+ T cells were depleted. Expression of Cxcr3 on CD8+ T cells is necessary and sufficient because CD8+ T cells from Cxcr3+/+ but not Cxcr3-/- mice rescued efficacy in T cell‒deficient mice. Finally, rational scheduling of anti-CTLA-4 "priming" with chemotherapy followed by anti-PD-1 therapy achieved equivalent efficacy with reduced overall drug exposure. These data suggest that this combination approach should be clinically tested to overcome resistance to current therapies in ICC patients.

Compliance to guideline-recommended pharmacotherapy in patients with heart failure, 2014 to 2020

Background

Poor drug adherence in heart failure (HF) is associated with increased morbidity and mortality.

Aims

We aimed to investigate compliance to European guidelines for treatment of HF in Norway by measuring initiation and persistence of inhibitors of the renin-angiotensin system (RASi), β-blockers (BB) and mineralocorticoid receptor antagonists (MRA).

Methods

We included all patients ≥18 years with a first hospital contact for HF registered in the Norwegian Patient Registry (NPR) between 2014–2020. Patients >80 years of age and patients that deceased within the first 30 days were excluded. The study population was linked to the Norwegian Prescription Database for longitudinal data on drug prescriptions. Dual HF therapy was defined as taking at least two recommended HF drug classes, triple HF therapy was defined as taking all three drug classes. To estimate initiation, we counted the days from index HF to the first HF prescription, dual HF therapy and triple HF therapy within the first 365 days. We repeated the analysis for drug-naive patients, as some patients receive HF drugs for other indications or based on a tentative HF diagnosis. Patients were considered persistent if they did not experience any treatment break of more than 30 days. We allowed for stockpiling up to a maximum of 60 days, except for when the dose changed or if patients switched medication within the same drug class. Initiation and persistence were calculated by the Kaplan-Meier method, followed to death or December 2020.

Results

Out of 54,899 patients, 75%, 69% and 21% initiated BB, RASi and MRA, respectively (Figure 1). 13% of the population did not receive any of the three drug groups. Dual HF therapy was prescribed to 61% of the patients and triple HF therapy to 16%. In drug-naive patients, a lower proportion received any HF-drug within the first year (BB, 61%; RASi, 55%; and MRA, 19%), however, a higher proportion was collected within the first 30 days (BB, 48%; RASi, 46%; and MRA, 11%). Among the patients initiating therapy, 72% were persistent on BB, 71% on RASi and 48% on MRA throughout the first year with prominent declines in persistence around 3 and 6 months after initiation (Figure 2). Two years after initiation, the proportions of patients on BB, RASi and MRA decreased to 58%, 57% and 31%, respectively. The 5-year persistence was 38%, 37% and 15%, respectively.

Conclusion

This study found poor treatment compliance to HF medications in a real-world population of HF patients with only 61% of patients initiating dual pharmacotherapy and only 16% received all three dug classes. Nearly half of the patients discontinued RASi and BB within 2 years. The results suggest that systematic efforts should be done to increase the proportion of patients on guideline recommended therapies. These efforts should be focused on early initiation of multiple drug therapies as well as to maintain patients on treatment over time.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Novartis Norway AS and The Norwegian Research Council

Changes in novel cardiac extracellular matrix biomarkers in STEMI: associations with adverse outcomes

Background

Ischemia-reperfusion (IR)-injury contributes to adverse outcomes following myocardial infarction undergoing reperfusion. Exaggerated remodelling of the extracellular matrix (ECM) is likely to be involved in IR-injury, potentially releasing ECM components to the systemic circulation. To improve prognostication and future therapeutic options in patients with myocardial infarction, more knowledge is warranted about ECM components associated with IR-injury.

Purpose

To investigate whether ECM components quantified in serum samples associate with myocardial injury and function, and clinical outcomes in patients with ST-elevation myocardial infarction (STEMI).

Methods

We selected biomarkers previously suggested to be involved in ECM changes in the heart, i.e. growth differentiation factor 15 (GDF-15), periostin, osteopontin, syndecan-1, syndecan-4, and bone morphogenetic protein 7. The concentrations of the biomarkers were measured in serum samples from patients with STEMI (n=239) enrolled in the POSTEMI trial, at day 1 and month 4 after hospital admission. Infarct size, microvascular obstruction (MVO), left ventricular remodelling, and left ventricular ejection fraction (LVEF) were determined by cardiac magnetic resonance imaging. Major adverse cardiovascular events (MACE) and all-cause mortality were recorded after 12 months and with a median of 70 months, respectively.

Results

Serum levels of GDF-15, osteopontin, syndecan-1 and syndecan-4 declined, whereas periostin increased, from day 1 to month 4. Higher levels of syndecan-1 were associated with the presence of MVO (n=116) (day 1 OR 1.39 (1.06–1.82); month 4 OR 1.53 (1.08–2.17)), while higher GDF-15 and syndecan-1 were associated with the development of large infarct size (>75th percentile, n=57) and reduced cardiac function defined as LVEF <50% (n=64) at month 4. Higher levels of GDF-15 at month 4 and periostin at both time points were associated with increased risk of both MACE (n=16) (GDF-15: HR 1.42 (1.04–1.94); periostin day 1: HR 1.88 (1.09–3.25); periostin month 4: HR 1.64 (1.03–2.62)) and all-cause mortality (n=20) (GDF-15: HR 1.59 (1.28–1.97); periostin day 1: HR 1.85 (1.16–2.95); periostin month 4: HR 2.02 (1.35–3.02)) (Figure 1). On the contrary, elevated levels of syndecan-4 at month 4 were associated with lower risk of adverse outcomes, including all-cause mortality (HR 0.48 (0.28–0.84)) (Figure 1) and less IR-injury as assessed by a higher myocardial salvage index.

Conclusion

Elevated serum levels of GDF-15, periostin, and syndecan-1 were associated with a higher risk of adverse outcomes or detrimental remodelling in patients with STEMI. Increased levels of syndecan-4 measured 4 months after STEMI were associated with a reduced risk of all-cause mortality. Our results suggest the potential use of these biomarkers as prognostic tools and may suggest a role for these ECM components in IR injury.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): South-Eastern Norway Regional Health AuthorityNorwegian Health Association

Placental growth factor promotes tumour desmoplasia and treatment resistance in intrahepatic cholangiocarcinoma

OBJECTIVE

Intrahepatic cholangiocarcinoma (ICC)-a rare liver malignancy with limited therapeutic options-is characterised by aggressive progression, desmoplasia and vascular abnormalities. The aim of this study was to determine the role of placental growth factor (PlGF) in ICC progression.

