Prediction of clinical outcomes in patients with coronavirus disease 2019 using high-sensitive troponin I and N-terminal pro-B-type natriuretic peptide

Background

Several comorbidities, including cardiovascular diseases or myocardial injury, are reported to be associated with poor prognosis in patients with Coronavirus disease 2019 (COVID-19). However, detailed prognostic analysis of myocardial injury by various biomarkers in COVID-19 patients is limited.

Purpose

This study aims to explore the prognostic values of high-sensitive Troponin I (hsTnI) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) for COVID-19 patients using Japanese real-world data.

Methods

The COVID-MI study is a retrospective cohort study that enrolls consecutive laboratory-confirmed COVID-19 patients admitted to the hospital from July 2020 to September 2021. We collected clinical data, including cardiac biomarker values, by chart review. If the prespecified biomarkers in concern were not available, we measured them using the institutional serum blood bank, which enrolled patients prospectively from July 2020. Patients with available biomarkers were analyzed according to the values of hsTnI or NT-proBNP, using the clinically relevant thresholds (hsTnI: 5 ng/L and 99th percentile of the upper reference limit [99%ile URL], and NT-proBNP: 125 pg/mL and 900 pg/mL). The primary outcome measure was all-cause death. Secondary outcome measures included acute respiratory distress syndrome, myocardial infarction, myocarditis/pericarditis, venous thromboembolism, cerebral infarction, and bleeding events.

Results

We enrolled 917 patients with COVID-19 confirmed by viral nucleic acid amplification test. The mean age was 61 years, and 591 patients (64%) were men. On admission, the number of patients classified as severe or critical COVID-19 was 515 (56%) and 85 (8.7%), respectively. Among the 544 patients with hsTnI values, 365 (67%) patients had elevated hsTnI of ≥5 ng/L, and 134 patients (25%) had TnI of ≥99%ile URL. Besides, among 546 patients with NT-proBNP values, 295 patients (54%) had elevated NT-pro-BNP of ≥125 pg/mL, and 93 patients (17%) had NT-proBNP of ≥900 pg/mL. The median follow-up period was 31 days (interquartile range: 11–90 days). In cumulative incidence analysis, higher levels of hsTnI and NT-proBNP were associated with significantly higher mortality (hsTnI: <5 ng/L group; 8.8%, 5 ng/L to 99%ile URL group; 19%, and ≥99%ile URL group; 37%, P<0.001, and NT-proBNP: <125 pg/mL group; 7.8%, 125 to 900 pg/mL group; 21%, and ≥900 pg/mL group; 45%, P<0.001). The adjusted risk for all-cause death remained significant for each threshold of cardiac biomarkers (hsTnI ≥99%ile URL: hazard ratio [HR] 1.98, 95% confidence interval [CI] 1.11–3.54, P=0.02, and NT-proBNP ≥900 pg/mL: HR 3.60, 95% CI 1.86–6.98, P<0.001).

Conclusion

Elevation of hsTnI or NT-proBNP was associated with poor prognosis in the current relatively severely ill COVID-19 patients. Measuring hsTnI or NT-proBNP can be an attractive option for risk stratification and deciding appropriate management in patients with COVID-19.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Institutional Research Fund at Kobe City Medical Center General Hospital

Sex differences in terms of recurrent atrial fibrillation after catheter ablation according to the history of heart failure: insights from the Kansai Plus Atrial Fibrillation (KPAF) registry

Background

There are significant differences in the prevalence and prognosis of cardiovascular diseases between male and female. We previously reported that catheter ablation (CA) of atrial fibrillation (AF) was less effective in female than male, but whether their history of heart failure influence the recurrence after CA of AF remains still unknown.

Purpose

We sought to clarify sex differences in terms of AF recurrence after RFCA of AF according to the history of heart failure.

Methods

We conducted a large-scale, prospective, multicenter, observational study (Kansai Plus Atrial Fibrillation Registry). We enrolled 5010 consecutive patients who underwent an initial RFCA of AF at 26 centers (64±10 years; 1369 [27.3%] females; non-paroxysmal AF, 35.7%). The median follow-up duration was 2.9 years.

Results

Fourteen % of female had a history of heart failure prior to CA, while 12.8% of male had a history of heart failure at baseline (p=0.29). The 3-year cumulative incidence of AF recurrence after a single procedure was 43.3% in female and 39.0% in male (log rank P=0.0046). In patients with the history of heart failure, AF recurrence rates were 42.2% in female and 45.8% in male (log rank P=0.51). On the other hand, in patients without history of heart failure, more females experienced AF recurrence (female vs. male, 43.5% vs. 38.0%, log rank P=0.001).

The rate of AF recurrence after multiple procedures was higher in female (24.2% vs. 19.6%, log rank P<0.0001). AF recurrence rates were similar between sexes in patients with history of heart failure (female vs. male, 26.0% vs. 26.7%, log rank P=0.86), while AF recurrence rates were higher in female without history of heart failure than those in male (females vs. males, 23.9% vs. 18.5%, log rank P<0.0001).

Conclusion

The Kansai Plus Atrial Fibrillation Registry revealed a distinct sex difference in terms of the AF recurrence after CA of AF. Females had higher recurrence rates compared with males in patients without history of heart failure, while recurrence rates were similar between sexes in patients with history of heart failure.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Research Institute for Production Development in Kyoto, Japan.

P-127 Identification of the optimal puncture position by image analysis may reduce oocyte degeneration in intracytoplasmic sperm injection (ICSI)

Study question

Is it possible to identify the optimal puncture position by image analysis where oocyte degeneration is reduced in ICSI procedure?

Summary answer

Visualizing the likelihood of unintentional membrane rupture (UMR) using image analysis can reduce oocyte degeneration and thereby generate more embryos available for treatment.

What is known already

It is known that the oocyte degeneration after both conventional-ICSI and Piezo-ICSI are often observed when UMR occurs during the puncturing process and the likelihood of UMR may depends on the location of the puncture site on the oolemma. Identifying the appropriate puncturing position may decrease the likelihood of membrane rupture and thus degeneration, however, there are no studies identifying the optimal puncture position during ICSI.

Study design, size, duration

We have developed the ICSI Position Detector (IPD), which can identify an area where rupture is likely to occur and visualize it on a video monitor. This study included 1,110 mature oocytes retrieved from 190 consenting patients. Matured oocytes were inseminated either by Conventional-ICSI (n = 437, average maternal age: 39.1±4.6 y.o.) or Piezo-ICSI (n = 673, average maternal age: 38.6±4.5 y.o.). ICSI was performed blindly, moving images were recorded and analyzed retrospectively during ICSI using IPD.

Participants/materials, setting, methods

Inseminated oocytes were subsequently divided into two groups according to IPD results, oocytes on which ICSI was performed at the position with a low chance of UMR (appropriate group), and with a high chance of UMR (non-appropriate group) by IPD. The rates of UMR, degeneration, fertilization (2PN), blastocyst formation, and good-quality blastocyst (Grade 3BB and above on day 5 by the Gardner scoring) were compared between the two groups of both conventional-ICSI and Piezo-ICSI.

Main results and the role of chance

The areas in which UMR is less likely to occur and more likely to occur are heterogeneously distributed. When ICSI was performed blindly, about half was from the non-appropriate position. In appropriate group of Piezo-ICSI, rates of UMR (4.3% vs. 17.4%, P < 0.001) and degeneration (1.0% vs. 5.7%, P < 0.001) were significantly lower than those of non-appropriate group, whereas rates of fertilization (88.0% vs. 78.4%, P < 0.01) and blastocyst formation (57.8% vs. 45.9%, P < 0.01) were significantly higher than those of non-appropriate group, respectively. The rate of good-quality blastocyst (28.8% vs. 24.9%) was in favor of appropriate group, but not significantly different. In appropriate group of Conventional-ICSI, rates of UMR (6.7% vs. 20.6%, P < 0.001) and degeneration (1.5% vs. 6.6%, P < 0.01) were significantly lower than those of non-appropriate group, whereas rate of fertilization (88.7% vs. 69.5, P < 0.001) was significantly higher than those of non-appropriate group, respectively. The rates of blastocyst formation (37.5% vs. 35.3%), good-quality blastocyst (21.3% vs. 18.7%) were all in favor of appropriate group, but not significantly different.

Limitations, reasons for caution

This is a single private fertility clinic study. Its reproducibility should be assessed in different laboratory conditions and the hands of different operators. Moreover, specific studies should be addressed on the effect of the other putative confounders under investigation (e.g. kind of ovulation trigger, patient demographics, culture environment, etc.).

Wider implications of the findings

This study demonstrated that the IPD is useful to identify the optimal puncture location site to prevent UMR on ICSI procedure, resulting in reducing UMR and degeneration of the oocytes and increasing culture results, thereby, generating more embryos available for transfer or cryopreservation.

Trial registration number

not applicable

Starting Neurohormonal Antagonists in Patients with Acute Heart Failure with Mid-Range and Preserved Ejection Fraction

Background

The clinical benefits of neurohormonal antagonist in patients with heart failure (HF) with mid-range and preserved ejection fraction (HFmrEF and HFpEF) were uncertain. This study aimed to evaluate the prognostic effect of starting angiotensin-converting enzyme inhibitors (ACE-I) / angiotensin II receptor blockers (ARB) and β-blocker during HF hospitalization in these patients.

