Association of hepatokines with markers of endothelial dysfunction and vascular reactivity in obese adolescents

OBJECTIVES

Obesity-induced insulin resistance (IR) is known to influence hepatic cytokines (hepatokines), including fibroblast growth factor (FGF-21), fetuin-A, and chemerin. This study aimed to investigate the association between hepatokines and markers of endothelial dysfunction and vascular reactivity in obese adolescents.

METHODS

A total of 45 obese adolescents were categorized into three groups based on glucose tolerance: normal glucose tolerance (NGT), prediabetes (PD), and type 2 diabetes (T2D). We examined the relationships between FGF-21, fetuin-A, and chemerin with endothelial markers (plasminogen activator inhibitor-1 [PAI-1], intercellular adhesion molecule-1 [ICAM-1], and vascular cell adhesion marker-1 [VCAM-1]) and vascular surrogates (brachial artery reactivity testing [BART] and peak reactive hyperemia [PRH]).

RESULTS

Obese adolescents (age 16.2±1.2 years; 62 % female, 65 % Hispanic) with NGT (n=20), PD (n=14), and T2D (n=11) had significant differences between groups in BMI; waist-hip ratio (p=0.05), systolic BP (p=0.008), LDL-C (p=0.02), PAI-1 (p<0.001). FGF-21 pg/mL (mean±SD: NGT vs. PD vs. T2D 54±42; 266±286; 160±126 p=0.006) and fetuin-A ng/mL (266±80; 253±66; 313±50 p=0.018), were significantly different while chemerin ng/mL (26±5; 31±10; 28±2) did not significantly differ between the groups. Positive correlations were found between chemerin and both PAI-1 (r=0.6; p=0.05) and ICAM-1 (r=0.6; p=0.05), FGF-21 and PAI-1 (r=0.6; p<0.001), and fetuin-A with TNFα (r=-0.4; p=0.05). Negative correlations were found between chemerin and PRH (r= -0.5; p=0.017) and fetuin-A and PRH (r=-0.4; p=0.05).

CONCLUSIONS

In our cohort, IR predicted higher FGF-21 levels suggesting a linear relationship may exist between the two parameters. Hepatokines can augment alterations in the microvascular milieu in obese adolescents as demonstrated by their associations with the markers PAI-1, ICAM-1, and PRH.

Development and external validation of a dynamic risk score for early prediction of cardiogenic shock in cardiac intensive care units using machine learning

BACKGROUND

Myocardial infarction and heart failure are major cardiovascular diseases that affect millions of people in the US with the morbidity and mortality being highest among patients who develop cardiogenic shock. Early recognition of cardiogenic shock allows prompt implementation of treatment measures. Our objective is to develop a new dynamic risk score, called CShock, to improve early detection of cardiogenic shock in cardiac intensive care unit (ICU).

METHODS

We developed and externally validated a deep learning-based risk stratification tool, called CShock, for patients admitted into the cardiac ICU with acute decompensated heart failure and/or myocardial infarction to predict onset of cardiogenic shock. We prepared a cardiac ICU dataset using MIMIC-III database by annotating with physician adjudicated outcomes. This dataset that consisted of 1500 patients with 204 having cardiogenic/mixed shock was then used to train CShock. The features used to train the model for CShock included patient demographics, cardiac ICU admission diagnoses, routinely measured laboratory values and vital signs, and relevant features manually extracted from echocardiogram and left heart catheterization reports. We externally validated the risk model on the New York University (NYU) Langone Health cardiac ICU database that was also annotated with physician adjudicated outcomes. The external validation cohort consisted of 131 patients with 25 patients experiencing cardiogenic/mixed shock.

RESULTS

CShock achieved an area under the receiver operator characteristic curve (AUROC) of 0.821 (95% CI 0.792-0.850). CShock was externally validated in the more contemporary NYU cohort and achieved an AUROC of 0.800 (95% CI 0.717-0.884), demonstrating its generalizability in other cardiac ICUs. Having an elevated heart rate is most predictive of cardiogenic shock development based on Shapley values. The other top ten predictors are having an admission diagnosis of myocardial infarction with ST-segment elevation, having an admission diagnosis of acute decompensated heart failure, Braden Scale, Glasgow Coma Scale, Blood urea nitrogen, Systolic blood pressure, Serum chloride, Serum sodium, and Arterial blood pH.

CONCLUSIONS

The novel CShock score has the potential to provide automated detection and early warning for cardiogenic shock and improve the outcomes for the millions of patients who suffer from myocardial infarction and heart failure.

Rare Variant Genetics and Dilated Cardiomyopathy Severity: The DCM Precision Medicine Study

BACKGROUND

Dilated cardiomyopathy (DCM) can lead to advanced disease, defined herein as necessitating a durable left ventricular assist device or a heart transplant (LVAD/HT). DCM is known to have a genetic basis, but the association of rare variant genetics with advanced DCM has not been studied.

METHODS

We analyzed clinical and genetic sequence data from patients enrolled between 2016 and 2021 in the US multisite DCM Precision Medicine Study, which was a geographically diverse, multiracial, multiethnic cohort. Clinical evaluation included standardized patient interview and medical record query forms. DCM severity was classified into 3 groups: patients with advanced disease with LVAD/HT; patients with an implantable cardioverter defibrillator (ICD) only; or patients with no ICD or LVAD/HT. Rare variants in 36 DCM genes were classified as pathogenic or likely pathogenic or variants of uncertain significance. Confounding factors we considered included demographic characteristics, lifestyle factors, access to care, DCM duration, and comorbidities. Crude and adjusted associations between DCM severity and rare variant genetic findings were assessed using multinomial models with generalized logit link.