DESIGN

We evaluated the expression of PlGF in specimens from ICC patients and assessed the therapeutic effect of genetic or pharmacologic inhibition of PlGF in orthotopically grafted ICC mouse models. We evaluated the impact of PlGF stimulation or blockade in ICC cells and cancer-associated fibroblasts (CAFs) using in vitro 3-D coculture systems.

RESULTS

PlGF levels were elevated in human ICC stromal cells and circulating blood plasma and were associated with disease progression. Single-cell RNA sequencing showed that the major impact of PlGF blockade in mice was enrichment of quiescent CAFs, characterised by high gene transcription levels related to the Akt pathway, glycolysis and hypoxia signalling. PlGF blockade suppressed Akt phosphorylation and myofibroblast activation in ICC-derived CAFs. PlGF blockade also reduced desmoplasia and tissue stiffness, which resulted in reopening of collapsed tumour vessels and improved blood perfusion, while reducing ICC cell invasion. Moreover, PlGF blockade enhanced the efficacy of standard chemotherapy in mice-bearing ICC. Conclusion PlGF blockade leads to a reduction in intratumorous hypoxia and metastatic dissemination, enhanced chemotherapy sensitivity and increased survival in mice-bearing aggressive ICC.

Complement activation is associated with neutrophil extracellular traps and all-cause mortality in ST-elevation myocardial infarction

Background

The complement system and neutrophil extracellular traps (NETs) are both parts of the innate immune system, and have been implicated in the ischemia-reperfusion injury in patients with ST-elevation myocardial infarction (STEMI). There is experimental evidence of reciprocal activation between the complement system and NETs. Any such link in patients with STEMI has not been investigated.

Purpose

To investigate a potential association between complement activation and clinical outcomes after STEMI, and assess any interplay between complement activation and NETs in this situation.

Methods

Patients with ST-elevation myocardial infarction were included at a median of 18 hours after percutaneous coronary intervention (n=864). The terminal complement complex (TCC) was measured by ELISA as a marker of complement activation. As markers of NETs were myeloperoxidase-deoxynucleic acid (MPO-DNA) and citrullinated histone 3 (CitH3) measured by ELISAs, while double stranded DNA (dsDNA) was measured by a nucleic acid stain. Patients were followed for a median of 4.6 years. The primary endpoint was a composite of new myocardial infarction, unscheduled revascularization, stroke, hospitalization for heart failure and death, whichever occurred first. All-cause mortality was also recorded.

Results

The composite endpoint occurred in 184 (21.3%) patients, while 70 (8.1%) died during follow-up. When dichotomizing at median TCC, the group with above-median TCC levels did not have an increased risk of reaching the composite endpoint (hazard ratio (HR): 1.069, 95% CI: [0.801, 1.428], p=0.651). However, this group exhibited an increased risk of all-cause mortality (HR: 1.650, 95% CI: [1.020, 2.671], p=0.041). This risk persisted when adjusting for age, sex, hypertension and LDL-cholesterol (HR: 1.673, 95% CI: [1.014, 2.761], p=0.044), but the significance was lost when adjusting for NT-proBNP (HR: 1.492, 95% CI: [0.885, 2.515], p=0.133). TCC was correlated to dsDNA (r=0.127, p<0.001) and CitH3 (r=0.102, p=0.003), but not MPO-DNA. The group with both TCC and dsDNA in the highest quartile exhibited a significantly higher incidence of all-cause mortality than the remaining population (17.6% vs, 7.2%, p=0.002). When examining the predictive value of TCC and dsDNA on all-cause mortality in ROC curve analysis, the area under the curve (AUC) for TCC was 0.549 (95% CI: [0.472, 0.625]), while the AUC for dsDNA was 0.653 (95% CI: [0.584, 0.722]). When combining TCC and dsDNA the predictive value was marginally higher than for TCC alone (AUC: 0.649, 95% CI: [0.579, 0.720])

Conclusion

In this STEMI population, complement activation measured by TCC was not associated with the primary composite endpoint, but was associated with increased risk of death. TCC was weakly correlated with markers of NETs. Despite a high mortality rate in patients with high levels of TCC and dsDNA, combining these variables did not increase the prognostic value compared to TCC alone.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Stein Erik Hagen's Foundation for Clinical Heart Research Survival according to cox regression

Long-term survival after a pharmacoinvasive strategy in patients with ST-elevation myocardial infarction and long distances to primary percutaneous coronary intervention – a prospective cohort study

Background

In patients with ST-elevation myocardial infarction (STEMI), a pharmacoinvasive (PI) strategy is the recommended reperfusion method if primary percutaneous coronary intervention (pPCI) cannot be performed within 120 minutes from diagnosis. Long-term prognosis for STEMI patients with long transfer distances to pPCI is sparsely documented.

Purpose

To compare short- and long-term survival, and cardiovascular (CV) death in STEMI patients treated with PI or pPCI strategy.

Methods

Consecutive STEMI patients admitted to our cardiac invasive centre were registered prospectively during 2005–2011 in a local quality registry. Follow-up data throughout 2013 were provided by the Norwegian Cause of death registry. Effects of treatment strategy were determined using a propensity score weighted analysis, adjusting for treatment-outcome confounding. Outcomes were 30-day mortality, overall survival and CV death during follow-up.

Results

Of 4762 STEMI patients, 543 (11.4%) were treated with thrombolysis before admission for rescue- or early coronary angiography (PI strategy), and 4044 (84.9%) were admitted for a pPCI strategy (3,7% excluded due to unspecified treatment strategy). Median age was 60 and 63 years in the PI and pPCI groups (19.5% and 24.1% women, respectively). Median time to reperfusion was 110 minutes (25–75th percentile: 75–163; symptom-to-thrombolysis) versus 230 minutes (149–435; symptom-to-balloon). Crude 30-day mortality was 3.9% and 6.6% in the PI- and pPCI groups. Median follow-up was 4.5 years (max 8.3 years). The overall 8-year survival was 84.6% (95% CI 79.4–88.4) in the PI group and 72.6% (95% CI 70.1–74.9) in the pPCI group (crude hazard ratio [HR] 0.56 (95% CI 0.43–0.72, p<0.0001). After propensity score weighting (based on age, gender, smoking, previous hypertension, stroke, diabetes, myocardial infarction, angina pectoris and peripheral artery disease, kidney function and pre-hospital resuscitation), patients had estimated 25% lower risk of long-term mortality with a PI strategy (weighted HR 0.75; 95% CI 0.53–1.07, p=0.113, Figure 1A). Cumulative incidence rate of CV death was 12.8 (PI strategy) and 27.8 (pPCI strategy) pr 1000 person-years (crude incidence rate ratio 0.46; 95% CI 0.32–0.68, p<0.0001), and was significantly lower in the PI group after weighting on the propensity score (p=0.048, Figure 1B).