Methods

We analyzed 858 consecutive patients with HFmrEF (EF:40–49%) or HFpEF (EF≥50%), who were hospitalized for acute decompensated HF, were discharged alive, and were not taking ACE-I/ARB or β-blockers at admission. The study population was classified into four groups according to the status of prescription of ACE-I/ARB and β-blocker at discharge: no neurohormonal antagonist (N=342, 39.9%), ACE-I/ARB only (N=128, 14.9%), β-blocker only (N=189, 22.0%), and both ACE-I/ARB and β-blocker (N=199, 23.2%) groups. The primary outcome measure was a composite of all-cause death or HF hospitalization.

Results

The cumulative 1-year incidence of the primary outcome measure was 41.2% in the no neurohormonal antagonist group, 34.0% in the ACE-I/ARB only group, 28.6% in the β-blocker only group, and 16.4% in the both ACE-I/ARB and β-blocker group (P<0.001). Compared with the no neurohormonal antagonist group, the both ACE-I/ARB and β-blocker group were associated with a significantly lower risk for a composite of all-cause death or HF hospitalization (HR: 0.59, 95% CI: 0.38–0.91, P=0.02).

Conclusions

In hospitalized patients with HFmrEF and HFpEF, starting both ACE-I/ARB and β-blocker was associated with a reduced risk of a composite of all-cause death or HF hospitalization compared with not starting ACE-I/ARB or β-blocker.

Funding Acknowledgement

Type of funding sources: None.

Impact of catheter ablation on functional tricuspid regurgitation in patients with atrial fibrillation

Background

Since atrial functional tricuspid regurgitation (AF-TR) is associated with increased heart failure and mortality, the management of AF-TR is clinically important. Atrial fibrillation (AF) plays the main role in AF-TR. However, the effectiveness of catheter ablation (CA) and mechanism of improvement of AF-TR haven't been fully evaluated.

Purpose

We sought to investigate the impact of CA for AF on AF-TR in patients with moderate or more TR.

Methods

We retrospectively investigated consecutive 2685 patients with AF who received CA from February 2004 to December 2019 in Japan. The current study population consisted of 102 patients with moderate or greater TR who underwent CA for AF. The echocardiographic parameters were compared between pre-ablation and post-ablation transthoracic echocardiography (TTE), and the recurrence rate of AF/ atrial tachycardia (AT) was measured.

Results

The mean age was 73.2 years, 53% were women. TR severity and TR jet area significantly improved after CA for AF (TR jet area: 5.8 [3.9–7.6] cm2 to 2.0 [1.1–3.0] cm2, p<0.001). In addition, mitral regurgitation (MR) jet area, left atrial (LA) area, mitral valve diameter, right ventricular (RV) end-diastolic area, right atrial (RA) area, tricuspid valve (TV) diameter decreased after CA (p<0.001, <0.001, <0.001, = 0.02, <0.001, and <0.001, respectively). There was no significant difference between one-year recurrence of AF/AT and TR severity at pre-ablation TTE (moderate 28.6%, moderate to severe 37.2%, and severe 31.6%, p=0.72).

Conclusions

TR severity and jet area improved after CA in patients with AF and moderate or more TR. RV size, RA size, TV diameter also decreased after CA, which may be associated with TR improvement. There was no significant difference between one-year recurrence of AF/AT and TR severity at pre-ablation TTE.

Funding Acknowledgement

Type of funding sources: None.

Autoimmune disorders and venous thromboembolism: a report from the COMMAND VTE Registry

Background/Introduction

Venous thromboembolism (VTE), including pulmonary embolism (PE) and deep vein thrombosis (DVT), is a major health problem in the world. Several studies reported that autoimmune disorder is one of important risk factors for development of VTE. Furthermore, autoimmune disorder is thought to be a relatively strong risk factor for VTE recurrence, and extended anticoagulation therapy are recommended for prevention of VTE recurrence in patients with autoimmune disorders. However, it remains controversial whether patients with autoimmune disorders have higher risk for clinical events after VTE than those without.

Purpose

We sought to evaluate the clinical characteristics, management strategies, and long-term outcomes of patients with autoimmune disorders after excluding patients with active cancer in a large observational database in Japan.

Methods

The COMMAND VTE Registry is a multicenter registry enrolling 3027 consecutive patients with acute symptomatic VTE. After excluding patients with active cancer, the current study population consisted of 2332 patients, who were divided into 2 groups: patients with autoimmune disorders and those without. We estimated the cumulative incidences of the clinical outcomes. To adjust for the clinically relevant confounders, we used the multivariable Cox proportional hazard model to estimate the hazard ratio (HR) and their 95% confidence interval (CI) for the risk of patients with autoimmune disorders relative to those without for the clinical outcome measures. Furthermore, we added corticosteroids use at discharge to explore the effect of corticosteroids use.

Results

There were 188 patients (8.1%) with autoimmune disorders and 2144 patients (92%) without autoimmune disorders. Patients with autoimmune disorders were more often women (74%), and more often received corticosteroids at discharge (69%). The discontinuation rate of anticoagulation therapy was not significantly different between patients with autoimmune disorders and those without (38.0% vs. 39.7% at 3-year, P=0.35). The cumulative 5-year incidences of recurrent VTE and major bleeding were significantly higher in patients with autoimmune disorders than in those without (recurrent VTE: 14.3% vs. 8.3%, P=0.01; major bleeding: 14.9% vs. 8.8%, P=0.02). Even after adjusting confounders of patient characteristic, the excess risk of patients with autoimmune disorders relative to those without remained significant for recurrent VTE (HR 1.81, 95% CI 1.08–2.88, P=0.03) and major bleeding (HR 1.70, 95% CI 1.05–2.63, P=0.03). However, after adjusting for corticosteroids use at discharge, the excess risk was no longer significant for recurrent VTE (HR 1.42, 95% CI 0.75–2.61, P=0.27) nor major bleeding (HR 1.53, 95% CI 0.84–2.69, P=0.16).

Conclusions

Patients with autoimmune disorders had a higher risk for recurrent VTE and major bleeding than those without, and the excess risk could at least partly be attributable to corticosteroids use.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Research Institute for Production Development, Mitsubishi Tanabe Pharma Corporation

Risk factors of recurrence and major bleeding in patients with intermediate-risk for recurrence of venous thromboembolism: from the COMMAND VTE Registry

Background/Introduction

Patients with venous thromboembolism (VTE), including pulmonary embolism (PE), have a long-term risk of recurrence, and anticoagulation therapy is recommended for the prevention of recurrence. The latest 2019 European Society of Cardiology (ESC) guideline classified the risks of recurrence into low- (<3%/year), intermediate- (3–8%/year), and high- (>8%/year) risk, and recommended the extended anticoagulation therapy of indefinite duration for high-risk patients as well as intermediate-risk patients. However, extended anticoagulation therapy of indefinite duration for all of intermediate-risk patients have been a matter of active debate. Thus, additional risk assessment of recurrence in intermediate-risk patients might be clinically relevant in defining the optimal duration of anticoagulation therapy. Furthermore, bleeding risk during anticoagulation therapy should also be taken into consideration for optimal duration of anticoagulation therapy. However, there are limited data assessing the risk of recurrence as well as bleeding in patients with intermediate-risk for recurrence based on the classification in the latest 2019 ESC guideline.

Purpose

The current study aimed to identify the risk factors of recurrence as well as major bleeding in patients with intermediate-risk for recurrence, using a large observational database of VTE patients in Japan.

Methods

The COMMAND VTE Registry is a multicenter registry enrolling consecutive 3027 patients with acute symptomatic VTE among 29 centers in Japan. The current study population consisted of 1703 patients with intermediate-risk for recurrence. The primary outcome measure was recurrent VTE during the entire follow-up period, and the secondary outcome measures were recurrent VTE and major bleeding during anticoagulation therapy.

Results

In the multivariable Cox regression model for recurrent VTE incorporating the status of anticoagulation therapy as a time-updated covariate, off-anticoagulation therapy was strongly associated with an increased risk for recurrent VTE (HR 9.42, 95% CI 5.97–14.86). During anticoagulation therapy, the independent risk factor for recurrent VTE was thrombophilia (HR 3.58, 95% CI 1.56–7.50), while the independent risk factors for major bleeding were age ≥75 years (HR 2.04, 95% CI 1.36–3.07), men (HR 1.52, 95% CI 1.02–2.27), history of major bleeding (HR 3.48, 95% CI 1.82–6.14) and thrombocytopenia (HR 3.73, 95% CI 2.04–6.37).