RESULTS

Patients' mean (SD) age was 51.9 (13.6) years; 42% were of African ancestry, 56% were of European ancestry, and 44% were female. Of 1198 patients, 347 had LVAD/HT, 511 had an ICD, and 340 had no LVAD/HT or ICD. The percentage of patients with pathogenic or likely pathogenic variants was 26.2%, 15.9%, and 15.0% for those with LVAD/HT, ICD only, or neither, respectively. After controlling for sociodemographic characteristics and comorbidities, patients with DCM with LVAD/HT were more likely than those without LVAD/HT or ICD to have DCM-related pathogenic or likely pathogenic rare variants (odds ratio, 2.3 [95% CI, 1.5-3.6]). The association did not differ by ancestry. Rare variant genetic findings were similar between patients with DCM with an ICD and those without LVAD/HT or ICD.

CONCLUSIONS

Advanced DCM was associated with higher odds of rare variants in DCM genes adjudicated as pathogenic or likely pathogenic, compared with individuals with less severe DCM. This finding may help assess the risk of outcomes in management of patients with DCM and their at-risk family members.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT03037632.

Genetic Architecture of Dilated Cardiomyopathy in Individuals of African and European Ancestry

Importance

Black patients with dilated cardiomyopathy (DCM) have increased familial risk and worse outcomes than White patients, but most DCM genetic data are from White patients.

Objective

To compare the rare variant genetic architecture of DCM by genomic ancestry within a diverse population of patients with DCM.

Design

Cross-sectional study enrolling patients with DCM who self-identified as non-Hispanic Black, Hispanic, or non-Hispanic White from June 7, 2016, to March 15, 2020, at 25 US advanced heart failure programs. Variants in 36 DCM genes were adjudicated as pathogenic, likely pathogenic, or of uncertain significance.

Exposure

Presence of DCM.

Main Outcomes and Measures

Variants in DCM genes classified as pathogenic/likely pathogenic/uncertain significance and clinically actionable (pathogenic/likely pathogenic).

Results

A total of 505, 667, and 26 patients with DCM of predominantly African, European, or Native American genomic ancestry, respectively, were included. Compared with patients of European ancestry, a lower percentage of patients of African ancestry had clinically actionable variants (8.2% [95% CI, 5.2%-11.1%] vs 25.5% [95% CI, 21.3%-29.6%]), reflecting the lower odds of a clinically actionable variant for those with any pathogenic variant/likely pathogenic variant/variant of uncertain significance (odds ratio, 0.25 [95% CI, 0.17-0.37]). On average, patients of African ancestry had fewer clinically actionable variants in TTN (difference, -0.09 [95% CI, -0.14 to -0.05]) and other genes with predicted loss of function as a disease-causing mechanism (difference, -0.06 [95% CI, -0.11 to -0.02]). However, the number of pathogenic variants/likely pathogenic variants/variants of uncertain significance was more comparable between ancestry groups (difference, -0.07 [95% CI, -0.22 to 0.09]) due to a larger number of non-TTN non-predicted loss of function variants of uncertain significance, mostly missense, in patients of African ancestry (difference, 0.15 [95% CI, 0.00-0.30]). Published clinical case-based evidence supporting pathogenicity was less available for variants found only in patients of African ancestry (P < .001).

Conclusion and Relevance

Patients of African ancestry with DCM were less likely to have clinically actionable variants in DCM genes than those of European ancestry due to differences in genetic architecture and a lack of representation of African ancestry in clinical data sets.

Screening for Dilated Cardiomyopathy in At-Risk First-Degree Relatives

BACKGROUND

Cardiovascular screening is recommended for first-degree relatives (FDRs) of patients with dilated cardiomyopathy (DCM), but the yield of FDR screening is uncertain for DCM patients without known familial DCM, for non-White FDRs, or for DCM partial phenotypes of left ventricular enlargement (LVE) or left ventricular systolic dysfunction (LVSD).

OBJECTIVES

This study examined the yield of clinical screening among reportedly unaffected FDRs of DCM patients.

METHODS

Adult FDRs of DCM patients at 25 sites completed screening echocardiograms and ECGs. Mixed models accounting for site heterogeneity and intrafamilial correlation were used to compare screen-based percentages of DCM, LVSD, or LVE by FDR demographics, cardiovascular risk factors, and proband genetics results.

RESULTS

A total of 1,365 FDRs were included, with a mean age of 44.8 ± 16.9 years, 27.5% non-Hispanic Black, 9.8% Hispanic, and 61.7% women. Among screened FDRs, 14.1% had new diagnoses of DCM (2.1%), LVSD (3.6%), or LVE (8.4%). The percentage of FDRs with new diagnoses was higher for those aged 45 to 64 years than 18 to 44 years. The age-adjusted percentage of any finding was higher among FDRs with hypertension and obesity but did not differ statistically by race and ethnicity (16.2% for Hispanic, 15.2% for non-Hispanic Black, and 13.1% for non-Hispanic White) or sex (14.6% for women and 12.8% for men). FDRs whose probands carried clinically reportable variants were more likely to be identified with DCM.

CONCLUSIONS

Cardiovascular screening identified new DCM-related findings among 1 in 7 reportedly unaffected FDRs regardless of race and ethnicity, underscoring the value of clinical screening in all FDRs.

Effectiveness of the Family Heart Talk Communication Tool in Improving Family Member Screening for Dilated Cardiomyopathy: Results of a Randomized Trial

BACKGROUND

Managing disease risk among first-degree relatives of probands diagnosed with a heritable disease is central to precision medicine. A critical component is often clinical screening, which is particularly important for conditions like dilated cardiomyopathy (DCM) that remain asymptomatic until severe disease develops. Nonetheless, probands are frequently ill-equipped to disseminate genetic risk information that motivates at-risk relatives to complete recommended clinical screening. An easily implemented remedy for this key issue has been elusive.