Conclusions

There was a non-significant 25% lower risk of mortality up to 8 years with a PI versus pPCI strategy in STEMI patients with long transfer distances to PCI, after adjustment for treatment-outcome confounding. Importantly, long-term incidence of CV death was significantly lower in the PI group. These findings from real life practice support the use of a PI strategy in STEMI patients without contraindications to thrombolysis, when pPCI within 120 minutes from diagnosis is not possible.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Funded by grant form the Scientific Board of the Southeastern Norway Regional Health Authority, Hamar, Norway.

Cardiovascular risk associated with long-term anabolic-androgenic steroid abuse: an observational study from Norway

Background

The use of anabolic-androgenic steroids (AAS) has become highly prevalent among recreational weightlifters. Numerous case reports have suggested an association between AAS use and a vast range of different cardiovascular diseases, including sudden cardiac death (SCD) and coronary artery disease (CAD). Few clinical studies have evaluated the risk of SCD and the prevalence of CAD in individuals with long-term AAS use.

Purpose

To evaluate the risk of ventricular arrhythmias and the prevalence of CAD among men with long-term AAS use.

Methods

Strength-trained men with at least three years of cumulative AAS use were recruited from recreational gyms. The control group consisted of strength-trained competing athletes who self-reported never using any performance enhancing drugs (non-users). AAS use was verified by sophisticated blood and urine analyses. Study participants went through a comprehensive cardiovascular evaluation including exercise ECG, 24 h ECG, heart rate variability (HRV) measures, signal averaged ECG (SAECG) and QT dispersion (QTd). Coronary computed tomography angiography (CCTA) was performed in AAS users. Not all participants had all tests.

Results

We included 51 AAS users and 21 non-users. Median age (25th-75th percentile) was 33 (29–37) years in the user group and 33 (29–42) years in the non-user group. Forty-eight (94%) of the users had been using AAS for five years or more. Characteristics are presented in the table. AAS users had significantly lower HDL values compared to non-users (p<0.001). No signs of ischemia or arrhythmias were detected during exercise ECG, however maximal exercise capacity was lower than in the control group and also compared to age-standardized values. A considerable, but statistically non-significant reduction was seen in overall HRV estimated as the standard deviation of the RR intervals for normal sinus beats (SDNN) (p=0.05). No difference was seen regarding left ventricular late potentials or QTd (table). Eight (19%) of the forty-two AAS users undergoing CCTA had at least a mild degree of CAD, and four of them three-vessel disease.

Conclusion

No ECG-findings indicated an increased risk of ventricular arrhythmias among the long-term AAS users. However, their maximal exercise capacity was lower than in controls, and one fifth of the long-term AAS users had verified CAD on CT coronary angiography.

Funding Acknowledgement

Type of funding sources: None. Table 1

A nationwide registry study on heart failure in Norway from 2008–2018: variations in lookback period affect incidence estimates

Background/Introduction

Incidence estimations of heart failure from registry-based studies may vary because they depend on a retrospective search in the database to exclude previous events (prevalent cases), termed the lookback period.

Purpose

The aim of this study was to assess to what extent different lookback periods affect temporal trends in heart failure incidence utilizing national registry data.

Methods

We identified all heart failure hospital contacts (ICD-10 codes I11.0, I13.0, I13.2, I42.x and I50.x) in adult Norwegian individuals in the Norwegian Patient Registry (NPR) during 2008–2018. To calculate the influence of varying lookback period on incident cases, we defined 2018 with 10 years of lookback as a reference and calculated the relative difference by using one through nine years of lookback. Temporal trends in age-adjusted incidence rates were estimated with sensitivity analyses using fixed and varying lookback periods (including all available data).

Results

Using a lookback period of 10 years, we identified 14 862 incident patients in 2018 (6 842 women, 8 020 men) with a diagnosis of heart failure. Compared to a 10-year lookback period, application of four, six, and eight years resulted in an overestimation of incident cases by 13.5%, 6.2% and 2.3%, respectively. This corresponds to incidence rates of 5.40, 5.04 and 4.85 per 1000 person-years, respectively. Figure 1 shows that the overestimation of incident cases declined with increasing number of years included in the lookback period. The overestimation was largest in the beginning of the observational period. When assessing temporal trends in incidence rate using a fixed lookback period, the incidence rates were lower with additional years in the lookback period. However, incidence rates increased regardless of whether four, six or eight years were applied. In contrast, incidence rates were lower and declined during the period when including all available data and thereby increasing the lookback period with time. Fig. 2 shows that a relatively shorter lookback period provided higher incidence rate estimates and that the direction of the curves were similar when using a fixed lookback period. Moreover, it shows that including all available data instead of using a fixed lookback period resulted in the misleading conclusion of declining incidence rates.

Conclusions

The length of the lookback period affects incidence estimates when calculating incidence rates from longitudinal health registry data. Our results suggest that one to five years of lookback is too short since incident cases are overestimated by 64% - 9%. A fixed lookback period of six year or more seems beneficial with less overestimation (≤6%).

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): This work was supported by the Research Council of Norway and Novartis Norway AS. KMO is a PhD-student at the University of Oslo and an employee of Novartis Norway AS. Overestimation of incident cases in 2018Incidence rates

Gender differences in characteristics, treatment and outcomes in ST elevation myocardial infarction patients in four European countries

Introduction

Women receive less evidence-based care than men and have higher mortality after myocardial infarctions than men. But it is not known how the gender difference in risk factors, treatments and outcomes differs between European countries.

Purpose

In order to investigate the gender differences in European countries with different economic predispositions we aimed to describe and compare baseline characteristics, in-hospital management, medications at discharge and death outcomes of man and woman ST-elevation infarction (STEMI) patients following routine clinical practice in Sweden, Norway, Hungary and Estonia.

Methods

The study population is patients over the age of 18 with STEMI who were treated in hospital 2014–2017 (for Norway between 2013–2016) and registered in one of the national myocardial infarction registers. Patients with non-ST elevation infarction and unstable angina were excluded. Risk factors, hospital treatment, and prescription medications were obtained from the national myocardial infarction registries from each country. Mortality in-hospital, after 30 days and after 1 year, was obtained from national death registers.