Conclusions

Among VTE patients with intermediate-risk for recurrence, discontinuation of anticoagulation therapy was a very strong independent risk factor of recurrence during the entire follow-up period. The independent risk factors of recurrent VTE and those of major bleeding during anticoagulation therapy were different: thrombophilia for recurrent VTE, and advanced age, men, history of major bleeding, and thrombocytopenia for major bleeding.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Research Institute for Production Development, Mitsubishi Tanabe Pharma Corporation

Risk factors of recurrence in patients with cancer-associated venous thromboembolism: from the COMMAND VTE Registry

Background/Introduction

Cancer is a strong risk factor for the development of venous thromboembolism (VTE) including pulmonary embolism (PE) and deep vein thrombosis (DVT). Patients with VTE have a long-term risk of recurrence, which can be prevented by anticoagulation therapy. Prolonged anticoagulation therapy is recommended for patients with cancer-associated VTE, although the risk of recurrence might depend on the individual patient.

Purpose

We aimed to identify the risk factors of recurrence in patients with cancer-associated VTE.

Methods

The COMMAND VTE Registry is a multicenter retrospective registry enrolling 3027 consecutive patients with acute symptomatic VTE among 29 Japanese centers between January 2010 and August 2014. The present study population consisted of 695 cancer-associated VTE patients. The primary outcome measure in the present study was recurrent VTE, which was defined as PE and/or DVT with symptoms accompanied by confirmation of a new thrombus or exacerbation of the thrombus by objective imaging examinations or autopsy. Discontinuation of anticoagulation was defined as a withdrawal of anticoagulation therapy lasting >14 days for any reason. We selected clinically relevant variables and variables with P values <0.1 in a univariate analysis as potential risk factors, and constructed a multivariable Cox proportional hazard model for recurrent VTE incorporating the anticoagulation therapy status as a time-updated covariate.

Results

Among the 695 study patients, recurrent VTE occurred in 78 patients, of whom 54 (69%) occurred within 6 months. The cumulative incidence of recurrent VTE was 7.7% at 3-months, 8.9% at 6-months, 11.8% at 1-year, and 17.7% at 5-years. The cumulative incidence of discontinuation of anticoagulation therapy was 18.0% at 3-months, 29.5% at 6-months, 43.4% at 1-year, and 66.5% at 5-years. The cumulative 5-year incidence of recurrent VTE was most frequent in patients with uterus/ovary cancer (26.0%), followed by those with lung cancer (24.7%). The multivariable Cox proportional hazard model revealed that chronic kidney disease (HR, 2.27; 95% CI, 1.36–3.77, P=0.002), a high D-dimer level at the time of VTE diagnosis (HR, 2.85; 95% CI, 1.71–4.74, P<0.001), advanced cancer (HR, 1.69; 95% CI, 1.05–2.72, P=0.03) and discontinuation of anticoagulation therapy (HR, 2.66; 95% CI, 1.53–4.63, P<0.001) were independently associated with an increased risk of recurrent VTE. No cancer site was independently associated with an increased risk for recurrent VTE when adjusting for the above mentioned risk factors in the multivariable Cox proportional hazard model, although the risk of recurrent VTE numerically differed according to the cancer site.

Conclusions

Among patients with cancer-associated VTE, chronic kidney disease, a high D-dimer level at the time of VTE diagnosis, advanced cancer, and discontinuation of anticoagulation therapy were independent risk factors of recurrence.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Research Institute for Production Development, Mitsubishi Tanabe Pharma Corporation Figure 1Figure 2

White discharge formation following a subepithelial connective tissue graft for anterior fixed partial denture pontics: a case report based on clinical and histological findings

PATIENT

A 54-year-old woman presenting with anterior alveolar ridge resorption was submitted to a connective tissue graft (CTG) for esthetic improvement before rehabilitation with a fixed partial denture. Palate-harvested connective tissue was used as a graft after extra-oral removal of the epithelium. Unexpectedly, complete wound healing was not observed. Moreover, 6 months post-surgery, a white discharge was detected at the grafted site. The adjacent tooth showing a root fracture was initially associated with the symptoms and was then extracted. Concomitantly, the unhealed tissue at the grafted site was also excised, leading to temporary symptom resolution. However, the white discharge reappeared after 2 months. The excision area was expanded to remove the grafted tissue entirely, and the wound was completely healed. Since the alveolar ridge resorption had become larger compared to the preoperative condition, the patient was subjected to a second CTG, now using a connective tissue harvested from the palate by a single incision technique. The wound healed uneventfully, and the final prosthesis was delivered 6 months after soft tissu e stabilization. The patient has been followed-up for more than 28 months without any recurrence of white discharge.

DISCUSSION

Histopathological and cytological examination detected keratinized epithelial tissues and cells, respectively, in excised tissues and white discharge specimens. Consequently, a possible relationship between white discharge and residual epithelium in the harvested graft was strongly suspected.

CONCLUSIONS

Success of the CTG procedure requires careful method selection for tissue transplantation and treatment execution.

Do Outcomes between Women and Men Differ after Endovascular Thrombectomy? A Meta-analysis

BACKGROUND

Research on the presence of sex-based differences in the outcomes of patients undergoing endovascular thrombectomy for acute ischemic stroke has reached differing conclusions.

PURPOSE

This review aimed to determine whether sex influences the outcome of patients with large-vessel occlusion stroke undergoing endovascular thrombectomy.

STUDY SELECTION

We performed a systematic review and meta-analysis of endovascular thrombectomy studies with either stratified cohort outcomes according to sex (females versus males) or effect size reported for the consequence of sex versus outcomes. We included 33 articles with 7335 patients.

DATA ANALYSIS

We pooled ORs for the 90-day mRS score, 90-day mortality, symptomatic intracranial hemorrhage, and recanalization.

DATA SYNTHESIS

Pooled 90-day good outcomes (mRS ≤ 2) were better for men than women (OR = 1.29; 95% CI, 1.09-1.53; P = <.001, I² = 56.95%). The odds of the other outcomes, recanalization (OR = 0.94; 95% CI, 0.77-1.15; P = .38, I² = 0%), 90-day mortality (OR = 1.11; 95% CI, 0.89-1.38; P = .093, I² = 0%), and symptomatic intracranial hemorrhage (OR = 1.40; 95% CI, 0.99-1.99; P = .069, I² = 0%) were comparable between men and women.

LIMITATIONS

Moderate heterogeneity was found. Most studies included were retrospective in nature. In addition, the randomized trials included were not specifically designed to compare outcomes between sexes.

CONCLUSIONS

Women undergoing endovascular thrombectomy for large-vessel occlusion have inferior 90-day clinical outcomes. Sex-specific outcomes should be investigated further in future trials as well as pathophysiologic studies.

Terahertz-field-induced polar charge order in electronic-type dielectrics

Ultrafast electronic-phase change in solids by light, called photoinduced phase transition, is a central issue in the field of non-equilibrium quantum physics, which has been developed very recently. In most of those phenomena, charge or spin orders in an original phase are melted by photocarrier generations, while an ordered state is usually difficult to be created from a non-ordered state by a photoexcitation. Here, we demonstrate that a strong terahertz electric-field pulse changes a Mott insulator of an organic molecular compound in κ-(ET)₂Cu[N(CN)₂]Cl (ET = bis(ethylenedithio)tetrathiafulvalene), to a macroscopically polarized charge-order state; herein, electronic ferroelectricity is induced by the collective intermolecular charge transfers in each dimer. In contrast, in an isostructural compound, κ-(ET)₂Cu₂(CN)₃, which shows the spin-liquid state at low temperatures, a similar polar charge order is not stabilized by the same terahertz pulse. From the comparative studies of terahertz-field-induced second-harmonic-generation and reflectivity changes in the two compounds, we suggest the possibility that a coupling of charge and spin degrees of freedom would play important roles in the stabilization of polar charge order.

A decrease in tricuspid regurgitation pressure gradient during follow-up in patients with heart failure

Objective

This study aimed to investigate the prognostic impact of the decrease in tricuspid regurgitation pressure gradient (TRPG) at 6-month follow-up in patients after discharge with heart failure (HF).

Background

No previous study has reported the association between TRPG decrease during follow-up and clinical outcomes in HF.

Methods

Among 748 patients with 6-months follow-up echocardiography after discharge from the acute decompensated heart failure in 19 centers in Japan, we analyzed 721 patients with available TRPG data and divided into two groups: the decrease in TRPG group (N=179) and no decrease in TRPG group (N=542). We defined the decrease in TRPG as &gt;10mmHg decrease compared in the initial hospitalization. The primary outcome measure was a composite of all cause deaths and hospitalization due to HF.

Results

The patients in the decrease in TRPG group had a lower prevalence of hypertension, dyslipidemia, atrial fibrillation, and a reduced EF, higher levels of blood albumin and lower levels of sodium than those in no decrease in TRPG group. The median follow-up duration after the follow up echocardiography was 302 (inter quartile range: 206–490), with a 90.9% follow up rate at 6-month. The cumulative 6-month incidence of the primary outcome measure was significantly lower in the decrease in TRPG group than in no decrease in TRPG group (12.2% vs. 18.9%, P=0.0011). After adjusting confounders, the excess risk of the decrease in TRPG relative to no decrease in TRPG for the primary outcome measure remained significant (HR: 0.60, 95% CI 0.34–0.99). There were no significant interactions between the subgroup factors and the effect of the decrease in TRPG for primary outcomes.

Conclusions

HF patients with the decrease in TRPG at 6-month after discharge had a lower risk of clinical outcome than those without decrease in TRPG.