METHODS

The DCM Precision Medicine Study developed Family Heart Talk, a booklet designed to help probands with DCM communicate genetic risk and the need for cardiovascular screening to their relatives. The effectiveness of the Family Heart Talk booklet in increasing cardiovascular clinical screening uptake among first-degree relatives was assessed in a multicenter, open-label, cluster-randomized, controlled trial. The primary outcome measured in eligible first-degree relatives was completion of screening initiated within 12 months after proband enrollment. Because probands randomized to the intervention received the booklet at the enrollment visit, eligible first-degree relatives were limited to those who were alive the day after proband enrollment and not enrolled on the same day as the proband.

RESULTS

Between June 2016 and March 2020, 1241 probands were randomized (1:1) to receive Family Heart Talk (n=621) or not (n=620) within strata defined by site and self-identified race/ethnicity (non-Hispanic Black, non-Hispanic White, or Hispanic). Final analyses included 550 families (n=2230 eligible first-degree relatives) in the Family Heart Talk arm and 561 (n=2416) in the control arm. A higher percentage of eligible first-degree relatives completed screening in the Family Heart Talk arm (19.5% versus 16.0%), and the odds of screening completion among these first-degree relatives were higher in the Family Heart Talk arm after adjustment for proband randomization stratum, sex, and age quartile (odds ratio, 1.30 [1-sided 95% CI, 1.08-∞]). A prespecified subgroup analysis did not find evidence of heterogeneity in the adjusted intervention odds ratio across race/ethnicity strata (P=0.90).

CONCLUSIONS

Family Heart Talk, a booklet that can be provided to patients with DCM by clinicians with minimal additional time investment, was effective in increasing cardiovascular clinical screening among first-degree relatives of these patients.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT03037632.

Abstract P437: Testing a Clinical Decision Support Tool to Promote Physical Activity

Introduction: Physical activity (PA) is an essential component of health, yet it is not regularly assessed, nor are patients routinely counseled on PA as recommended by the AHA. The aim of this study was to evaluate the acceptability and clinical utility of incorporating an electronic clinical decision support (CDS) tool and remote patient monitoring to assess, promote and monitor PA in a preventive cardiology clinic.

Methods: The CDS tool was pilot-tested in the Epic electronic health record (EHR) from July 2021-June 2022. Patients answered 3 questions about routine PA in their patient portal prior to an office visit. The CDS alerted the provider to counsel the patient if their PA level was < 50% of recommended PA. These patients were invited to participate in remote patient monitoring for PA using a Fitbit connected to their EHR. The Practical, Robust Implementation and Sustainability Model (PRISM) was used to guide and evaluate the implementation. Qualitative feedback was collected from providers and patients.

Results: Over 12 months, patients answered a 3-question PA screener 33%-43 % per month and the CDS tool fired a range of 79-125 times per month. The HCP opened and signed the CDS tool between 3.2% to 21.6% monthly; it was acknowledged (e.g., ‘PA not appropriate for this patient at this time’) between 1-22% per month. Changes to the CDS during the pilot included removing the CDS tool from the medical assistant’s workflow to prevent them from taking action on it, and revising the options for acknowledgements based on provider feedback. Patients (n=59) were enrolled in 12 weeks of remote PA monitoring with 4 patients lost to follow-up, and 58% able to sync their Fitbit to Epic EHR using written directions. Feedback from the providers indicated they found the CDS easy to use but wanted additional information as to why patients were not reaching recommended PA (e.g., boredom). Patients wanted to add more detail about their PA in the patient portal, and spoke about needing motivation and more frequent reminders about being active. All were willing to engage in remote monitoring again.

Conclusion: Implementing the electronic PA assessment, counseling, and remote monitoring is feasible in a preventive cardiology clinic. However, use of the PA screener by patients and the CDS tool by providers was low and strategies are needed to improve its uptake. Patients may also need more guidance in connecting an activity tracker to the EHR for remote monitoring.

Physician preferences for revascularization in patients with ischemic cardiomyopathy: Defining equipoise from web-based surveys

Background

The optimal revascularization approach in patients with heart failure with reduced ejection fraction (HFrEF) and ischemic heart disease ("ischemic cardiomyopathy") is unknown. Physician preferences regarding clinical equipoise for mode of revascularization and their willingness to consider offering enrollment in a randomized trial to patients with ischemic cardiomyopathy have not been characterized.

Methods

We conducted two anonymous online surveys: 1) a clinical case scenario-based survey to assess willingness to offer clinical trial enrollment for a patient with ischemic cardiomyopathy (overall response rate to email invitation 0.45 %), and 2) a Delphi consensus-building survey to identify specific areas of clinical equipoise (overall response rate to email invitation 37 %).

Results

Among 304 physicians responding to the clinical case scenario-based survey, the majority were willing to offer the opportunity for clinical trial enrollment to a prototypical patient with ischemic cardiomyopathy (92 %), and felt that a finding of non-inferiority for PCI vs. CABG would influence their clinical practice (78 %). Among 53 physicians responding to the Delphi consensus-building survey, the median appropriateness rating for CABG was significantly higher than that of PCI (p < 0.0001). In 17 scenarios (11.8 %), there was no difference in CABG or PCI appropriateness ratings, suggesting clinical equipoise in these settings.

Conclusions

Our findings demonstrate willingness to consider offering enrollment in a randomized clinical trial and areas of clinical equipoise, two factors that support the feasibility of a randomized trial to compare clinical outcomes after revascularization with CABG vs. PCI in selected patients with ischemic cardiomyopathy, suitable coronary anatomy and co-morbidity profile.