Results

Women were on average older, had more comorbidities and higher mortality in hospital, after 30 days and one year after hospitalization. Women received coronary angiography, percutaneous coronary intervention, left ventricular ejection fraction assessment and evidence-based drugs to a lesser extent than men.

Conclusions

The study illustrates that there are differences in characteristics, management, treatments and outcomes between men and women in all of the studied countries no matter economic predispositions. Generally, women are treated with guideline recommended therapy to a lesser extent than men in the studied countries.

Funding Acknowledgement

Type of funding sources: None.

Comparison of management and outcomes of ST-segment elevation myocardial infarction patients in Estonia, Hungary, Norway and Sweden according to national ongoing registries

Background

There is a high need for real-world international comparisons of management of patients with acute myocardial infarction. In Europe Estonia, Hungary, Norway and Sweden are among the few countries with national ongoing acute myocardial infarction registries with a high degree of completeness of data.

Purpose

To compare the management and outcome of hospitalized ST-segment elevation myocardial infarction (STEMI) patients in four European countries with a national ongoing myocardial infarction registry.

Methods

We compared patient baseline characteristics, use of in-hospital procedures and medications at discharge as well as 30-day and 1-year mortality for all patients admitted with STEMI during 2014–2017 using EMIR (Estonia; n=4,584), HUMIR (Hungary; n=23,685), NOMIR (Norway; n=12,414; data available for years 2013–2016) and SWEDEHEART (Sweden; n=23,342). Country-level results were compared as aggregated data.

Results

Mean age ranged from 65 to 69 years (table 1). Estonia and Hungary had compared to Norway and Sweden a higher proportion of women (resp. 39%; 38% vs. 29%; 31%), as well as patients with hypertension (resp. 79%; 72% vs. 39%; 50%), diabetes (resp. 21%; 27% vs. 14%; 19%) and peripheral artery disease (resp. 9% vs. 6%; 4%). Proportion of current smokers was highest in Norway (38%) and lowest in Sweden (27%). Rates of discharge medications were generally high. The results for in-hospital procedures and mortality are shown in table 1. Estonia had the lowest rates of dual antiplatelet treatment (78%) and statins (86%). Norway had the lowest rates of beta-blockers (80%) and angiotensin converting enzyme inhibitors/ angiotensin II receptor blockers (61%).

Conclusions

This cross-country comparison of four national European registries provide new insights into differences in risk factors, treatment regiments and outcomes of patients with STEMI. There are several possible reasons for the observed differences, including differences in underlying expected mortality in the populations, inclusion-criteria and coverage of the registries and variable definitions, that need to be further explored.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Estonian Research Council

A single high-sensitivity cardiac troponin T compared to the HEART score for a rapid rule-out of acute myocardial infarction at a prehospital emergency clinic

Background

Patients presenting with acute chest pain outside of hospitals represent a diagnostic challenge.

Purpose

We aimed to validate whether a single high-sensitivity cardiac troponin T (hs-cTnT) safely can rule out acute myocardial infarction (AMI) in a primary care emergency setting. In addition, we aimed to investigate if the hs-HEART (History, Electrocardiogram (ECG), Age, Risk factors, and hs-Troponin) score would add valuable diagnostic information.

Methods

This is a secondary analysis from a prospective diagnostic study, including 1711 patients with acute non-specific chest pain presenting to a primary care emergency clinic from November 2016 to October 2018. The European Society of Cardiology (ESC) 0/1-hour algorithm triages patients towards direct rule-out if the 0-hour hs-cTnT is below 5 ng/L, combined with a normal ECG and a 3-hour symptom duration. The hs-HEART score (0–10 points) was calculated retrospectively, and a score ≤3 points was considered low-risk. In addition, a modified hs-HEART score, with more comparable hs-cTnT cut-off values, was applied. The primary endpoint was AMI during the index episode; the secondary the 90-day incidence of AMI (including index) and all-cause death.

Results

Among 1711 patients, 61 (3.6%) had an AMI, and 525 (30.7%) were assigned towards direct rule-out. With no AMIs in this group, the rule-out safety was high (negative predictive value (NPV) and sensitivity 100%). The hs-HEART score triaged more patients (n=966) as low-risk, but missed six AMIs (NPV 99.4% and sensitivity 90.2%). The modified hs-HEART score (n=707, AMI=3) increased the low-risk sensitivity to 95.1%. The 90-day incidence of AMI and all-cause death in the direct rule-out, low-risk hs-HEART, and modified hs-HEART group, were 0.0%, 0.7%, and 0.4%, respectively.

Conclusions

The ESC direct rule-out approach, with a single hs-cTnT below 5 ng/L, combined with a normal ECG, and a 3-hour symptom duration, is superior to the two hs-HEART scores in ruling out AMI in a primary care emergency setting.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): The Norwegian Research Fund for General Practice

Comparison of warfarin, dabigatran, rivaroxaban and apixaban for effectiveness and safety among elderly patients with atrial fibrillation: a nationwide cohort study

Introduction

Age is a strong independent risk factor for stroke and systemic embolism (SE) in patients with atrial fibrillation (AF). Reducing risk of stroke/SE with oral anticoagulation (OAC) in elderly patients involves a correspondingly greater risk of bleeding than in younger patients. Non-vitamin K antagonist oral anticoagulants (NOACs) are associated with a net clinical benefit over vitamin K antagonists in the elderly population, but knowledge is lacking about the comparative effectiveness and safety between specific oral anticoagulants in these patients.

Purpose

The aim of this study was to compare the rates of stroke/SE and major bleeding between new users of warfarin, dabigatran, rivaroxaban, and apixaban, in a nationwide cohort of AF patients over 75 years.

Methods

From Norwegian national registries we identified all anticoagulant naïve initiators of warfarin, dabigatran, rivaroxaban and apixaban over 75 years of age between January 2013 and December 2017. During follow-up, patients were censored upon switching OAC, discontinuation of OAC, death, or end of study period. Multivariate competing risk regression was used to evaluate association between treatment and the outcomes stroke/se and major bleeding, treating death as a competing risk.

Results

A total of 30 401 patients were identified; 6 650 starting warfarin, 3 857 starting dabigatran, 6 108 starting rivaroxaban, and 13 786 starting apixaban. The median age was 82 years. Dabigatran-users had less comorbidity than all other OAC-users; the greatest difference was seen in the proportion of patients with chronic kidney disease (4.3% in the dabigatran-group versus 7.0%, 10.5%, and 16.5% in the rivaroxaban, apixaban, and warfarin groups, respectively). The median follow-up time was 15 months, during which time 1 386 (4.6%) patients suffered a stroke/SE; 1 277 (4.2%) patients had a major bleeding episode; and 3 270 (10.8%) died. Adjusted subhazard ratios for stroke/SE and major bleeding are presented in the figure.