Funding Acknowledgement

Type of funding source: None

Clinical characteristics and outcomes of patients with venous thromboembolism according to diagnosis on weekends versus weekdays: from the COMMAND VTE Registry

Background/Introduction

The medical systems of hospitals often differs between on weekends and weekdays. These differences could lead different clinical outcomes for patients with acute medical conditions that require complex treatment strategies. However, the effect of the time of diagnosis on clinical outcomes in patients with acute venous thromboembolism (VTE), including pulmonary embolism (PE) and deep vein thrombosis (DVT), is still controversial.

Purpose

We sought to evaluate the clinical characteristics and outcomes of patients with VTE comparing on weekends and weekdays in a large observational database of VTE in Japan.

Methods

The COMMAND VTE Registry is a multicenter registry enrolling 3027 consecutive patients with acute symptomatic VTE objectively confirmed by imaging examination or by autopsy among 29 centers in Japan between January 2010 and August 2014. In the current analysis, diagnosis on weekends was defined as diagnosis during the period from 00:00 hours on Saturday to 24:00 on Sunday. All other times were defined as weekdays. We divided the entire cohort into 2 groups; diagnosis on weekends and diagnosis on weekdays groups, and we compared the clinical characteristics, management strategies and 30-day outcomes between the 2 groups.

Results

The current study population consisted of 337 patients diagnosed on weekends and 2690 patients diagnosed on weekdays. The median days from onset to diagnosis were shorter in the patients diagnosed on weekends than in those diagnosed on weekdays (2 days vs. 4 days, P&lt;0.001). The patients diagnosed on weekends presented with PE more frequently (72% vs. 55%, P&lt;0.001), and they showed more severe condition for PE with a higher simplified pulmonary embolism severity index score. The vast majority of PE patients were diagnosed by contrast-enhanced computed tomography in both groups (97% vs. 97%, P=0.67). The patients diagnosed on weekends more often received initial parenteral anticoagulation therapy and thrombolysis than those diagnosed on weekdays. The cumulative 30-day incidence of all-cause death was not significantly different between the 2 groups among PE patients (diagnosis on weekends: 6.2% vs. diagnosis on weekdays: 6.5%, P=0.87), as well as among DVT patients (0.0% vs. 1.5%, P=0.24) (Figure). After adjusting the confounders, the risk of diagnosis on weekends relative to diagnosis on weekdays for all-cause death among PE patients was still insignificant (adjusted HR: 0.76; 95% CI: 0.42–1.28). The most frequent cause of deaths was fatal PE in both groups among PE patients. The risks for recurrent VTE and major bleeding at 30 days were not significantly different between the 2 groups among PE patients nor DVT patients.

Conclusions

The VTE patients diagnosed on weekends presented with PE more frequently, and they showed more severe condition for PE, although the risks for short-term mortality were not significantly different between patients diagnosed on weekends and weekdays.

Kaplan-Meier curves for all-cause death

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Research Institute for Production Development, Mitsubishi Tanabe Pharma Corporation

Predictive factors of recurrent atrial tachyarrhythmia after multiple procedures of radiofrequency catheter ablation for paroxysmal atrial fibrillation: Kansai Plus Atrial Fibrillation Registry (KPAF)

Background

The predictors of arrhythmia recurrence after radiofrequency catheter ablation (RFCA) for paroxysmal atrial fibrillation (PAF) have not yet been fully evaluated.

Purpose

The aim of this study was to develop and validate a risk scoring system to predict the incidence of recurrence of atrial tachyarrhythmia after the final RFCA for PAF.

Methods

The study population consisted of 3223 consecutive patients undergoing first-time RFCA for PAF from November 2011 to March 2014 in 26 cardiovascular centers in Japan who were enrolled in the Kansai Plus Atrial Fibrillation (KPAF) registry. We developed a scoring system in a derivation cohort with 2149 patients and assessed its reproducibility in a validation cohort with 1074 patients. The primary endpoint was recurrent atrial tachyarrhythmia lasting for ≥30 seconds after 91 days post the final ablation.

Results

During a median follow-up period of 3.1 years, 404 (18.8%) patients of the derivation cohort had AF recurrence after the final RFCA. The baseline patient characteristics of the derivation cohort were as follows: mean age 64.7 years, male 1480 (68.9%), mean body mass index (BMI) 23.6 kg/m2, hypertension 1122 (52.2%), prior heart failure 182 (8.5%), diabetes mellitus 203 (9.5%), prior stroke and/or transient ischemic attack 21 (1.0%), prior vascular disease 209 (9.7%), prior valvular disease 105 (4.9%), median CHADS2 score 1.1, median CHA2DS2-VASc score 2.1, mean number of ineffective antiarrhythmic drugs (AAD) 0.80, median duration of history of AF episodes 2.1 years, mean left atrial diameter (LAD) 38.2 mm, mean left ventricular ejection fraction (LVEF) 65.3%, and mean eGFR 68.7 mL/min/1.73m2. There was no significant difference in the baseline characteristics between derivation and validation cohorts. The results of the multivariate logistic regression models identified 5 independent variables of recurrent atrial tachyarrhythmia after the final RFCA: female (odds ratio (OR) = 1.45, p=0.0017), BMI &lt;25 kg/m2 (OR=1.40, p=0.0081), duration of AF history 3 years≤ (OR=1.39, p&lt;0.0034), chronic kidney disease (CKD) (OR=2.1, p=0.005, for stage 2/3CKD, OR=2.6, p=0.018 for stage 4/5 CKD), and LVEF (OR=2.1, p=0.039 for LVEF &lt;50%, OR=1.5, p=0.022 for LVEF 50–60%). The predictive score for each factor was 3 points for CKD stage 4/5, 2 for CKD stage2/3 and LVEF &lt;50%, and 1for the others (11 points in total). The arrhythmia-free rates after the final RCFA in the derivation cohort according to the score were as follows: 0–2 points = 91.7%, 3–4 = 80.7%, 5&lt; = 72.6%, respectively. The similar results were reproduced in the validation cohort (Figure 1).

Conclusion

Our newly developed scoring system, composed of female, BMI, AF duration, CKD, and LVEF, could reproducibly predict arrhythmia recurrence after the final RFCA for PAF.

Funding Acknowledgement

Type of funding source: None

Predictive ability of modified Ottawa score for recurrence in patients with cancer-associated venous thromboembolisms: from the COMMAND VTE Registry

Background/Introduction

Patients with cancer-associated venous thromboembolisms (VTEs) have a markedly higher risk of recurrence as well as bleeding, compared to those without, leading to difficulty in achieving a good risk-to-benefit balance with anticoagulation therapy. Thus, the assessment of the risk of recurrence in an individual patient is essential. The modified Ottawa score has been developed to predict the risk of recurrence in patients with cancer-associated VTEs during anticoagulation therapy, however, the validity of the score is still controversial.

Purpose

We aimed to evaluate the utility and limitations of the modified Ottawa score in the risk stratification of recurrent VTEs in patients with cancer-associated VTEs.

Methods

The COMMAND VTE Registry is a multicenter retrospective registry enrolling 3027 consecutive patients with acute symptomatic VTEs among 29 Japanese centers between January 2010 and August 2014. The present study population consisted of 614 cancer-associated VTE patients with anticoagulation therapy beyond 10 days after the diagnosis, who were divided into 3 groups; High-risk group with a modified Ottawa score ≥1, Intermediate-risk group with a score = 0, and Low-risk group with a score ≤−1. To evaluate the discriminating power of the modified Ottawa score for recurrence, we described the receiver operating characteristic curve with a C-statistic, and evaluated the positive likelihood ratio as the predictive performance of the score for recurrence in each subgroup.

Results

The high-risk group accounted for 202 patients (33%), intermediate-risk group for 269 (44%), and low-risk group for 143 (23%). During the first 6 months of anticoagulation therapy, recurrent VTEs occurred in 39 patients. The cumulative incidence of recurrent VTEs substantially increased in the higher risk categories by the modified Ottawa score (High-risk group: 13.6%, Intermediate-risk group: 5.9%, and Low-risk group: 3.0%, Log-rank P=0.02) (Figure 1). The discriminating power of the score was modest with a C-statistic of 0.63 (95% CI 0.55–0.71). The positive likelihood ratios as the predictive performance of the score were 1.71 in the high-risk group, 0.81 in the intermediate-risk group, and 0.42 in the low-risk group. Women and patients with prior VTEs had numerically higher cumulative 6-month incidences of recurrent VTEs compared with those without, while patients with lung cancer, breast cancer, and without metastasis had numerically lower cumulative 6-month incidences of recurrent VTEs. Depending on the presence or absence of each score component, the risks of recurrence seemed to differ in the low-, intermediate-, and high-risk groups.

Conclusions

The risks of recurrence in patients with cancer-associated VTEs substantially increased in the higher risk categories by using the modified Ottawa score, but the discriminating power of the score for recurrence was modest with a widely variable impact of each score component on recurrence.

Figure 1

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Research Institute for Production Development, Mitsubishi Tanabe Pharma Corporation

Biodegradable-polymer versus durable-polymer drug eluting stents for coronary artery disease: systematic review and a meta-analysis

Background

Biodegradable polymer drug-eluting stents (BP-DES) has been developed to overcome the potential drawbacks of the first-generation durable polymer drug-eluting stents (DP-DES). However, it is still under debate whether BP-DES is associated with superior efficacy and safety over DP-DES.

