High interindividual variability in LDL-cholesterol reductions after inclisiran administration in a real-world multicenter setting in Germany

BACKGROUND AND AIMS

Low-density lipoprotein cholesterol (LDL-C) is the main therapeutic target in the treatment of hypercholesterolemia. Small interfering RNA (siRNA) inclisiran is a new drug, which targets PCSK9 mRNA in the liver, reducing concentrations of circulating LDL-C. In randomized trials, inclisiran demonstrated a substantial reduction in LDL-C. The German Inclisiran Network (GIN) aims to evaluate LDL-C reductions in a real-world cohort of patients treated with inclisiran in Germany.

METHODS

Patients who received inclisiran in 14 lipid clinics in Germany for elevated LDL-C levels between February 2021 and July 2022 were included in this analysis. We described baseline characteristics, individual LDL-C changes (%) and side effects in 153 patients 3 months (n = 153) and 9 months (n = 79) after inclisiran administration.

RESULTS

Since all patients were referred to specialized lipid clinics, only one-third were on statin therapy due to statin intolerance. The median LDL-C reduction was 35.5% at 3 months and 26.5% at 9 months. In patients previously treated with PCSK9 antibody (PCSK9-mAb), LDL-C reductions were less effective than in PCSK9-mAb-naïve patients (23.6% vs. 41.1% at 3 months). Concomitant statin treatment was associated with more effective LDL-C lowering. There was a high interindividual variability in LDL-C changes from baseline. Altogether, inclisiran was well-tolerated, and side effects were rare (5.9%).

CONCLUSION

In this real-world patient population referred to German lipid clinics for elevated LDL-C levels, inclisiran demonstrated a high interindividual variability in LDL-C reductions. Further research is warranted to elucidate reasons for the interindividual variability in drug efficacy.

[Frequency and severity of sarcopenia in patients with inflammatory and noninflammatory musculoskeletal diseases : Results of a monocentric study in a tertiary care center]

INTRODUCTION

Sarcopenia (SP) is defined as the pathological loss of muscle mass and function. This is a clinically relevant problem, especially in geriatric patients, because SP is associated with falls, frailty, loss of function, and increased mortality. People with inflammatory and degenerative rheumatic musculoskeletal disorders (RMD) are also at risk for developing SP; however, there is little research on the prevalence of this health disorder in this patient group using currently available SP criteria.

OBJECTIVE

To investigate the prevalence and severity of SP in patients with RMD.

METHODS

A total of 141 consecutive patients over 65 years of age with rheumatoid arthritis (RA), spondylarthritis (SpA), vasculitis, and noninflammatory musculoskeletal diseases were recruited in a cross-sectional study at a tertiary care center. The European Working Group on Sarcopenia in Older People (EWGSOP 1 and 2) definitions of presarcopenia, SP, and severe SP were used to determine the prevalence. Lean mass as a parameter of muscle mass and bone density were measured by dual X‑ray absorptiometry (DXA). Handgrip strength and the short physical performance battery (SPPB) were performed in a standardized manner. Furthermore, the frequency of falls and the presence of frailty were determined. Student's T-test and the χ2-test were used for statistics.

RESULTS

Of the patients included 73% were female, the mean age was 73 years and 80% had an inflammatory RMD. According to EWGSOP 2, 58.9% of participants probable had SP due to low muscle function. When muscle mass was added for confirmation, the prevalence of SP was 10.6%, 5.6% of whom had severe SP. The prevalence was numerically but not statistically different between inflammatory (11.5%) and noninflammatory RMD (7.1%). The prevalence of SP was highest in patients with RA (9.5%) and vasculitis (24%), and lowest in SpA (4%). Both osteoporosis (40% vs. 18.5%) and falls (15% vs. 8.6%) occurred more frequently in patients with SP than those without SP.

DISCUSSION

This study showed a relatively high prevalence of SP, especially in patients with RA and vasculitis. In patients at risk, measures to detect SP should routinely be performed in a standardized manner in the clinical practice. The high frequency of muscle function deficits in this study population supports the importance of measuring muscle mass in addition to bone density with DXA to confirm SP.

Association of propionate with coronary artery disease in a large cross-sectional study

Background

Microbiome has been linked to the pathogenesis of coronary artery disease (CAD) but data providing direct evidence for an association of short-chain fatty acids (SCFA) like propionate with CAD are lacking.