Conclusion

Comparing NOACs with warfarin, we found no significant differences in risk of stroke/SE, while apixaban was associated with lower risk of major bleeding than warfarin. Comparing NOACs with each other; dabigatran was associated with a significantly lower risk of stroke/SE compared with rivaroxaban and apixaban, while both dabigatran and apixaban were associated with significantly lower risks of major bleeding compared with rivaroxaban.

Incidence rates and subhazard ratios

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): South-Eastern Norway regional Health Authority

European differences in characteristics, treatments and outcomes in patients with non-ST-elevation myocardial infarction – novel insights from four national real-world registries

Background

Large-scale collection of standardized variables in patients with myocardial infarction (MI) in national real-world registries are only available in a few European countries and there is lack of cross-country comparisons.

Purpose

To compare demography, risk factors, hospital treatment and short- and long-term survival in patients hospitalized for non-ST elevation MI (NSTEMI) in four different European countries.

Methods

NSTEMI patients hospitalized and enrolled in national MI registries; EMIR (Estonia), HUMIR (Hungary), NORMI (Norway (2013–2016)) and SWEDEHEART (Sweden) from 2014 to 2017 were included.

Results

In total 119,191 patients with NSTEMI were included. The mean age at admission ranged from 70 years (Hungary) to 75 years (Estonia). The proportion of women was 36% in Sweden and 44% in Estonia. In Norway 24% were smokers, as compared to 17% in Sweden. Patients in Hungary had a high rate of diabetes mellitus (37%) and antihypertensive treatment (84%) but a low rate of lipid lowering treatment (32%). The proportion of patients with prior MI ranged from 28% (Norway) to 37% (Sweden). The presence of previous peripheral artery disease ranged from 7% (Sweden) to 17% (Hungary). The absolute proportion of performed coronary angiographies (58% versus 75%) and percutaneous coronary interventions (38% versus 56%), differed most between Norway and Hungary. Dual antiplatelet therapy ranged from 60% (Estonia) to 81% (Hungary) and statins from 78% (Norway) to 89% (Hungary), at discharge. The crude mortality rates at 1 month and 1 year are listed in table 1.

Conclusion

Cross-comparison of four national European MI registries provide new insights in differences in risk factors, treatment and outcomes. Possible reasons for the observed differences, include differences in the underlying expected mortality in the populations, inclusion-criteria and coverage of the registries and variable definitions, that need to be further explored.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Estonian Research Council

P3470Comparative effectiveness and safety of non-vitamin K oral anticoagulants and warfarin in non-valvular atrial fibrillation - a cohort study in 3 Nordic countries

Background

Non-vitamin K oral anticoagulants (NOACs) are an alternative to warfarin in the prevention of stroke in non-valvular atrial fibrillation (NVAF). Nordic countries have high quality of warfarin treatment, making them an especially suitable setting for assessing effectiveness and safety of NOACs against warfarin.

Purpose

The BEYOND Pooled (BEnefit of NOACs studY of nOn-valvular AF patieNts in NorDic countries) study compared risks of ischaemic or haemorrhagic stroke/systemic embolism (S/SE), and risk of bleeding with acute hospitalisation with an overnight stay (bleeding) in NVAF patients treated with apixaban, dabigatran or rivaroxaban, each compared with warfarin treatment.

Methods

A cohort study of treatment-naïve adult NVAF patients dispensed apixaban, dabigatran, rivaroxaban or warfarin was identified from 01 Jan 2013 to 31 Dec 2016. The population and study variables were identified from national registries in Denmark, Norway and Sweden. After 1:1 propensity score (PS) matching for each NOAC-warfarin comparison, individual-level data were pooled across the countries. Cox proportional-hazards regression was used to estimate adjusted hazard ratios (aHRs) of the endpoints.

Results

PS matched NOAC cohort sizes were: apixaban (55,696) dabigatran (28,526) and rivaroxaban (30,701), and the total follow-up in the PS-matched population was 291,171 years (mean 1.3 years). During the follow-up, 35,450 oral anticoagulation (OAC) patients had a S/SE and 38,620 OAC patients had bleeding. Adjusted HRs for the two endpoints are presented in the table. PH assumption has not been formally tested but cum incidence curves did not indicate substantial differences in the effects over time.

Table 1. Adjusted hazard ratios (aHR) of stroke/systemic embolism and bleeding for non-vitamin K oral anticoagulants versus warfarin Endpoint Apixaban vs Warfarin: aHR (95% CI) Dabigatran vs Warfarin: aHR (95% CI) Rivaroxaban vs Warfarin: aHR (95% CI) Stroke/SE 0.93 (0.85–1.03) 0.89 (0.80–1.00) 0.97 (0.88–1.08) Bleeding 0.72 (0.67–0.77) 0.87 (0.80–0.95) 1.12 (1.04–1.20)

Conclusions

Relative to warfarin, apixaban and dabigatran were associated with lower rates of bleeding whereas rivaroxaban was associated with a higher rate. The three NOACs had comparable rates of stroke and systemic embolism relative to warfarin.

Acknowledgement/Funding

This study was funded by the Pfizer/Bristol-Myers Squibb Alliance.

P668Aspirin for primary prevention of cardiovascular disease

Background

Platelet inhibition by aspirin reduces ischemic events but increases the risk of bleeding events. Yet, the role of aspirin in primary prevention of cardiovascular disease remains unclear.

Purpose

To produce a clinically relevant benefit-risk assessment of aspirin for primary prevention of cardiovascular disease.

Methods

We performed a meta-analysis of aspirin effects in primary prevention of cardiovascular disease comprising 13 randomized-controlled trials in 164.225 patients comparing aspirin versus placebo/control during a mean follow-up period of 6.4 years. Using a random effect model, relative risks and 95% confidence intervals were calculated for each outcome.

Results

Aspirin reduced the relative risk of ischemic stroke by 10% (RR: 0.90; 95% CI: 0.82–0.99), myocardial infarction by 14% (RR: 0.86; 95% CI: 0.77–0.95) and the major adverse cardiovascular events by 9% (RR: 0.91; 95% CI: 0.86–0.95) but was associated with a 46% relative risk increase of major bleeding events (RR: 1.46; 95% CI: 1.30–1.64). Aspirin did not reduce the risk of cardiovascular mortality (RR: 0.99; 95% CI: 0.90–1.08), all-cause mortality (RR: 0.98; 95% CI: 0.93–1.02) or cancer (RR 1.05; 95% CI, 0.87–1.26). Aspirin use did not translate into a net clinical benefit adjusted for event-associated mortality risk (mean 0.034%; 95% CI: −0.18 to 0.25%).