Purpose

We sought to compare the effects of BP-DES and DP-DES in patients with coronary artery disease.

Methods

We performed systematic review and a meta-analysis of randomized controlled trials comparing BP-DES and DP-DES on clinical outcomes in patients with coronary artery disease using CE-mark approved drug-eluting stents (DES) with at least 1-year follow-up. We included 32 studies involving 39,686 patients (BP-DES: 21,439 patients, and DP-DES: 18,247 patients). Primary outcome measure was target vessel failure (TVF; equivalent to the composite of cardiac death, target-vessel myocardial infarction, or ischemia-driven target vessel revascularization). We performed subgroup analysis according to the DP-DES generations (newer-generation DP-DES: 15,179patients, and first-generation DP-DES: 3,068 patients), and the effects of newer-generation DP-DES was compared with the BP-DES according to the BP-DES strut thickness (Ultra-thin strut [&lt;80μm]: 7,572 patients, Thin-strut [80–100μm]: 5,465 patients, and Thick-strut [≥80μm]: 5,876 patients).

Results

The odds for TVF was not significantly different between the BP-DES group and the DP-DES group in the entire study population (odds ratio [OR] 0.96, 95% confidence interval [CI] [0.90–1.02], P=0.20). The odds for TVF was significantly low in the BP-DES group relative to the first-generation DP-DES group, however the odds were comparable between the BP-DES group and the newer-generation DP-DES group (BP-DES versus first-generation DP-DES: OR 0.82, 95% CI [0.73–0.92], P&lt;0.001, and BP-DES versus newer-generation DP-DES: OR 1.00, 95% CI [0.93–1.08], P=0.99). We also found no significant differences between the BP-DES and newer-generation DP-DES, in all subgroups stratified by the BP-DES strut thickness (Ultra-thin strut BP-DES versus newer-generation DP-DES: OR 0.88, 95% CI [0.76–1.02], P=0.10, Thin-strut BP-DES versus newer-generation DP-DES: OR 1.01, 95% CI [0.90–1.13], P=0.89, and Thick strut BP-DES versus newer-generation DP-DES: OR 1.11, 95% CI [0.99–1.25], P=0.08).

Conclusions

In this meta-analysis of randomized controlled trials evaluating clinical outcomes, there was no significant differences between BP-DES and DP-DES. We found beneficial effects of BP-DES relative to the first-generation DP-DES, however, there was no statistical differences between BP-DES and newer-generation DP-DES, irrespective of the BP-DES strut thickness.

Pooled odds ratios for clinical outcomes

Funding Acknowledgement

Type of funding source: None

Sex differences in the predictors of recurrent atrial fibrillation after catheter ablation: insights from the Kansai Plus Atrial Fibrillation (KPAF) registry

Background

The impact of sex differences on the clinical outcomes of radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF) is controversial. We previously reported that females experienced more frequent AF recurrences than males after the index and last RFCA procedures.

Purpose

To identify the risk factors associated with recurrent AF in females and males after RFCA of AF.

Methods

We conducted a large-scale, prospective, multicenter, observational study (Kansai Plus Atrial Fibrillation Registry). We enrolled 5010 consecutive patients who underwent an initial RFCA of AF at 26 centers (64±10 years; 1369 [27.3%] females; non-paroxysmal AF, 35.7%). The median follow-up duration was 2.9 years.

Results

The incidence of AF recurrences after a single procedure was 43.3% in females and 39.0% in males. After a multivariate adjustment at baseline, the significant predictors of AF recurrence in females after the index RFCA were non-paroxysmal AF (hazard ration [HR],1.59; 95% confidence interval [CI],1.31–1.93, p&lt;0.0001), a history of AF ≥2 years (HR,1.47; 95% CI,1.24–1.74, p&lt;0.0001), coronary artery disease (HR,1.43; 95% CI,1.03–1.98, p=0.0035), and an estimated glomerular filtration rate (eGFR)&lt;60 mL/min/1.73m2 (HR,1.46; 95% CI,1.10–1.95, p=0.0086). On the other hand, significant predictors of AF recurrence in males after the index RFCA were non-paroxysmal AF (HR,1.54; 95% CI,1.37–1.73, p&lt;0.0001), a history of AF ≥2 years (HR,1.40; 95% CI,1.26–1.56, p&lt;0.0001), the number of antiarrhythmic drugs (HR,1.06; 95% CI,1.003–1.13, p=0.040), a left atrial diameter≥40mm (HR,1.13; 95% CI,1.007–1.27, p=0.038), and dilated cardiomyopathy (HR,1.55; 95% CI,1.07–2.26, p=0.021), however, an eGFR&lt;60 mL/min/1.73m2 was not associated with AF recurrence in males (HR, 1.00; 95% CI, 0.88–1.13, p=0.97).

Conclusion

The Kansai Plus Atrial Fibrillation Registry revealed a distinct sex difference in terms of the predictors of recurrent AF after RFCA. Non-Paroxysmal AF and a long history of AF were common risk factors both in females and males. However, renal dysfunction was a significant predictor of AF recurrence in females, while it was not a risk of recurrence in males.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Research Institute for Production Development in Kyoto, Japan.

Risk factors for major bleeding during prolonged anticoagulation therapy in cancer-associated venous thromboembolisms: from the COMMAND VTE registry

Background/Introduction

Patients with cancer-associated venous thromboembolisms (VTEs) are at a high risk for recurrent VTEs and are recommended to receive prolonged anticoagulation therapy if they are at a low risk for bleeding. However, there are no established risk factors for bleeding during prolonged anticoagulation therapy.

Purpose

We aimed to identify the risk factors for major bleeding during prolonged anticoagulation therapy in cancer-associated VTE patients.

Methods

The COMMAND VTE Registry is a multicenter retrospective registry enrolling 3027 consecutive patients with acute symptomatic VTEs among 29 Japanese centers between January 2010 and August 2014. After excluding those without active cancer (N=2332), patients with major bleeding (N=15), death (N=17), and lost to follow-up (N=10) within 10 days after the diagnosis, and those without anticoagulation therapy beyond 10 days after the diagnosis (N=61), the present study population consisted of 592 cancer-associated VTE patients with anticoagulation therapy beyond 10 days after the diagnosis. The outcome measurement was International Society of Thrombosis and Hemostasis (ISTH) major bleeding during anticoagulation therapy beyond 10 days, which occurred before the first discontinuation of the anticoagulation therapy. We constructed a multivariable Cox proportional hazard model to estimate the hazard ratio (HR) and 95% confidence intervals (CIs) of the potential risk factors for major bleeding. As a sensitivity analysis, we used Fine and Gray's method to estimate the HR and 95% CI, taking into account the competing risk of all-cause death.

Results

During a median follow-up period of 199 days, major bleeding occurred in 72 patients (31 patients within 3 months; 41 beyond 3 months). The cumulative incidence of major bleeding was 5.8% at 3-months, 13.8% at 1-year, 17.5% at 2-year, and 28.1% at 5-years. The most frequent major bleeding site was gastrointestinal (47%), followed by intracranial (17%) and genitourinary (11%). Major bleeding tended to occur from the sites of the cancer, however, the sites of the cancer and sites of major bleeding were not necessarily concordant. The multivariable Cox regression model demonstrated that terminal cancer (adjusted HR, 4.17; 95% CI, 2.22–7.85, P&lt;0.001), chronic kidney disease (adjusted HR, 1.89; 95% CI 1.06–3.37, P=0.031), and gastrointestinal cancer (adjusted HR, 1.78; 95% CI, 1.04–3.04, P=0.037) were independently associated with an increased risk of major bleeding. After taking into account the competing risk of all-cause death, the multivariable Cox regression model demonstrated almost consistent results with the main analysis.

Conclusions

Major bleeding events were common during prolonged anticoagulation therapy in real-world cancer-associated VTE patients. Terminal cancer, chronic kidney disease, and gastrointestinal cancer were the independent risk factors for major bleeding.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Research Institute for Production Development, Mitsubishi Tanabe Pharma Corporation

Study of charged particle activation analysis (II): Determination of boron concentration in human blood samples

Boron Neutron Capture Therapy (BNCT) is a radiotherapy for the treatment of intractable cancer. In BNCT precise determination of ¹⁰B concentration in whole blood sample before neutron irradiation of the patient, as well as accurate neutron dosimetry, is crucial for control of the neutron irradiation time. For this purpose ICP-AES and neutron induced prompt γ-ray analysis are generally used. In Ibaraki Neutron Medical Research Center (iNMRC), an intense proton beam will be accelerated up to 8 MeV, which can also be used for Charged Particle Activation Analysis (CPAA). Thus, in this study, we apply the CPAA utilizing the proton beam to non-destructive and accurate determination of ¹⁰B concentration in whole blood sample. A CPAA experiment is performed by utilizing an 8 MeV proton beam from the tandem accelerator of Nuclear Science Research Institute in Japan Atomic Energy Agency. The 478 keV γ-ray of ⁷Be produced by the ¹⁰B(p, α)⁷Be reaction is used to quantify the ¹⁰B in human blood. The 478 keV γ-ray intensity is normalized by the intensities of the 847 keV and 1238 keV γ-rays of ⁵⁶Co originating from Fe in blood. The normalization methods were found to be linear in the range of 3.27 μg ¹⁰B/g to 322 μg ¹⁰B/g with correlation coefficients of better than 0.9999.