Purpose

To study the association of propionate in blood samples with the presence of CAD

Methods

This was a cross-sectional study enrolling patients admitted to invasive coronary angiography in a university hospital in Germany. Patients were prospectively recruited between from March 2017 to January 2020. Patients with known or suspected CAD and risk factors for cardiovascular diseases were screened for eligibility to participate in the trial. Main exclusion criteria were inflammatory/rheumatic disease, active cancer disease and acute infection. Blood sampling was performed after overnight fasting and before invasive procedures. Measurement of propionate was performed though liquid chromatography.

Results

The study included 691 patients (median n [IQR] age, 69 [60–78] years; 406 men [59%]). A total of 368 had invasively confirmed CAD with at least one coronary artery stenosis ≥50% and 323 had non CAD and 194 had invasively excluded CAD. 129 additional patients without suspicion for CAD and without diabetes/smoking were also recruited in the no CAD group. CAD patients had significant lower levels of propionate (median) 6.08 μM (IQR, 4.31–7.65) compared to the no CAD groups 6.92 μM (4.89–9.25, <0.05). Linear regression multivariate analysis adjusted for age, gender, body mass index, hypertension, smoking, diabetes and hyperlipidemia revealed an odds ratio of 0.92 (CI 0.89–0,96, p<0.001) for propionate as predictor of CAD.

Conclusions

The study provides large-scale data for a protective role of propionate in the development of CAD, independent of the presence of other known cardiovascular risk factors.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Internal Grant, Medical School of Brandenburg

High individual variability in LDL-reductions after inclisiran administration in a “real-world setting”

Background and aims

Inclisiran inhibits hepatic synthesis of proprotein convertase subtilisin-kexin type 9 (PCSK9) (1). Previous studies suggest that inclisiran provides sustained reductions in low-density lipoprotein (LDL) cholesterol levels with infrequent dosing. Patients included in the ORION program received inclisiran on top of maximally tolerated statin therapy and demonstrated a profound 50% LDL-C reduction as early as 3 months (2). The aim of this retrospective, multi-center analysis was to use individual patient data to determine the extent of the variability in LDL-C reduction in response to inclisiran administration in a real-world setting.

Methods

Since February 2021 the German Inclisiran Network (GIN) enrolled patients who received inclisiran due elevated LDL-cholesterol (LDL-C) levels in German lipid clinics. In contrast to patients included in the ORION program inclisiran could be administered to a broad range of patients with elevated LDL-C levels, including patients naive of lipid-lowering drugs, as well as patients on apheresis who failed to attain LDL-C goals.

Results

In 10 lipid clinics in Germany a total of 117 consecutive patients received inclisiran. Patients, who were not on stable lipid-lowering medication at least 3 months prior to inclisiran administration, were excluded. Thus, a total of 61 patients were analyzed. Mean LDL-C level at baseline was 151.86±64.31 mg/dl (95 percent confidence interval (CI): 135.39 to 168.33 mg/dl). After 3 months, inclisiran reduced LDL-C levels by 34.6% (95% CI: 29.3 to 39.8%), mean LDL-C levels were 103.26±60.36 mg/dl (95% CI: 87.8 to 118.72 mg/dl). At baseline 18 (30%) patients received statins, 22 (36%) ezetimibe and 13 (21%) bempedoic acid. Twenty-five (41%) patients were not on any lipid lowering therapy at baseline and 15 (25%) were on apheresis and failed to attain LDL-C target levels at baseline. Altogether there was a high inter-individual variability in LDL-C reduction 3 months after the first administration of inclisiran (Figure 1). Interestingly, patients who received statins at baseline demonstrated a trend towards a more profound LDL-C reduction (42.6±20.6 vs. 30.33±19.2%). This effect, however, was not significant. Two patients did not demonstrate any LDL-C reduction after the first administration. Inclisiran was well tolerated. Only one patient reported a minor injection-site reaction. No further side-effects were reported.

Conclusion

These results indicate that there is substantial individual variability in the LDL-C reduction after the first administration of inclisiran. Inclisiran was well tolerated without any serious side-effects. A longer follow-up period and further research is warranted to elucidate reasons for the high inter-individual variability in LDL-reductions in this real-world setting.

Funding Acknowledgement

Type of funding sources: None.

Reduced antioxiadant high-density lipoprotein function in patients with acute coronary syndrome

Background

High-density lipoprotein (HDL) function rather than concentration plays an important role in the pathogenesis of cardiovascular diseases associated with oxidative stress and inflammation such as coronary artery disease (CAD). In the last years, inflammation has been identified to have a pivotal role in the pathogenesis of acute coronary syndrome (ACS).