Long-term follow-up of acute and chronic rejection in heart transplant recipients from hepatitis C viremic (NAT+) donors

The long-term safety of heart transplants from hepatitis C viremic (NAT+) donors remains uncertain. We conducted a prospective study of all patients who underwent heart transplantation at our center from January 2018 through August 2020. Routine testing was performed to assess for donor-derived cell-free DNA, acute cellular rejection (ACR), antibody-mediated rejection (AMR), and cardiac allograft vasculopathy (CAV). Allograft dysfunction and mortality were also monitored. Seventy-five NAT- recipients and 32 NAT+ recipients were enrolled in the study. All NAT+ recipients developed viremia detected by PCR, were treated with glecaprevir/pibrentasvir at the time of viremia detection, and cleared the virus by 59 days post-transplant. Patients who underwent NAT testing starting on post-operative day 7 (NAT+ Group 1) had significantly higher viral loads and were viremic for a longer period compared with patients tested on post-operative day 1 (NAT+ Group 2). Through 3.5 years of follow-up, there were no statistically significant differences in timing, severity, or frequency of ACR in NAT+ recipients compared with the NAT- cohort, nor were there differences in noninvasive measures of graft injury, incidence or severity of CAV, graft dysfunction, or mortality. There were five episodes of AMR, all in the NAT- group. There were no statistically significant differences between Group 1 and Group 2 NAT+ cohorts. Overall, these findings underscore the safety of heart transplantation from NAT+ donors.

Concurrent IRF4 Rearrangements in a Patient with B Cell and T Cell Disorders

Introduction/Objective

IRF4 is a regulatory protein which required at several stages of B and T cell development and differentiation. Rearrangements of the IRF4 chromosomal region have been detected in various B and T cell neoplasms including a distinct entity in the WHO tumor classification for diffuse large B cell lymphoma (DLBCL) with IRF4 rearrangement and another for an IRF4 rearranged subtype of the CD30-positive T cell lymphoproliferative disorder, lymphomatoid papulosis (LyP).

Methods/Case Report

We present the case of a 52-year-old man with a past medical history of treated Hodgkin disease in remission who now presents with a DLBCL of the tonsil as well a cutaneous LyP, both of which demonstrate the IRF4 gene rearrangement. Immunohistochemical stains support the morphologic diagnoses and the rearrangement is detected in both cases using fluorescence in situ hybridization (FISH).

Results (if a Case Study enter NA)

NA.

Conclusion

The detection of IRF4 translocation in two separate cell lineages may result from one of a handful of possible explanations that we explore. First, a mutation in a multipotent hematopoietic progenitor cell may give rise to common lymphoid progenitors which pass the mutation on to subsequent B and T differentiated lymphocytes. Second, de novo mutations may be occurring in both B and T cell lines leading to the mature lesions. Finally, it may be possible that one of the two lesions is not truly positive for IRF4 rearrangement, but rather the background B cells in the skin or T cells in the tonsil are the cells positive for the aberration. This is a unique case of a B and T cell lesion in the same patient which both possess the same rare genetic rearrangement. The implications on our understanding of the genetic development of such lesions is significant and may subsequently impact diagnosis and therapy going forward.

Pre-transplant immune cell function assay as a predictor of early cardiac allograft rejection

INTRODUCTION

ImmuKnow, an immune cell function assay that quantifies overall immune system activity can assist in post-transplant immunosuppression adjustment. However, the utility of pre-transplant ImmuKnow results representing a patient's baseline immune system activity is unknown. This study sought to assess if pre-transplant ImmuKnow results are predictive of rejection at the time of first biopsy in our cardiac transplant population.

METHODS

This is a single center, retrospective observational study of consecutive patients from January 1, 2018 to October 1, 2020 who underwent orthotopic cardiac transplantation at NYU Langone Health. Patients were excluded if a pre-transplant ImmuKnow assay was not performed. ImmuKnow results were categorized according to clinical interpretation ranges (low, moderate, and high activity), and patients were divided into two groups: a low activity group versus a combined moderate-high activity group. Pre-transplant clinical characteristics, induction immunosuppression use, early postoperative tacrolimus levels, and first endomyocardial biopsy results were collected for all patients. Rates of clinically significant early rejection (defined as rejection ≥ 1R/1B) were compared between pre-transplant ImmuKnow groups.

RESULTS

Of 110 patients who underwent cardiac transplant, 81 had pre-transplant ImmuKnow results. The low ImmuKnow activity group was comprised of 15 patients, and 66 patients were in the combined moderate-high group. Baseline characteristics were similar between groups. Early rejection occurred in 0 (0%) patients with low pre-transplant ImmuKnow levels. Among the moderate- high pre-transplant ImmuKnow group, 16 (24.2%) patients experienced early rejection (P = .033). The mean ImmuKnow level in the non-rejection group was the 364.9 ng/ml of ATP compared to 499.3 ng/ml of ATP for those with rejection (P = .020).

CONCLUSION

Patients with low pre-transplant ImmuKnow levels had lower risk of early rejection when compared with patients with moderate or high levels. Our study suggests a possible utility in performing pre-transplant ImmuKnow to identify patients at-risk for early rejection who may benefit from intensified upfront immunosuppression as well as to recognize those where slower calcineurin inhibitor initiation may be appropriate.

Prevalence and Cumulative Risk of Familial Idiopathic Dilated Cardiomyopathy

Importance

Idiopathic dilated cardiomyopathy (DCM) aggregates in families, and early detection in at-risk family members can provide opportunity to initiate treatment prior to late-phase disease. Most studies have included only White patients, yet Black patients with DCM have higher risk of heart failure-related hospitalization and death.

Objective

To estimate the prevalence of familial DCM among DCM probands and the age-specific cumulative risk of DCM in first-degree relatives across race and ethnicity groups.