P832LDL-C levels on statins and cardiovascular event risk in stable coronary artery disease: An observation from the REAL-CAD study

Background

The relation between very low on-treatment low-density lipoprotein cholesterol (LDL-C) level and the cardiovascular event risk is still unclear in patients receiving the same doses of statins.

Methods

From the REAL-CAD study comparing high-dose with low-dose pitavastatin therapy in Japanese patients with stable coronary artery disease, 11105 patients without reported non-adherence for the study drug were divided into 3 groups according to the on-treatment LDL-C level at 6-month (<70 mg/dL, 70–100 mg/dL, and ≥100 mg/dL; N=1016, N=3078, and N=1665 in the pitavastatin 1 mg/day stratum; N=2431, N=2524, and N=391 in the pitavastatin 4 mg/day stratum). Primary outcome measure was a composite of cardiovascular death, non-fatal myocardial infarction, non-fatal ischemic stroke, or unstable angina requiring emergent admission.

Results

In the pitavastatin 1 mg/day stratum, cumulative 4-year incidence of the primary outcome measure was not significantly different across the 3 groups (5.0%, 5.7%, and 5.2%, P=0.51), while in the 4 mg/day stratum, it was significantly higher in the LDL-C ≥100 mg/dL group than in other groups (4.5%, 3.4%, and 9.1%, P<0.001). The adjusted risks of the LDL-C <70 mg/dL group relative to the LDL-C 70–100 mg/dL group (reference) remained insignificant for the primary outcome measure in both 1 mg/day and 4 mg/day strata (HR 0.84, 95% CI 0.58–1.18, P=0.32, and HR 1.25, 95% CI 0.88–1.79, P=0.22). The adjusted risk of LDL-C ≥100 mg/dL group relative to the reference group was not significant for the primary outcome measure in the 1 mg/day stratum (HR 0.82, 95% CI 0.60–1.11, P=0.21), while it was highly significant in the 4 mg/day stratum (HR 3.32, 95% CI 2.08–5.17, P<0.001). In the on-treatment LDL-C ≥100 mg/dL group in the 4 mg/day stratum, LDL-C increased by 6.3 mg/dL from baseline to 6-month despite dose escalation of pitavastatin from 1 mg/day to 4 mg/day, suggesting the presence of unreported poor adherence in this small subgroup.

Adjusted Effects of On-treatment LDL-C

Conclusions

Very low on-treatment LDL-C level (<70 mg/dL) was not associated with lower cardiovascular event risk compared with moderately low on-treatment LDL-C level (70–100 mg/dL) in patients receiving the same doses of statins. Too much emphasis on the target LDL-C strategy might mislead the clinical practice.

Acknowledgement/Funding

The Comprehensive Support Project for Clinical Research of Lifestyle-Related Disease of the Public Health Research Foundation.

P1618A polymethoxy flavonoid, Nobiletin, Has a therapeutic potency against the development of heart failure through NBP1 activation

Introduction

Maladaptive hypertrophy is being recognized as a critical event during the development of heart failure. The control of cardiac hypertrophy may be one of the therapeutic strategy for heart failure therapy. In our previous study, we screened natural compound library and found that a natural compound, Nobiletin, could inhibit cardiomyocyte hypertrophy in culture. Nobiletin has various useful effects such as anti-cancer, anti-inflammation, and anti-oxidant and may be applicable to pharmacological therapy for heart failure.

Hypothesis

We thought that nobiletin might prevent the development of heart failure in vivo and investigated the target molecule of Nobiletin in the heart.

Methods and results

In primary cardiomyocytes, Nobiletin significantly inhibited phenylephrine (PE)-induced hypertrophic responses such as increases in cell size and hypertrophic gene transcription, such as ANF and BNP. C57BL6 mice were subjected to sham or transarotic constriction (TAC). Oral administrations of Nobiletin (20 mg/kg/day) or vehicle were repeated for 8 weeks. Nobiletin treatment significantly prevented TAC-induced increases in PWT and systolic dysfunction. Nobiletin also suppressed TAC-induced myocardial cell hypertrophy, perivascular fibrosis, and hypertrophic gene transcriptions. To investigate the target molecule of Nobiletin, Nobiletin-binding proteins were purified from rat heart using biotin-conjugated Nobiletin. We identified 162 novel binding protein of Nobiletin by LC/MS-MS. One of them, Nobiletin-binding protein 1 (NBP1) related to cellular metabolic pathway. Pulldown assay demonstrated that biotin-conjugated Nobiletin, but not biotin, directly interacted with recombinant NBP1. In vitro enzyme assay showed that Nobiletin enhanced NBP1 activity. Although NBP1 knockdown could not affect PE-induced hypertrophic response gene transcriptions and cardiomyocyte hypertrophy, NBP1 knockdown failed to exhibit Nobiletin-mediated anti-hypertrophic effects. NBP1-KO mice and WT mice were subjected to sham or TAC and randomly divided into two groups: Nobiletin (20 mg/kg/day) and vehicle. After 8 weeks, Nobiletin significantly improved TAC-induced cardiac hypertrophy and systolic dysfunction in WT mice but not in NBP1-KO mice. Nobiletin also prevented TAC-induced increases in HW/BW rate, myocardial cell hypertrophy, and mRNA levels of ANF and β-MHC in WT mice but not in NBP1-KO mice.

Conclusions

In this study, we demonstrate that Nobiletin inhibits cardiomyocyte hypertrophy and the development of heart failure in vivo. NBP1 activity is required to exhibit therapeutic potency of Nobiletin for heart failure. These finding suggest that a natural compound, nobiletin, might be a candidate for heart failure agent in human.

Acknowledgement/Funding

This work was supported by JSPS KAKENHI Grant.

1136Prognostic impact of mineralocorticoid receptor antagonists in patients hospitalized for acute heart failure

Background

The favourable effect of mineralocorticoid receptor antagonists (MRAs) on mortality was established in patients with stable heart failure (HF) with reduced ejection fraction (EF). However, its prognostic effect of MRAs in acute decompensated heart failure (ADHF) including HF with preserved EF (HFpEF) was unclear.

Purpose

This study sought to investigate the long-term impact of MRA on the post-discharge outcomes in patients with ADHF.

Methods

From the consecutive 3717 patients hospitalized for ADHF and discharged alive in the KCHF registry, we developed the propensity score (PS) for MRA use and constructed the PS-matched cohort. We compared the effect of MRA use on the primary outcome measure of all-cause death or HF hospitalization.

Results

A total of 1678 patients (45%) received MRA at discharge from the index hospitalization. Median follow-up was 470 days with 96% 1-year follow-up rate. In the PS-matched cohort (N=1034 in each group), the cumulative 1-year incidence of the primary outcome measure was significantly lower in the MRA group than in the no MRA group (28.4% vs. 33.9%, P=0.003) (Figure 1). The cumulative 1-year incidence of HF hospitalization was significantly lower in the MRA group than in the no MRA group (18.7% vs. 24.8%, P<0.001), while there was no difference in mortality between the 2 groups (15.6% vs. 15.8%, P=0.85). There was no interaction between the effect of MRA and the 3 subgroups stratified by EF (EF <40%, EF 40–49%, EF ≥50%) (interaction P=0.12).

Figure 1

Conclusion

The use of MRA was associated with lower risk for the primary composite outcome of all-cause death or HF hospitalization in patients hospitalized for ADHF including HFpEF, which was mainly driven by the lower risk for HF hospitalization.

P4544Impact of hyponatremia improvement on one-year outcomes in patients with acute decompensated heart failure

Background

Impact of hyponatremia improvement on prognosis in patients with acute decompensated heart failure (ADHF) remains unclear.

Methods

Patients hospitalized for ADHF at 19 hospitals in Japan were enrolled between October 2014 and March 2016. Hyponatremia was defined as serum sodium concentration less than 135 mmol/l. Primary endpoint was composite of all-cause death and heart failure rehospitalization one year after discharge.

Results

Among 3805 patients enrolled, 486 patients with hyponatremia at admission showed higher in-hospital mortality (13.3% vs. 5.4%, p<0.001). Of 486 hyponatremic patients, 396 patients were discharged alive. One hundred forty-three patients showed persistent hyponatremia at discharge (group P), whereas 253 patients showed improvement of hyponatremia (group I). Baseline characteristics are shown in the table. Patients in group I showed higher sodium concentration at admission (132±3 mmol/l vs. 130±4 mmol/l, p<0.001) and more increase in serum sodium concentration at discharge (7±4 mmol/l vs. 1±5 mmol/l, p<0.001). One-year survival rate free from primary endpoint was not different between the groups (56.4% in group P vs. 58.5% in group I, p=0.79). After adjusting for confounders, improvement of hyponatremia was not associated with better prognosis (hazard ratio 1.00; 95% confidence interval 0.70–1.45, p=0.99). Hyponatremia improvement showed significant interaction with left ventricular ejection fraction (LVEF) less than 40% (p=0.01). In patients with LVEF<40%, improvement of hyponatremia was associated with better prognosis (hazard ratio 0.48, 95% confidence interval 0.28–0.85, p=0.01) whereas not in patients LVEF≥40%.