Purpose

The aim of the present study is to determine whether reduced antioxidant function of HDL is associated with ACS.

Methods

197 patients with ACS were prospectively recruited and blood samples were taken in the first 48h after enrollment. Patients with chronic coronary syndrome CCS (n=727) and with invasively excluded CAD (no CAD, n=498) from another cohort from our group served as control patients. A validated cell-free biochemical assay was used to determine reduced HDL antioxidant function as assessed by increased HDL-lipid peroxide content (HDLox) normalized by HDL-C levels and the mean value of a pooled serum control from healthy participants (nHDLox; no units).

Results

Patients with ACS had significantly increased HDLox blood levels compared to patients with CCS and to patients without CAD (p<0.001, Figure 1A). Prior intake of statins did not influenc the differences of HDLox among the groups (Figure 1B). In the regression analysis increased HDLox was a strong risk factor for the presence of ACS compared to CCS (odds ratio 4.09 (2.98–5.62), p<0.001, Figure 2).

Conclusions

HDL peroxidation is associated with the presence of ACS independent of the presence of other traditional risk factors.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): BIOX

POS1281 DIFFERENT HUMORAL BUT SIMILAR CELLULAR RESPONSES OF PATIENTS WITH AUTOIMMUNE INFLAMMATORY RHEUMATIC DISEASES UNDER DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS AFTER COVID-19 VACCINATION

Background

The interplay between humoral and cellular response after vaccination against SARS-CoV-2 in patients (pts.) with autoimmune inflammatory rheumatic diseases (AIRD) remains unknown.

Objectives

To investigate the impact of different immunosuppressive therapies on the development of humoral and cellular immune responses to full 2-dose SARS-CoV-2 vaccination in AIRD pts. with stable low disease activity.

Methods

The immune reactivity to COVID-19 vaccination was investigated in a prospectively recruited AIRD cohort with rheumatoid arthritis, axial spondyloarthritis or psoriatic arthritis which received a therapy with IL-17i, TNFi, JAKi or MTX (alone or in combination). Almost all patients received mRNA-based vaccine, only 4 patients had a heterologous scheme. Anti-spike(S) antibodies(ab.) and sera neutralizing capacity (neutralization dilution 50; ND50) were measured 4 weeks after the first (prime+4w) and 4 weeks after the second vaccination (boost+4w). Vaccine-specific cellular immunity was evaluated by quantifying expression of activation markers on T cells as well as their production of key cytokines, at prime+4w and boost+4w.

Results

Overall, a total of 92 pts. were included in the final cohort. 31 (33.7%) pts. were on TNFi, 24 (26.1%) on IL-17i, 24 (26.1%) on JAKi, each group encompassing pts. receiving drug inhibitors alone or in combination with MTX.13 (14.1%) were treated with MTX alone. The median time between the vaccination and blood sampling was 31 [IQR: 28-34] days after prime+4w and 28 [IRQ: 28-28] days after boost+4w. Although at prime+4w only 34/90 (37.8%) of pts. presented neutralizing ab., the majority (86/91, 94.5%), developed them at boost+4w. The highest neutralization titer developed the pts. on IL-17i both at prime+4w (74 [IQR: 13-91]) and boost+4w (798 [IQR: 511-1344]), while no statistically significant differences were found in the neutralization titer at boost+4w for the TNFi, JAKi, and MTX groups: 207 ND50 [IQR: 120-576], 319 [IQR: 133-461] and 749 [IQR: 264-1920], respectively. 81/90 (90.0%) pts. developed IgG ab. against SARS-CoV-2 S-protein at prime+4w and 91/92 (98.9%) at boost+4w. Pts. receiving IL-17i developed higher ab. titers (8295 U/mL [IQR: 4586-11,237]) compared to the other three groups: JAKi (4405 U/mL [IQR: 1436-7265], TNFi (2313 [IQR: 1156-3630] U/mL) and MTX (2010 U/mL [IQR: 693-9254]). Neutralization capacity correlated well with the titer of anti-S ab. at both timepoints. Co-administration of biologic/tsDMARDs and MTX led to lower titers compared to biologic/tsDMARDs monotherapy. All therapies left frequencies of CD154+CD137+ CD4+ T cells and CD137+ CD8+ T cells at prime+4w and boost+4w unchanged. Polyfunctionality and T cell cytokine profiles across therapies did not significantly vary at boost+4w.