Design, Setting, and Participants

A family-based, cross-sectional study conducted by a multisite consortium of 25 US heart failure programs. Participants included patients with DCM (probands), defined as left ventricular systolic dysfunction and left ventricular enlargement after excluding usual clinical causes, and their first-degree relatives. Enrollment commenced June 7, 2016; proband and family member enrollment concluded March 15, 2020, and April 1, 2021, respectively.

Exposures

The presence of DCM in a proband.

Main Outcomes and Measures

Familial DCM defined by DCM in at least 1 first-degree relative; expanded familial DCM defined by the presence of DCM or either left ventricular enlargement or left ventricular systolic dysfunction without known cause in at least 1 first-degree relative.

Results

The study enrolled 1220 probands (median age, 52.8 years [IQR, 42.4-61.8]; 43.8% female; 43.1% Black and 8.3% Hispanic) and screened 1693 first-degree relatives for DCM. A median of 28% (IQR, 0%-60%) of living first-degree relatives were screened per family. The crude prevalence of familial DCM among probands was 11.6% overall. The model-based estimate of the prevalence of familial DCM among probands at a typical US advanced heart failure program if all living first-degree relatives were screened was 29.7% (95% CI, 23.5% to 36.0%) overall. The estimated prevalence of familial DCM was higher in Black probands than in White probands (difference, 11.3% [95% CI, 1.9% to 20.8%]) but did not differ significantly between Hispanic probands and non-Hispanic probands (difference, -1.4% [95% CI, -15.9% to 13.1%]). The estimated prevalence of expanded familial DCM was 56.9% (95% CI, 50.8% to 63.0%) overall. Based on age-specific disease status at enrollment, estimated cumulative risks in first-degree relatives at a typical US advanced heart failure program reached 19% (95% CI, 13% to 24%) by age 80 years for DCM and 33% (95% CI, 27% to 40%) for expanded DCM inclusive of partial phenotypes. The DCM hazard was higher in first-degree relatives of non-Hispanic Black probands than non-Hispanic White probands (hazard ratio, 1.89 [95% CI, 1.26 to 2.83]).

Conclusions and Relevance

In a US cross-sectional study, there was substantial estimated prevalence of familial DCM among probands and modeled cumulative risk of DCM among their first-degree relatives.

Trial Registration

ClinicalTrials.gov Identifier: NCT03037632.

Dietary Inflammatory Index and Cardiovascular Disease Risk Factors in Patients With Chronic Kidney Disease and Type 2 Diabetes

Objectives

Inflammation is associated with several chronic diseases, including chronic kidney disease (CKD) and type 2 diabetes (T2D). Because dietary choices may impact chronic inflammation, the Dietary Inflammatory Index (DII) was developed to assess the inflammatory potential of the diet. Using the DII, this study examined the association of cardiovascular disease (CVD) risk factors and diet in patients with CKD and T2D.

Methods

Baseline three-day food records were obtained from 241 participants in a lifestyle intervention study, and analyzed using Nutrition Data System for Research (2014). DII scores were calculated, with higher scores suggesting a more pro-inflammatory diet. Participants were dichotomized into an anti-inflammatory diet (AID; DII &lt; 0; n = 118) or pro-inflammatory diet (PID; DII ≥ 0; n = 123) group, based on DII score. CVD risk factors included estimated glomerular filtration rate (eGFR), C-reactive protein (CRP), systolic blood pressure (BP), diastolic BP, pulse wave velocity, fasting lipids (total cholesterol, LDL-cholesterol, HDL-cholesterol, triglycerides), and hemoglobin A1C (HbA1C). Independent two sample t-tests assessed differences in CVD risk factors between groups.

Results

Participants were 50% male, 88% non-Hispanic, 66% white, and 65 ± 9SD years of age with a mean body mass index of 33.7 ± 5.1SD kg/m2. Approximately 51% of the participants followed a diet that would be considered pro-inflammatory. Participants in the AID group had a higher eGFR (AID: 75 ± 21SD mL/min/1.73m2, PID: 68 ± 20SD mL/min/1.73m2; p = 0.017) compared to the PID group. No significant differences were found between groups for the other CVD risk factors (CRP, systolic BP, diastolic BP, pulse wave velocity, fasting lipids [total cholesterol, LDL-cholesterol, HDL-cholesterol, triglycerides], and HbA1C).

Conclusions

Participants reporting an AID had a higher eGFR than those reporting a PID. Contrary to expectations, other CVD risk factors did not differ between groups. Additional research should examine the role of an AID, emphasizing whole grains, fruits, vegetables, fatty fish, nuts, and legumes, for disease management in patients with CKD and T2D.

Funding Sources

Supported by NIH RO1 DK100492.

InterCarb: A Community Effort to Improve Interlaboratory Standardization of the Carbonate Clumped Isotope Thermometer Using Carbonate Standards

Increased use and improved methodology of carbonate clumped isotope thermometry has greatly enhanced our ability to interrogate a suite of Earth-system processes. However, interlaboratory discrepancies in quantifying carbonate clumped isotope (Δ47) measurements persist, and their specific sources remain unclear. To address interlaboratory differences, we first provide consensus values from the clumped isotope community for four carbonate standards relative to heated and equilibrated gases with 1,819 individual analyses from 10 laboratories. Then we analyzed the four carbonate standards along with three additional standards, spanning a broad range of δ47 and Δ47 values, for a total of 5,329 analyses on 25 individual mass spectrometers from 22 different laboratories. Treating three of the materials as known standards and the other four as unknowns, we find that the use of carbonate reference materials is a robust method for standardization that yields interlaboratory discrepancies entirely consistent with intralaboratory analytical uncertainties. Carbonate reference materials, along with measurement and data processing practices described herein, provide the carbonate clumped isotope community with a robust approach to achieve interlaboratory agreement as we continue to use and improve this powerful geochemical tool. We propose that carbonate clumped isotope data normalized to the carbonate reference materials described in this publication should be reported as Δ47 (I-CDES) values for Intercarb-Carbon Dioxide Equilibrium Scale.