Patient characteristics Group P (n=143) Group I (n=253) p value Age (years) 81 (72–86) 81 (72–87) 0.73 Female 71 (49.7) 110 (43.5) 0.24 Ischemic etiology 42 (29.4) 81 (32.0) 0.58 Prior hospitalization 62 (43.7) 98 (39.5) 0.42 SBP at admission (mmHg) 140±36 144±38 0.40 HR at admission (bpm) 92±23 95±29 0.27 Atrial Fibrillation 47 (32.9) 103 (40.7) 0.12 NYHA class IV 60 (42.2) 138 (54.8) 0.02 Intravenous inotropic use 35 (24.5) 59 (23.3) 0.80 LVEF <40% 54 (37.8) 95 (37.6) 0.97 Values are median (interquartile range), mean ± standard deviation or number (%).

Conclusion

Improvement of hyponatremia at discharge was not associated with better prognosis in patients hospitalized for ADHF.

P5593The association of recurrence and bleeding events with mortality after venous thromboembolism: from the COMMAND VTE Registry

Background/Introduction

Venous thromboembolism (VTE), including pulmonary embolism (PE) and deep vein thrombosis (DVT), has a long-term risk for recurrence, which can be prevented by anticoagulation therapy. The duration of anticoagulation therapy after VTE should be based on the balance between risks of recurrent VTE and bleeding. However, there is uncertainty about the impact of these events on subsequent mortality.

Purpose

We sought to evaluate the impact of recurrent VTE events and bleeding events on subsequent mortality in patients with VTE in a large retrospective observational database in Japan.

Methods

We evaluated the association of recurrent VTE and major bleeding with mortality among 3026 patients in the COMMAND VTE Registry. We estimated the risks of recurrent VTE events and major bleeding events for subsequent all-cause death with the multivariable Cox proportional hazard model. We incorporated the recurrent VTE events and major bleeding events during follow-up into the multivariable Cox model as time-updated covariates together with the clinically-relevant 16 risk-adjusting factors. We expressed the adjusted risks of each covariate as hazard ratios (HR) and their 95%confidence intervals (CI). Furthermore, to assess the risks of recurrent PE and recurrent DVT events for subsequent all-cause death respectively, we divided recurrent VTE events into recurrent PE (PE with or without DVT) and recurrent DVT (DVT only), and incorporated these events as well as major bleeding events into the multivariable Cox model as time-updated covariates.

Results

In the current study population, the mean age was 67 years, 61% were women, and mean body weight and body mass index were 57.9 kg and 23.2 kg/m2, respectively. During the median follow-up period of 1,218 days, 763 patients died, 225 patients developed recurrent VTE events, and 274 patients developed major bleeding events. The time-updated multivariable Cox proportional hazard model revealed that both the recurrent VTE events and the major bleeding events were strongly associated with subsequent mortality risk (recurrent VTE events: HR 3.24, 95% CI 2.57–4.08, P<0.001; major bleeding events: HR 3.53, 95% CI 2.88–4.31, P<0.001). Both the recurrent PE events and the recurrent DVT events were associated with subsequent mortality risk with the numerically greater magnitude of effect with the recurrent PE events than with the recurrent DVT events (recurrent PE events: HR 4.42, 95% CI 3.28–5.95, P<0.001; recurrent DVT events: HR 2.42, 95% CI 1.75–3.36, P<0.001).

Conclusions

In the real-world patients with VTE, both recurrent VTE events and major bleeding events were strongly associated with subsequent mortality risk with the comparable effect size. Recurrent PE and recurrent DVT events were also associated with increased risks for mortality, although the magnitude of the effect on mortality was numerically greater with the recurrent PE events than with the recurrent DVT events.

Acknowledgement/Funding

Research Institute for Production Development, Mitsubishi Tanabe Pharma Corporation

P1608Inhibition of GATA4 dimerization suppress hypertrophic responses

Introduction

Hypertrophic signals eventually reach the nuclei of cardiomyocytes, change patterns of gene expression, and cause the development of heart failure. During the development of heart failure, intrinsic histone acetyltransferase called p300 induce GATA4 acetylation. Acetylated GATA4 increases its DNA binding, up-regulates cardiac hypertrophic response genes, and lead to heart failure. A zinc finger protein, GATA4 is the transcription factor that expression level is high in heart. It has been reported that GATA1, the same GATA family, regulates transcriptional activity through its homo-dimerization. However, GATA4 homo-dimerization and its relationship to hypertrophic responses are still unknown.

Purpose

To clarify the relationship between GATA4 homo-dimerization and transcriptional activity and investigate whether inhibition of this homo-dimerization become therapeutic target for cardiac hypertrophy.

Methods

GST pull-down and DNA pull-down assay were performed using GST fusion full length and deletion mutants of GATA4 and biotin-conjugated ET-1 promoter probe including a GATA element. Recombinant C-zinc finger domain (256–326), including C-zinc finger motif (256–295) and acetylation site (308–326) was cross-linked using glutaraldehyde and subjected to silver staining. An expression plasmid with three GATA4-acetylation site mutant-conjugated with nuclear localization sequence (3xG4D) was constructed. Immunoprecipitation and western blotting were performed using nuclear extract from HEK293T cells expressing p300, GATA4, and 3xG4D. Luciferase assay was using ANF and ET-1 promoter sequences. Neonatal rat cultured cardiomyocyte expressed 3xG4D and then stimulated with phenylephrine (PE) for 48 hours. Next cardiomyocytes stained with α-actinin antibody and measured the cell surface area.

Results

The acetylation site of GATA4 was required for the dimerization of GATA4. But, C-zinc finger motif (256–295) and the acetylation site were required for the DNA binding. Recombinant C-zinc finger domain formed not only a homo-dimer but also a multimer. Co-expression of p300 increased the formation of homo-dimer as well as the acetylation of GATA4 in HEK293T cells. The GATA4 homo-dimer was disrupted by acetyl-deficient GATA4 or HAT-deficient p300 mutant. Overexpression of 3xG4D prevented the dimerization of GATA4, but not acetylation of GATA4. The result of luciferase assay showed that overexpression of 3xG4D prevented p300/GATA-induced ANF and ET-1 promoter activities. Furthermore, overexpression of 3xG4D inhibited phenylephrine-induced cardiomyocyte hypertrophy.

Conclusions

These results suggest that GATA4 dimerization may play an important role in hypertrophy-response gene activation. Thus, it is likely that inhabitation of GATA4 dimerization become therapeutic target for cardiac hypertrophy.

P5652Catheter ablation outcome and heart failure hospitalization in atrial fibrillation patients with preserved left ventricular ejection fraction: insights from the Kansai plus atrial fibrillation (KPAF)

Background

Heart failure (HF) is the leading cause of death in patients with atrial fibrillation (AF), and AF is an independent prognostic factor in HF patients with preserved left ventricular ejection fraction (LVEF). Radiofrequency catheter ablation (RFCA) for AF is effective to maintain sinus rhythm.

Purpose

We sought to clarify incidence of HF hospitalization and whether AF ablation outcome influenced incidence of HF hospitalization after the procedures in patients with preserved LVEF.

Methods

We conducted a large-scale, prospective, multicenter, observational study. A total of 4522 consecutive patients with normal LVEF (>/- 50%) who underwent an initial RFCA for AF in 26 centers were enrolled (average age, 64±10 years; non-paroxysmal AF, 33.7%). The median follow-up duration was 2.9 years.

Results

The 3-year cumulative incidence of AF recurrence after a single procedure was 40.3%. Hospitalization for HF was observed in 60 patients (1.3%) and was significantly higher in patients with AF recurrence than those without it (2.63% vs 0.44%, log-rank p<0.001). After adjustment by age ≥65 years, estimated glomerular filtration rate ≤60ml/min, history of HF, and female, all of which were statistically associated with a risk of HF hospitalization, AF recurrence after the index RFCA was an independent predictor of HF hospitalization (hazard ratio; 4.75, 95% confidence interval; 2.59–9.42, p<0.001).

Conclusions

Recurrence after RFCA for AF was a significant risk of HF hospitalization among AF patients with preserved LVEF.

Acknowledgement/Funding

This study was supported by the Research Institute for Production Development in Kyoto, Japan.

P4998Novel GATA4 binding proteins, RbAp48/46, regulate cardiomyocyte hypertrophy with depending on the phosphorylate State of GATA4

Introduction

Cardiac hypertrophy is being recognized as a critical event during the development of heart failure. A zinc finger protein GATA4 associates with an intrinsic histone acetyltransferase p300 and regulates myocardial transcriptional activities in response to hypertrophic stimuli. Here, we show that Retinoblastoma protein (Rb)-associated protein 48 and 46 (RbAp48, RbAp46) are novel components of p300/GATA4 complex. Both RbAp48 and 46 form a repressor complex with HDACs and has been implicated in chromatin remodeling and transcriptional repression. However, the precise functional relationships among p300, GATA4, RbAp48, and RbAp46 remain unknown.