Conclusion

Even after insufficient seroconversion for neutralizing capacity and ab. response against SARS-CoV-2 S-proteins between pts. of different mod of action agents, particularly for MTX and JAKi after first vaccination, a second vaccination covered almost all pts. regardless of DMARDs therapy, with better outcomes in those on IL-17i. T cell immunity revealed similar frequencies of activated T cells in all modes of action after the second vaccination.

Table 1.

Demographics and therapy

AllIL-17iIL-17i+MTXTNFiTNFi+MTXJAKiJAKi+MTXMTXPatients (n)9219527418613Age (years)50 [39-56]42 [36-53]37 [32-38]51 [42-56]58 [54-61]50 [43-56]55 [49-59]54 [37-64]Female sex46 (50.0%)6 (31.6%)3 (60.0%)10 (37.0%)3 (75.0%)13 (72.2%)3 (50.0%)8 (61.5%)Patients with concomitant glucocorticoids (n)13 (14.1%)1 (5.3%)1 (20.0%)0 (0.0%)0 (0.0%)5 (27.8%)3 (50.0%)3 (23.1%)Prednisolone dosage (mg)5.0 [2.5-5.0]5.0[5.0-5.0]3.0 [3.0-3.0]5.0 [2.5-5.0]2.0 [2.0-4.0]5.0 [4.0-5.0]

IL interleukin, i inhibitor, MTX methotrexate: TNF tumor necrosis factor, JAK janus kinase. For quantitative variables, data are provided as median [IQR], for categorical variables the count (% frequency)

Acknowledgements

We thank all the patients who participated in this study. We thank the study nurses Gordana Brnos and Silke Kunkel for their support in the implementation of the study. We thank Toralf Roch, Sarah Skrzypczyk, Jan Zapka, Julia Kurek and Eva Kohut for their technical assistance

Disclosure of Interests

None declared

Clinical presentation, disease course, and outcome of COVID-19 in hospitalized patients with and without pre-existing cardiac disease: a cohort study across 18 countries

AIMS

Patients with cardiac disease are considered high risk for poor outcomes following hospitalization with COVID-19. The primary aim of this study was to evaluate heterogeneity in associations between various heart disease subtypes and in-hospital mortality.

METHODS AND RESULTS

We used data from the CAPACITY-COVID registry and LEOSS study. Multivariable Poisson regression models were fitted to assess the association between different types of pre-existing heart disease and in-hospital mortality. A total of 16 511 patients with COVID-19 were included (21.1% aged 66-75 years; 40.2% female) and 31.5% had a history of heart disease. Patients with heart disease were older, predominantly male, and often had other comorbid conditions when compared with those without. Mortality was higher in patients with cardiac disease (29.7%; n = 1545 vs. 15.9%; n = 1797). However, following multivariable adjustment, this difference was not significant [adjusted risk ratio (aRR) 1.08, 95% confidence interval (CI) 1.02-1.15; P = 0.12 (corrected for multiple testing)]. Associations with in-hospital mortality by heart disease subtypes differed considerably, with the strongest association for heart failure (aRR 1.19, 95% CI 1.10-1.30; P < 0.018) particularly for severe (New York Heart Association class III/IV) heart failure (aRR 1.41, 95% CI 1.20-1.64; P < 0.018). None of the other heart disease subtypes, including ischaemic heart disease, remained significant after multivariable adjustment. Serious cardiac complications were diagnosed in <1% of patients.

CONCLUSION

Considerable heterogeneity exists in the strength of association between heart disease subtypes and in-hospital mortality. Of all patients with heart disease, those with heart failure are at greatest risk of death when hospitalized with COVID-19. Serious cardiac complications are rare during hospitalization.

Biomarkers in acute kidney injury - pathophysiological basis and clinical performance

Various biomarkers of acute kidney injury (AKI) have been discovered and characterized in the recent past. These molecules can be detected in urine or blood and signify structural damage to the kidney. Clinically, they are proposed as adjunct diagnostics to serum creatinine and urinary output to improve the early detection, differential diagnosis and prognostic assessment of AKI. The most obvious requirements for a biomarker include its reflection of the underlying pathophysiology of the disease. Hence, a biomarker of AKI should derive from the injured kidney and reflect a molecular process intimately connected with tissue injury. Here, we provide an overview of the basic pathophysiology, the cellular sources and the clinical performance of the most important currently proposed biomarkers of AKI: neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), liver-type fatty acid-binding protein (L-FABP), interleukin-18 (IL-18), insulin-like growth factor-binding protein 7 (IGFBP7), tissue inhibitor of metalloproteinase 2 (TIMP-2) and calprotectin (S100A8/9). We also acknowledge each biomarker's advantages and disadvantages as well as important knowledge gaps and perspectives for future studies.