Forest plot of major outcomes.

Conclusions

Aspirin use in primary prevention is associated with a reduced risk of stroke and myocardial infarction, but at a cost of an increased risk of major bleeding.

Acknowledgement/Funding

None

3298Prehospital assessment of the one-hour rule-in/rule-out algorithm using a high-sensitivity cardiac troponin t assay in a low-prevalence population for acute coronary syndrome (OUT-ACS)

Background

The majority of patients with chest pain in Norway initially present to the primary health care system, which serves to triage them to the specialist health care services including hospitals. In some emergency primary care institutions, patients who are not hospitalised directly undergo further diagnostic testing to rule out acute myocardial infarction (AMI).

Purpose

Several studies have shown the advantage of using high-sensitivity assays for fast interpretation of cardiac troponins. The majority of these studies included patient populations from hospital emergency departments. In contrast, we aimed to investigate whether the 1-hour algorithm for high-sensitivity cardiac troponin T (hs-cTnT) is safe and useful for implementation in a primary care emergency setting where the patients have a much lower pre-test probability for an acute coronary syndrome.

Methods

In this prospective cohort study, we included 1672 patients with acute non-specific chest pain from November 2016 to October 2018 at a primary care emergency outpatient clinic in Norway. Serial hs-cTnT samples were analysed after 0, 1 and 4 hours on the Cobas 8000 e602 analyzer. We divided the results into one of three groups (rule-out, rule-in, or further observation), according to the 0/1-hour algorithm for hs-cTn from the current ESC guidelines on non-ST-elevation myocardial infarction. In the rule-out group, the 0/1-hour results were compared to the standard 4-hour hs-cTnT. Final hospital diagnoses were collected as a gold standard for the patients in the rule-in group.

Results

A total of 44 (2.6%) of 1672 patients were diagnosed with AMI. By applying the algorithm, 1274 (76.2%) patients were assigned to the rule-out group. One of the rule-out patients had a significant increase in hs-cTnT in the 4-hour sample. This results in a sensitivity for AMI of 97.7% (95% confidence interval [CI] 88.0–99.9) and negative predictive value of 99.9% (95% CI 99.6–100.0). There were 50 (3.0%) patients in the rule-in group, amongst whom 35 had a verified AMI. This gives a specificity for AMI of 99.1% (95% CI 98.5–99.5) and a positive predictive value at 70.0% (95% CI 55.4–82.1). Among the 348 (20.8%) patients assigned to further observation, eight patients had an AMI. The 15 rule-in patients who did not have an AMI, had other acute illnesses that required further diagnostic work-up at the hospital.

Conclusions

With a negative predictive value at 99.9%, the 1-hour algorithm for hs-cTnT seems safe and applicable for a faster assessment of patients with non-specific chest pain in a primary care emergency setting. Prehospital implementation of this algorithm may reduce the need for hospitalisation of these patients and hence may probably lower the costs.

ClinicalTrial.gov identifier: NCT02983123

Acknowledgement/Funding

Norwegian Research Fund for General Practice, The Norwegian Physicians' Association Fund for Quality Improvement and Patient Safety

Fibrinolytic treatment of ST-elevation myocardial infarction

Primary percutaneous coronary intervention (PPCI) is the preferred reperfusion therapy in ST-elevation myocardial infarction (STEMI), as long as it can be delivered within 90-120 minutes from patient’s first medical contact, and is the leading reperfusion strategy in most European countries. However, as PPCI cannot be offered in a timely manner to all patients, fibrinolytic therapy (FT) is the recommended choice in patients with an anticipated delay to PPCI of >90-120 minutes, presenting early after symptom onset and without contra-indications. FT should preferably be started in the pre-hospital setting. Following FT, all patients should be transferred to a PCI-center for rescue PCI or routine coronary angiography with PCI as indicated. Such a pharmaco-invasive strategy, combining FT with invasive treatment, has recently been shown to be non-inferior to PPCI in patients living in areas with long transfer delays to PCI (>60 minutes).

In this overview, we will briefly present the evidence for the benefit of FT in STEMI, and discuss the role of FT in the current era of PPCI as well as the optimal treatment following pharmacologic reperfusion.

Hyperemesis gravidarum and long-term mortality: a population-based cohort study

OBJECTIVE

To investigate whether exposure to hyperemesis gravidarum (HG) is associated with increased maternal long-term mortality.

DESIGN

Population-based cohort study.

SETTING

Medical Birth Registry of Norway (1967-2002) linked to the Cause of Death Registry.

POPULATION

Women in Norway with singleton births in the period 1967-2002, with and without HG. Women were followed until 2009 or death.

METHODS

Cox proportional hazard regression model was applied to estimate hazard ratios (HRs) with 95% confidence interval (CI).

MAIN OUTCOME MEASURES

The primary outcome was all-cause mortality during follow up. Secondary outcomes were cause-specific mortality (cardiovascular mortality, deaths due to cancer, external causes or mental and behavioural disorders).

RESULTS

Of 999 161 women with singleton births, 13 397 (1.3%) experienced HG. During a median follow up of 26 years (25 902 036 person-years), 43 470 women died (4.4%). Women exposed to HG had a lower risk of long-term all-cause mortality compared with women without HG (crude HR 0.82; 95% CI 0.75-0.90). When adjusting for confounders, this reduction was no longer significant (adjusted HR 0.92; 95% CI 0.84-1.01). Women exposed to HG had a similar risk of cardiovascular death as women not exposed (adjusted HR 1.04; 95% CI 0.83-1.29), but a lower long-term risk of death from cancer (adjusted HR 0.86; 95% CI 0.75-0.98).

CONCLUSION

In this large population-based cohort study, HG was not associated with an increased risk of long-term all-cause mortality. Women exposed to HG had no increase in mortality due to cardiovascular disease, but had a reduced risk of death from cancer.

TWEETABLE ABSTRACT

Population-based cohort study: Hyperemesis was not associated with an increased risk of long-term mortality.