Hydroxychloroquine is associated with lower platelet activity and improved vascular health in systemic lupus erythematosus

OBJECTIVE

Hydroxychloroquine (HCQ) is a mainstay of therapy in the treatment of SLE. The effect of HCQ on platelets and vascular health is uncertain. We investigated the relationship between HCQ use and dose with platelet activity, platelet transcriptomics and vascular health in patients with SLE.

METHODS

Platelet aggregation, platelet mRNA expression and vascular health (sublingual capillary perfused boundary region (PBR), red blood cell filling (RBCF) and brachial artery reactivity testing) were analysed by HCQ use and dose.

RESULTS

Among 132 subjects with SLE (age: 39.7±12.9 years, 97% female), 108 were on HCQ. SLE disease activity was similar between subjects on and off HCQ. Platelet aggregation in response to multiple agonists was significantly lower in patients on HCQ. There were inverse relationships between HCQ dose and gene expression pathways of platelet activity. Gene expression of P-selectin (SELP) was inversely correlated with HCQ dose (r=-0.41, p=0.003), which was validated at the protein level. Subjects on HCQ had improved vascular function correlating with HCQ dose as measured by lower PBR (r=-0.52, p=0.007), higher RBCF (r=0.55, p=0.004) and greater brachial artery reactivity (r=0.43, p=0.056).

CONCLUSION

HCQ use was associated with decreased platelet activation and activation-related transcripts and improved vascular health in SLE.

The Association of Frailty With In-Hospital Bleeding Among Older Adults With Acute Myocardial Infarction: Insights From the ACTION Registry

OBJECTIVES

The aim of this study was to determine whether frailty is associated with increased bleeding risk in the setting of acute myocardial infarction (AMI).

BACKGROUND

Frailty is a common syndrome in older adults.

METHODS

Frailty was examined among AMI patients ≥65 years of age treated at 775 U.S. hospitals participating in the ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry from January 2015 to December 2016. Frailty was classified on the basis of impairments in 3 domains: walking (unassisted, assisted, wheelchair/nonambulatory), cognition (normal, mildly impaired, moderately/severely impaired), and activities of daily living. Impairment in each domain was scored as 0, 1, or 2, and a summary variable consisting of 3 categories was then created: 0 (fit/well), 1 to 2 (vulnerable/mild frailty), and 3 to 6 (moderate-to-severe frailty). Multivariable logistic regression was used to examine the independent association between frailty and bleeding.

RESULTS

Among 129,330 AMI patients, 16.4% had any frailty. Frail patients were older, more often female, and were less likely to undergo cardiac catheterization. Major bleeding increased across categories of frailty (fit/well 6.5%; vulnerable/mild frailty 9.4%; moderate-to-severe frailty 9.9%; p < 0.001). Among patients who underwent catheterization, both frailty categories were independently associated with bleeding risk compared with the non-frail group (vulnerable/mild frailty adjusted odds ratio [OR]: 1.33, 95% confidence interval [CI]: 1.23 to 1.44; moderate-to-severe frailty adjusted OR: 1.40, 95% CI: 1.24 to 1.58). Among patients managed conservatively, there was no association of frailty with bleeding (vulnerable/mild frailty adjusted OR: 1.01, 95% CI: 0.86 to 1.19; moderate-to-severe frailty adjusted OR: 0.96, 95% CI: 0.81 to 1.14).

CONCLUSIONS

Frail patients had lower use of cardiac catheterization and higher risk of major bleeding (when catheterization was performed) than nonfrail patients, making attention to clinical strategies to avoid bleeding imperative in this population.

Plant Protein Intake Is Not Associated with Cardiovascular Disease Risk Factors in Diabetic Patients with Chronic Kidney Disease (P08-055-19)

Objectives

A higher percentage of protein consumed from plants may have cardiovascular benefits and be associated with lower mortality in chronic kidney disease (CKD) patients. The purpose of this study was to examine the association of self-reported dietary protein intake with cardiovascular disease (CVD) risk factors in patients with type 2 diabetes (T2D) and CKD.

Methods

Baseline 3-day food records were obtained from 202 participants of an ongoing lifestyle intervention study, and analyzed using Nutrition Data System for Research (2014). Participants were categorized into tertiles based on total protein intake (<66.9 g, 66.9–92.4 g, > 92.4 g) and percent of total protein coming from plant sources (<27.9%, 27.9–37.8%, >37.8%). CVD risk factors included estimated glomerular filtration rate (eGFR), pulse wave velocity (PWV), fasting lipids (total cholesterol, LDL-cholesterol, HDL-cholesterol, triglycerides [TG]), and hemoglobin A1c [HbA1c]). Analyses of covariance examined mean differences in CVD risk factors among the tertiles, controlling for age and total energy intake.

Results

The participants were 57% male, 89% non-Hispanic, 69% white, and 66 ± 9 years of age with a mean body mass index of 33.6 ± 5 kg/m2. Prior myocardial infarction was reported by 25(12.6%) of participants. Average daily protein intake was 83.3 ± 29.3 g (0.9 ± 0.3 g/kg body weight), with the average % of protein consumed from plant sources 34 ± 13%. There were no statistically significant differences between the total protein intake tertiles for the CVD risk factors (eGFR [P = .36], PWV [P = .86], total cholesterol [P = .09], LDL-cholesterol [P = .26], HDL-cholesterol [P = .88], TG [P = .88], HbA1c [P = .82]. Additionally, there were no statistically significant differences between the % of total protein intake from plant sources tertiles for the CVD risk factors (eGFR [P = .32], PWV [P = .92], total cholesterol [P = .29], LDL-cholesterol [P = .10], HDL-cholesterol [P = .57], TG [P = .13], HbA1c [P = .93].