The critical role of adenosine and guanosine in the affinity of dinucleoside polyphosphates to P(2X)-receptors in the isolated perfused rat kidney

1. The activation of P(2x)-receptors in the rat renal vasculature by dinucleoside polyphosphates with variable phosphate group chain length (Xp(n)X; X=Adenin (A) /Guanin (G), n=4 - 6) was studied by measuring their effects on perfusion pressure of the isolated perfused rat kidney at constant flow in an open circuit. 2. Like Ap(4)A, Ap(5)A and Ap(6)A the dinucleoside polyphosphates Ap(4)G, Ap(5)G and Ap(6)G exerted a vasoconstriction which could be blocked by suramin and pyridoxal-phosphate-6-azophenyl-2; 4-disulphonic acid (PPADS). 3. Gp(4)G, Gp(5)G and Gp(6)G showed only very weak vasoconstriction at high doses. 4. Ap(6)A and alpha, beta-meATP could not be blocked by the selective P(2x1)-receptor antagonisten NF023 (30 microM), whereas Ap(4)A, Ap(4)G, Ap(5)A, Ap(5)G and Ap(6)G were partially blocked by NF023. 5. Inhibition of endothelial NO-synthase by N(omega)-nitro-L-arginine methyl ester (L-NAME) did not affect vasoconstrictions induced by dinucleosidepolyphosphates. 6. P(2x)-receptor can only be activated if at least one adenosine moiety is present in the molecule. 7. Ap(n)G show a weaker vasoconstrictive action than corresponding Ap(n)A, concluding that two adenosine moieties enhance the P(2x)-receptor binding and activation. 8. Xp(n)X containing five phosphate groups show the most pronounced vasoconstrictive effect whereas four phosphate groups show the less effect, therefore the number of phosphate groups critically changes receptor affinity. 9. Additional experiments using permanent perfusion with alpha, beta-methylene ATP (alpha,beta-meATP) and the selective P(2x1)-receptor antagonist NF023 showed that the newly discovered human dinucleoside polyphosphates activated the vascular P(2x1)-receptor and an recently identified new P(2x)-receptor subtype. 10. The differential effects of dinucleoside polyphosphates allow a fine tuning of local perfusion via composition of Xp(n)Xs.

Captopril restores hemodynamic responsiveness to atrial natriuretic peptide in rats with heart failure

Atrial natriuretic peptide levels are elevated in heart failure. However, the hemodynamic responses to exogenous atrial natriuretic peptide infusion in heart failure are blunted. To determine if captopril can restore hemodynamic responsiveness to atrial natriuretic peptide infusion in rats with heart failure, studies were performed in a rat model of heart failure after coronary artery ligation. Rats with heart failure received either captopril (2 g/l drinking water) or placebo for 4 weeks and then were treated with an infusion of atrial natriuretic peptide (0.3 microgram/kg/min). Captopril treatment alone improved hemodynamics. Left ventricular end-diastolic pressure, mean aortic pressure, and mean circulatory filling pressure decreased from 22 +/- 2 to 14 +/- 1, from 106 +/- 4 to 76 +/- 3, and from 10.5 +/- 0.6 to 8.8 +/- 0.4 mm Hg, respectively. Heart rate, right atrial pressure, and hematocrit were unchanged. Total blood volume decreased from 66.0 +/- 1.0 to 60.0 +/- 1.0 ml/kg; venous compliance increased from 2.1 +/- 0.1 to 2.7 +/- 0.1 ml/kg/mm Hg. Atrial natriuretic peptide alone had minimal hemodynamic effects on rats with heart failure. There was no change in right atrial pressure, mean aortic pressure, left ventricular end-diastolic pressure, mean circulatory filling pressure, and total blood volume. However, atrial natriuretic peptide infusion increased venous compliance from 2.1 +/- 0.1 to 2.4 +/- 0.1 ml/kg/mm Hg. Heart rate and hematocrit increased from 323 +/- 5 to 359 +/- 8 beats/min and from 48 +/- 1% to 51 +/- 1%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)