Androgen receptor is a potential novel prognostic marker and oncogenic target in osteosarcoma with dependence on CDK11

Osteosarcoma is the most common bone cancer in children and adolescents. Previously, we have found that cyclin-dependent kinase 11 (CDK11) signaling was essential for osteosarcoma cell growth and survival. Subsequently, CDK11 siRNA gene targeting, expression profiling, and network reconstruction of differentially expressed genes were performed between CDK11 knock down and wild type osteosarcoma cells. Reconstructed network of the differentially expressed genes pointed to the AR as key to CDK11 signaling in osteosarcoma. CDK11 increased transcriptional activation of AR gene in osteosarcoma cell lines. AR protein was highly expressed in various osteosarcoma cell lines and patient tumor tissues. Tissue microarray analysis showed that the disease-free survival rate for patients with high-expression of AR was significantly shorter than for patients with low-expression of AR. In addition, AR gene expression knockdown via siRNA greatly inhibited cell growth and viability. Similar results were found in osteosarcoma cells treated with AR inhibitor. These findings suggest that CDK11 is involved in the regulation of AR pathway and AR can be a potential novel prognostic marker and therapeutic target for osteosarcoma treatment.

Trait-anxiety and pain intensity predict symptoms related to dysfunctional breathing (DB) in patients with chronic pain

Aims

The purpose of this cross-sectional study was to inves-tigate the occurrence of symptoms related to dysfunctional breathing (DB) in chronic pain patients and to examine factors associated with these symptoms.

Methods

A questionnaire was sent to 527 adults referred to out-patient pain clinics at Oslo university hospital. The questionnaire provided demographic data, Brief Pain Inventory, Spielberger state- trait anxiety inventory, and Nijmegen questionnaire (NQ). Multiple regression analyses were performed using SPSS.

Results

A total of 108 patients (20%) responded to the questionnaire and was included. Mean age was 49 years and two third of the participants were female. More than four out of ten had a NQ score ≥ 23 (a conservative cutoff value for DB). The median NQ score in the sample was 19. Trait-anxiety (Beta = .412, p < 0.001) and maximal pain intensity during the past week (Beta = .264, p = 0.004) predicted symptoms related to DB even when controlling for age and gender.

Conclusions

The study shows that a large portion of patients with chronic pain experiences symptoms that have been associated with hyperventilation and DB and at a higher level than previously reported. Although trait-anxiety is a strong predictor for symptoms related to DB, we find it interesting that maximal pain intensity during the last week also was associated with these symptoms. The cross-sectional design, low response rate, and lack of diagnoses limit our ability to draw conclusions about causal relationship and extrapolate to a larger populations of patients with chronic pain.

Markers of thrombin generation are associated with myocardial necrosis and left ventricular impairment in patients with ST-elevation myocardial infarction

Introduction

Platelet activation, thrombin generation and fibrin formation play important roles in intracoronary thrombus formation, which may lead to acute myocardial infarction.

We investigated whether the prothrombotic markers D-dimer, pro-thrombin fragment 1 + 2 (F1 + 2) and endogenous thrombin potential (ETP) are associated with myocardial necrosis assessed by Troponin T (TnT), and left ventricular impairment assessed by left ventricular ejection fraction (LVEF) and N-terminal pro b-type natriuretic peptide (NT-proBNP).

Materials/Methods

Patients (n = 987) with ST-elevation mycardial infarction (STEMI) were included. Blood samples were drawn at a median time of 24 h after onset of symptoms.

Results

Statistically significant correlations were found between both peak TnT and D-dimer (p < 0.001) and F1 + 2 (p < 0.001), and between NT-proBNP and D-dimer (p = 0.001) and F1 + 2 (p < 0.001). When dividing TnT and NT-proBNP levels into quartiles there were significant trends for increased levels of both markers across quartiles (all p < 0.001) D-dimer remained significantly associated with NT-proBNP after adjustments for covariates (p = 0.001) whereas the association between NTproBNP and F1 + 2 was no longer statistically significant (p = 0.324).

A significant inverse correlation was found between LVEF and D-dimer (p < 0.001) and F1 + 2 (p = 0.013). When dichotomizing LVEF levels at 40 %, we observed significantly higher levels of both D-dimer (p < 0.001) and F1 + 2 (p = 0.016) in the group with low EF (n = 147).

Summary/conclusion

In our cohort of STEMI patients we demonstrated that levels of D-dimer and F1 + 2 were significantly associated with myocardial necrosis as assessed by peak TnT. High levels of these coagulation markers in patients with low LVEF and high NTproBNP may indicate a hypercoagulable state in patients with impaired myocardial function.

Ethnicity and acute myocardial infarction: risk profile at presentation, access to hospital management, and outcome in Norway

Background

Previous studies in North America have shown ethnic variation in the presentation of acute myocardial infarction (AMI), and sex and racial differences in the management and outcome of AMI. In the present study, our aim was to investigate the risk profile of AMI for patients with minority background compared with indigenous Norwegians, at hospital presentation, and to investigate racial differences in hospital care and outcomes.

Patients and methods

A dual-design study was adopted: a cross-sectional study to examine ethnic differences of risk prevalence at hospital presentation and a cohort study to estimate access to angiography, percutaneous coronary intervention (PCI), and hospital and long-term mortality. From a study population of 3105 patients with AMI presenting at Oslo University Hospital between January 1, 2006 and December 31, 2007, we identified 147 cases of AMI in patients with minority background and selected a random sample of 588 indigenous Norwegians with AMI as controls. Prognostic and explanatory strategies were used in the analysis.

Results

Compared with indigenous Norwegians with AMI, AMI patients with minority background suffered their AMI 10 years younger, were generally male, were twice as likely to be smokers, three times as likely to have type 2 diabetes, had lower high-density lipoprotein levels. This group also had 50% less history of hypertension. In terms of hospital care, AMI patients with minority background had shorter times from onset of symptoms to PCI and the same frequency of access to angiography and acute PCI as indigenous Norwegians when adjusting for the confounding effect of age, sex, and nature of myocardial infarction with or without ST elevation.

Conclusion

At presentation to hospital, patients with minority background had a higher risk profile and a shorter time from onset of symptoms to admission to catheterization laboratory than indigenous Norwegians, but the same access to angiography and acute PCI during hospitalization.

Studies on methanol poisoning

Eleven patients concomitantly poisoned with methanol are described. Their whole blood methanol concentration ranged from 137.2 mmol/l (4.39 g/l) to 7.4 mmol/l (0.24 g/l). The clinical course in most patients was mild, which was attributed to the concomitant and subsequent ethanol ingestion and rapid transport to dialysing units. One patient suffered permanent visual impairment of one eye while the others recovered completely. Symptoms of poisoning were most clearly correlated to the degree of metabolic acidosis. All patients were hemodialysed. In two patients the average dialysator clearance of methanol was 157 and 176 ml/min at blood flows of 200 and 215 ml/min, respectively. In the same patients the average dialysator clearance of ethanol was 149 and 164 ml/min. Assuming a volume of distribution of methanol of 0.7 l/kg, the dialysator represented about 89 and 95%, respectively, of the total body clearance of methanol during ethanol therapy. Ethanol in concentrations even lower than usually recommended may be useful as the only treatment of patients with blood methanol concentrations up to 15 mmol/l (0.5 g/l), provided there is no acidosis or visual impairment.