Conclusions

Contrary to expectations, CVD risk factors did not differ among tertiles for total protein intake or % of total protein from plant sources. These findings suggest that, at baseline, dietary protein was not associated with CVD risk factors in patients with T2D and CKD.

Funding Sources

National Institutes of Health (NIDDK, NINR).

The Impact of Daytime Sleepiness on Dietary Intake in Overweight/Obese Individuals with Diabetes and Chronic Kidney Disease (P08-019-19)

Objectives

Sleep disturbances have been recognized as risk factors in the etiology of chronic disease and obesity. Although multifactorial, the link may be due to dietary intake, mediated by appetite hormones, hedonic feeding, altered intake times, and extended intake hours. The purpose of this study was to examine daytime sleepiness and dietary intake in overweight/obese individuals with diabetes and chronic kidney disease.

Methods

Three-day food records were completed at baseline from 133 participants in an ongoing lifestyle intervention study, and analyzed using the Nutrition Data System for Research (2014). Daily dietary intakes were summarized for energy (kcal), carbohydrate (g), fat (g), alcohol (g), added sugars (g), and refined grains (ounce equivalents). Self-reported measures of daytime sleepiness were measured using the Epworth Sleepiness Scale (ESS). Participants rated their level of sleepiness (scale 0–3) in eight different situations, which were summed to provide a total score. The ESS scores were dichotomized with 0–10 indicating “normal daytime sleepiness” (NDS) and 11–24 indicating “excessive daytime sleepiness” (EDS). IBM SPSS Statistics (version 25.0) was utilized to complete the descriptive and inferential analyses. Independent sample t-tests examined differences between the two sleepiness groups. Results were considered significant at p ≤ 0.05.

Results

The participants were 53.4% male, 89.5% non-Hispanic, 65.4% white, and 65.0 ± 9.4SD years of age with a mean body mass index of 34.0 ± 5.1SD kg/m2. Although there were no differences between sleepiness groups for fat and alcohol intakes, the EDS group reported a higher mean intake of carbohydrate (EDS: 247 ± 148SD g, NDS: 183 ± 76SD g; P = 0.048) and refined grains (EDS: 7.0 ± 6.5SD ounce, NDS: 4.2 ± 3.0SD ounce; P = 0.048). Although not statistically significant, the EDS group exhibited a trend toward having a higher energy intake (EDS: 2130 ± 1083SD kcal, NDS: 1776 ± 618SD kcal; P = 0.133) and added sugar intake (EDS: 44 ± 53SD g, NDS: 28 ± 26SD g, P = 0.179).

Conclusions

Similar to other reports, sleep disturbances, as noted by EDS, were associated with a higher intake of carbohydrate and refined grains. The results of this study support the role of sleep, alongside diet and physical activity, as important modifiable risk factors for chronic disease and obesity.

Funding Sources

National Institutes of Health (NIDDK, NINR)

Inflammasome Signaling and Impaired Vascular Health in Psoriasis

Objective- Psoriasis is an inflammatory skin disease which heightens the risk of cardiovascular disease. This study directly investigated vascular endothelial health and systemically altered pathways in psoriasis and matched controls. Approach and Results- Twenty patients (mean age, 40 years; 50% male) with active psoriasis and 10 age-, sex-matched controls were recruited. To investigate systemically alerted pathways, a deep sequencing omics approach was applied, including unbiased blood transcriptomic and targeted proteomic analysis. Vascular endothelial health was assessed by transcriptomic profiling of endothelial cells obtained from the brachial veins of recruited participants. Blood transcriptomic profiling identified inflammasome signaling as the highest differentially expressed canonical pathway ( Z score 1.6; P=1×10^-7) including upregulation of CASP5 and interleukin ( IL) -1β. Proteomic panels revealed IL-6 as a top differentially expressed cytokine in psoriasis with pathway analysis highlighting IL-1β ( Z score 3.7; P=1.02×10^-23) as an upstream activator of the observed upregulated proteins. Direct profiling of harvested brachial vein endothelial cells demonstrated inflammatory transcript (eg, IL-1β, CXCL10, VCAM-1, IL-8, CXCL1, Lymphotoxin beta, ICAM-1, COX-2, and CCL3) upregulation between psoriasis versus controls. A linear relationship was seen between differentially expressed endothelial inflammatory transcripts and psoriasis disease severity. IL-6 levels correlated with inflammatory endothelial cell transcripts and whole blood inflammasome-associated transcripts, including CASP5 and IL-1β. Conclusions- An unbiased sequencing approach demonstrated the inflammasome as the most differentially altered pathway in psoriasis versus controls. Inflammasome signaling correlated with psoriasis disease severity, circulating IL-6, and proinflammatory endothelial transcripts. These findings help better explain the heightened risk of cardiovascular disease in psoriasis. Clinical Trial Registration- URL: http://www.clinicaltrials.gov . Unique identifier: NCT03228017.

Reversal and Resumption of Antithrombotic Therapy in LVAD-Associated Intracranial Hemorrhage

BACKGROUND

Little data exist regarding reversal and resumption of antithrombotics after left ventricular assist device (LVAD)-associated intracranial hemorrhage.

METHODS

Prospectively collected data of LVAD patients with intracranial hemorrhage were reviewed. Coagulopathy reversal agents, antithrombotic regimens, and thrombotic (venous thromboembolism, ischemic stroke, myocardial infarction) and hemorrhagic (recurrent intracranial hemorrhage, gastrointestinal bleed, anemia requiring transfusion) complications were recorded.