Measurements of heart motion using accelerometers

We have used acceleration sensors to monitor the heart motion during surgery. A three-axis accelerometer was made from two commercially available two-axis sensors, and was used to measure the heart motion in anesthetized pigs. The heart moves due to both respiration and heart beating. The heart beating was isolated from respiration by high-pass filtering at 1.0 Hz, and heart wall velocity and position were calculated by numerically integrating the filtered acceleration traces. The resulting curves reproduced the heart motion in great detail, noise was hardly visible. Events that occurred during the measurements, e.g. arrhythmias and fibrillation, were recognized in the curves, and confirmed by comparison with synchronously recorded ECG data. We conclude that acceleration sensors are able to measure heart motion with good resolution, and that such measurements can reveal patterns that may be an indication of heart circulation failure.

Physiology of erythropoietin during mammalian development

Growth is a fundamental process of mammalian development. Several observations regarding regulation of erythropoiesis during growth are not easily explained by the hypoxia-erythropoietin (Epo) concept. This review focuses primarily on this aspect of the physiology of Epo. The question is raised of whether this regulation during growth is based on the hypoxia-Epo mechanism alone, or whether Epo acts in concert with general growth-promoting factors, particularly growth hormone (GH) and the insulin-like growth factors (IGF-I and -II). Supporting the latter hypothesis is the observation that the Epo and GH/IGF systems are activated by hypoxia and share similar receptors and pathways. Recent studies indicate that human fetal and infant growth is stimulated by GH, IGF-I and IGF-II. Epo, GH and IGFs are expressed early in fetal life. Although the rate of erythropoiesis in the fetus is high, serum Epo levels are low. The Epo response to hypoxia in the fetus and neonate is reduced compared with adults. Following delivery the Epo levels vary between species, probably related to the oxygen transport capacity of the hemoglobin (Hb) mass. IGF-I levels are low in the fetus and increase slowly following birth, except in preterm infants in whom the levels decline. In all mammals Hb declines following birth, giving rise to "early anemia". Except in the human, Epo levels increase proportionally with the fall in Hb, but there is a discrepancy between the curves for serum immunoreactive Epo (siEpo) and for erythropoiesis stimulating factors (ESF): the latter include other stimulatory factors in addition to Epo. Hypertransfusion of mice in the period of "early anemia" suppresses siEpo, but not ESF and erythropoiesis, as it does in adult mice. GH and IGF-I have direct effects on erythropoiesis in vitro and act particularly at the later stages of red cell differentiation. IGF-I acts synergistically with Epo, and its effects are most marked when Epo levels are low. Human recombinant (rhu) IGF-I stimulates erythropoiesis in neonatal rats, but not in newborn mice and lambs. In adult mice, in hypophysectomized rats and in mice with end-stage renal failure, however, a stimulatory effect of this growth factor was found on red cell production. RhuGH stimulates erythropoiesis in GH-deficient short children.

CONCLUSION

Fetal and early postnatal erythropoiesis are dependent on factors in addition to Epo. The likely candidates are GH and IGF-I. The in vitro stimulating effects of these factors on erythropoiesis are convincing, but more data are needed on the in vivo effects.

Left ventricular function and infarct size 20 months after primary angioplasty for acute myocardial infarction

OBJECTIVE

To study changes in left ventricular function and infarct size during long-term follow-up after acute myocardial infarction treated with primary angioplasty.

DESIGN

From 1996 to 1998, 100 consecutive patients were treated with primary angioplasty for acute ST-elevation myocardial infarction. Angioplasty was successful in 95% of the patients. Global left ventricular ejection fraction (LVEF) was determined by radionuclide ventriculography before discharge, after 6 weeks and after a mean follow-up time of 20 months. Infarct size was assessed by technetium 99m-tetrofosmin myocardial perfusion tomography (SPECT) at rest, performed at the same time intervals.

RESULTS

Mean LVEF was 56% at discharge, 55% after 6 weeks and 57% after 20 months of follow-up. No significant improvement in LVEF was observed. Only 8% of the patients at follow-up had LVEF lower than 40%. After 1 week, a mean perfusion defect of 19% was measured by SPECT. After 6 weeks and 20 months of follow-up, the mean perfusion defects were reduced to 14% (p < 0.001) and 15%, respectively.

CONCLUSION

Left ventricular function was well preserved with a mean LVEF of 57% 20 months after primary angioplasty for acute myocardial infarction. No significant change in LVEF was observed from 1 week after angioplasty to follow-up. Infarct sizes as assessed by SPECT imaging with tetrofosmin were reduced from 1 to 6 weeks, but did not change further during long-term follow-up. The reduction in the perfusion defects over time was probably due to gradual relief of stunning.

[Diagnoses and increased levels of troponin T among discharged patients]

BACKGROUND

New criteria for diagnosing acute myocardial infarction, in which the cardiac troponin T or I plays a central role, have recently been proposed. We wanted to estimate what an application of these criteria would have meant for the diagnoses given patients discharged from our hospital in 2000.

MATERIAL AND METHODS

From the hospital data bases, 3,461 in-hospital patients were identified in whom troponin T levels in blood had been determined. Maximal troponin T levels and diagnoses on discharge were recorded. Only one diagnosis was used for each patient. The diagnoses were selected in a priority order favouring those diseases that are known most often to cause increased troponin T levels, starting with the codes for acute myocardial infarction.

RESULTS

By applying the new criteria, the number of patients with myocardial infarction was estimated to increase 17%, 33% and 61% depending on the decision level for troponin T used, 0.20, 0.10 or 0.03 microgram/l, respectively. Congestive heart failure and atrial fibrillation were the most frequent cardiac diagnoses in patients with increased troponin T level without evidence of acute coronary syndromes. Other, non-cardiac diagnoses included renal diseases, sepsis, and acute lung diseases.

INTERPRETATION

Application of the new diagnostic criteria will markedly increase the recorded incidence of acute myocardial infarction. The number of positive troponin T values in patients without acute coronary syndromes will increase progressively by lowering the diagnostic decision level of troponin T.