RESULTS

Of 405 patients, intracranial hemorrhage occurred in 39 (10%): 23 intracerebral hemorrhages, 10 subarachnoid hemorrhages, and 6 subdural hematomas. Of 27 patients who received antithrombotic reversal, 8 (30%) had inadequate coagulopathy reversal, and 3 of these patients had hemorrhage expansion or died before repeat imaging. One (4%) patient had a thrombotic complication (deep vein thrombosis). Antithrombotic therapy was resumed in 17 (100%) survivors in a median time 8 days for antiplatelet agents and 14 days for warfarin. Recurrent intracranial hemorrhage occurred within a median of 7 days of antithrombotic resumption, while ischemic stroke occurred in a median of 428 days. Patients who resumed antiplatelets alone (n = 4) had a trend toward more thrombotic events (1.37 versus 0.14 events/patient-year [EPPY]; p = 0.08), including more fatal thrombotic events (0.34 EPPY versus 0.08 EPPY; p = 0.89) compared with those resuming warfarin ± antiplatelet (n = 14). Nonfatal hemorrhage event rates were 0.34 EPPY in the warfarin ± antiplatelet versus 0 EPPY in the antiplatelet-alone group (p = 0.16). No fatal hemorrhagic events occurred.

CONCLUSIONS

Reversal of anticoagulation appears safe after LVAD-associated intracranial hemorrhage, though inadequate reversal was common. Resumption of warfarin ± antiplatelet was associated with fewer fatal and nonfatal thrombotic events compared with antiplatelets alone, though more nonfatal hemorrhage events occurred.

Glucocorticoid-induced osteoporosis preventive care in rheumatology patients

Glucocorticoid-induced osteoporosis (GIOP) is common in patients prescribed with long-term glucocorticoids. Guidelines suggest patients receiving moderate-dose glucocorticoid therapy receive GIOP preventive care. Previous studies have shown preventive care rates are not optimal. We look at GIOP preventive care rates in rheumatology patients and predictors of various components of care.

PURPOSE

Glucocorticoid-induced osteoporosis (GIOP) is a common concern in patients prescribed with long-term glucocorticoids. Studies have shown GIOP preventive care is not provided optimally in the general population; however, little is published on GIOP preventive care among patients with rheumatic disease. The objective of this study is to determine the proportion of rheumatology patients who received GIOP preventive care.

METHODS

A population-based retrospective quality assurance study of adults seen at the University of Alberta Rheumatology Clinic was performed using the electronic outpatient medical record. Records of adult patients prescribed with prednisone from January 1st to December 31st, 2016 by a rheumatologist were initially included for review. Those who had been prescribed ≥ 7.5 mg/day for ≥ 3 months were assessed for concurrent GIOP preventive care.

RESULTS

A total of 745 discreet courses of prednisone were prescribed in 433 patients with 113 meeting the above inclusion criteria. Following the prednisone prescription, 79% were taking vitamin D, 86% were taking calcium, and 50% were prescribed with osteoporosis pharmacotherapy. Twenty-five percent of patients had DXA imaging ordered by the rheumatologist within the first 6 months; of these, 86% of patients completed the DXA.

CONCLUSIONS

Overall, our study shows that patients under the care of rheumatologists receive better GIOP preventative care than previously reported care in the general population. However, there is still room for improvement. In particular, men, younger patients, and rural patients seem to be at the most at risk of not receiving optimal GIOP prevention.

Abstract 256: The Direct Characterization of Endothelial Inflammation in Patients with Psoriasis

Objective: Psoriasis, an inflammatory autoimmune disease, increases the risk of cardiovascular disease (CVD). Active psoriatic disease is linked to systemic vascular inflammation, yet how this contributes to CVD is unknown. Using in vivo and ex-vivo measures of the vascular endothelium our study investigates the vascular health of psoriasis patients to better understand the mechanism(s) that predispose psoriatics to CVD.

Methods: Ten patients with active psoriasis (average age 46 years, 50% male (5 of 10), 6% [3.5% – 90%] body surface area involvement) were compared to age- and sex- matched controls. In vivo vascular endothelial function was assessed by brachial artery reactivity testing (BART, %) with high resolution ultrasonography. Venous endothelial cells were collected from the brachial vein using guidewires inserted through an angiocatheter and isolated with magnetic beads directed against CD146. Following collection, endothelial RNA was isolated, converted to cDNA and inflammatory gene profiling performed by RT-qPCR with Taqman probes and primers.

Results: Transcriptomic profiling of venous endothelial cells revealed upregulation of genes associated with inflammatory cytokines and chemokines ( lymphotoxin beta [2.5 - fold], CCL3 [3.5 - fold], and IL-1 β [2.8 - fold], P < 0.05 for all) and genes related to intracellular adhesion and inflammation ( ICAM1 [2.3 – fold] and COX-2 [1.4 – fold], P < 0.05 for both) in psoriatics vs. controls. Unexpectedly, endothelial nitric oxide synthase (eNOS) and phosphorylated eNOS (higher levels indicate healthy endothelial NO production) were upregulated (2 - 3 fold) in psoriatics vs. controls (p = 0.24, p = 0.14 respectively). BART was also higher in psoriatics when compared to controls (7.1 ± 1% vs. 3.9 ± 2.7%, P = 0.03).

Conclusion: This cross-sectional study is the first to directly examine the vascular endothelium of psoriatic patients. Compared to controls, active psoriatic disease was associated with upregulation of cytokines, chemokines and genes regulating intracellular adhesion as well as increased expression of eNOS, and increased BART. These findings suggest potential mechanisms to explain the increased prevalence of atherosclerosis and CVD risk seen in those with psoriasis.