Hypothesis

We assessed the hypothesis that RbAp48/46 form a functional complex with p300/GATA4 and regulated hypertrophic responses in cardiomyocytes.

Methods and results

IP-WB using nuclear extract from rat heart demonstrated that GATA4 formed a complex with RbAp48, RbAp46, HDAC1, and HDAC2. GST pull down assay using recombinant proteins showed that GATA4 physically interacted with both RbAp48 and RbAp46 but not HDAC1 and HDAC2. Deletion mutant assay revealed that N-terminal domain of GATA4 interacted with RbAp48/46. In HEK293T cell, overexpression of RbAp48/46 recruited HDAC1/2 to GATA4, inhibited p300-induced GATA4 acetylation and suppressed p300/GATA4-dependent ANF and ET-1 promoter activations. Conversely, the knockdown of RbAp48/46 reversed these changes. Although overexpression of HDAC1/2 did not change p300/GATA4-induced these promoter activities, co-expression of HDAC1 or HDAC2 with RbAp48/46 enhanced RbAp48/46-mediated inhibitory actions. In cardiomyocytes, overexpression of RbAp48/46 significantly inhibited phenylephrine (PE)-induced GATA4 acetylation, activation of ANF and ET-1 promoters, and cardiomyocyte hypertrophy. The knockdown of RbAp48/46 reversed these changes. Moreover, the knockdown of HDAC1/2 deteriorated PE-induced hypertrophy-responsive events and did not exhibit RbAp48/46-induced inhibitory actions. Finally, MEK1/ERK-mediated S105 phosphorylation of GATA4 by PE stimulus induced the dissociation of RbAp48/46 with GATA4, the increase of p300-induced GATA4-acetylation, the synergistic activation of ANF and ET-1 promoters with p300/GATA4, and the decrease of RbAp48/46 recruitments onto the GATA element of the ANF promoter. Conversely, PD98059, a MEK1 inhibitor, treatment inhibited GATA4-phosphorylation and these changes.

Conclusion

In this study, we demonstrate that RbAp48/46 mediate the binding between GATA4 and HDAC1/2 and regulate p300/GATA4 axis. The phosphorylation of S105 GATA4 has a critical role on the dissociation of GATA4/RbAp48/46/HDAC repressor complex, the formation of 300/GATA4 activator complex, and the increase of GATA4 acetylation and hypertrophic responses. These findings suggest that RbAp48/46 may regulate hypertrophic responses involved in modulating the posttranslational modification crosstalk of GATA4.

Acknowledgement/Funding

This work was supported by JSPS KAKENHI Grant.

P772Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers for heart failure patients with different left ventricular ejection fraction categories: from the KCHF Registry

Background

The current guidelines recommend different medical treatment strategies for heart failure (HF) patients according to category of left ventricular ejection fraction (LVEF). Angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACE-I/ARB) is an established medical treatment for heart failure with reduced ejection fraction (HFrEF), whereas its usefulness remains to be elucidated for non-HFrEF, especially for heart failure with mid-range ejection fraction (HFmrEF).

Purpose

This study aimed to assess the difference in association between ACE-I/ARB and clinical outcomes depending on LVEF category.

Methods

The Kyoto Congestive Heart Failure (KCHF) Registry is a multicentre registry without any exclusion criteria which included consecutive patients hospitalized for congestive HF in Japan. In each LVEF group (HFrEF, HFmrEF and heart failure with preserved ejection fraction [HFpEF]), we compared those who were prescribed ACE-I/ARB as discharge medication and those not, and assessed their 1-year clinical outcomes. We defined the primary outcome measure as a composite of all-cause death and HF hospitalization. We constructed a multivariable Cox regression model incorporating 24 clinically relevant factors. We assessed adjusted hazard ratios (HRs) of those with ACE-I/ARB relative to those not, and also interaction between ACE-I/ARB prescription at discharge and LVEF category.

Results

A total of 3717 patients were included in this study, where the number of patients in each LVEF group were as follows; 1383 patients with HFrEF, 703 with HFmrEF and 1631 with HFpEF, respectively (Figure). As shown in the table, the HRs for the primary outcome measure were significant in the HFrEF and HFmrEF groups, whereas the HR in the HFpEF group was insignificant. The interaction between ACE-I/ARB prescription and LVEF category for the primary outcome measure was statistically significant.

Hazard ratios by LVEF category Outcome measures HFrEF HFmrEF HFpEF P interaction HR (95% CI) P value HR (95% CI) P value HR (95% CI) P value All-cause death + HF hospitalization 0.66 (0.54–0.79) <0.001 0.61 (0.45–0.82) 0.001 0.95 (0.80–1.14) 0.61 0.01 All-cause death 0.62 (0.48–0.81) <0.001 0.52 (0.35–0.77) 0.001 0.73 (0.58–0.93) 0.01 0.10 HF hospitalization 0.73 (0.57–0.92) 0.009 0.59 (0.40–0.87) 0.007 1.14 (0.90–1.44) 0.28 0.07 Hazard ratios of ACE-I/ARB relative to non-ACE-I/ARB for primary outcome measures in each LVEF category.

Study flowchart

Conclusions

The risk ratios of those who were prescribed ACE-I/ARB relative to those not were significantly low in HFmrEF as well as HFrEF, whereas the risk ratios were insignificant in HFpEF. ACE-I/ARB could be a potential choice of treatment for HFmrEF patients.

P3847Deep vein thrombosis in upper extremities: clinical characteristics, management strategies and long-term outcomes from the COMMAND VTE Registry

Background/Introduction

Pulmonary embolism (PE) is caused by blockage of pulmonary arteries by thrombus. The sources of thrombus are thought to be mostly veins in lower extremities, whereas deep vein thrombosis (DVT) in upper extremities rarely occurs spontaneously. Recent studies reported that DVT in upper extremities might have significant complications, and DVT in upper extremities could be increasing. However, there is a paucity of data on patients with DVT in upper extremities, leading to uncertainty in optimal treatment strategies including anticoagulation therapy.

Purpose

We sought to evaluate the clinical characteristics, management strategies, and long-term outcomes of patients with DVT in upper extremities in a large observational database in Japan.

Methods

The COMMAND VTE Registry is a multicenter registry enrolling 3027 consecutive patients with acute symptomatic venous thromboembolism (VTE) objectively confirmed by imaging examination or by autopsy among 29 centers in Japan between January 2010 and August 2014. The current study population consisted of 2498 patients with DVT in upper or lower extremities, after excluding 381 patients with PE only, 144 patients who had thrombus in locations other than upper or lower extremities, and 4 patients with DVT in both upper and lower extremities. The study patients were divided into 2 groups: patients with DVT in upper extremities and patients with DVT in lower extremities. We compared the clinical characteristics, management strategies and long-term outcomes between the 2 groups.

Results

There were 74 patients (3.0%) with upper extremities DVT and 2498 patients (97%) with lower extremities DVT. Patients with upper extremities DVT more often had active cancer at diagnosis (58%) and central venous catheter use (22%). The proportion of concomitant PE at diagnosis was lower in patients with upper extremities DVT than in those with lower extremities DVT (14% and 51%, P<0.001). Discontinuation of anticoagulation therapy was more frequent in patients with upper extremities DVT (63.8% and 29.8% at 1-year, P<0.001). The cumulative 3-year incidence of recurrent VTE was not different between the 2 groups (9.8% and 7.4%, P=0.43) (Figure). After adjusting confounders, the risks of upper extremities DVT relative to lower extremities DVT for recurrent VTE remained insignificant (HR 0.94, 95% CI 0.36–2.01, P=0.89).

Kaplan-Meier event curves for recurrence

Conclusions

The prevalence of patients with DVT in upper extremities was 3.0% in the current large-scale real-world registry. Patients with DVT in upper extremities more often had active cancer at diagnosis and central venous catheter use as a transient risk factor for VTE, and less often had concomitant PE. Patients with DVT in upper extremities had similar long-term risk for recurrent VTE as those with DVT in lower extremities despite shorter duration of anticoagulation.

Acknowledgement/Funding

Research Institute for Production Development, Mitsubishi Tanabe Pharma Corporation

P3846The association between statin prescription, recurrent venous thromboembolism and bleeding events: from the COMMAND VTE Registry

Background

Statin prevents occurrence and recurrence of atherosclerotic events. With regard to venous thromboembolism (VTE), a randomized controlled trial suggested that statin reduced occurrence of VTE, whereas its usefulness as secondary prevention of VTE remains to be elucidated.

Purpose

This study aimed to assess the association between statin prescription, recurrent VTE and bleeding events in patients with VTE.

Methods

The COMMAND VTE Registry is a multicentre registry enrolling consecutive 3027 patients with acute symptomatic VTE among 29 centres in Japan. We divided the cohort into the patients who were prescribed statin (N=437) and those not (N=2590), and compared the two groups. We assessed hazard ratios (HRs) of those with statin relative to those without for long-term clinical outcomes (recurrent symptomatic VTE and International Society of Thrombosis and Hemostasis [ISTH] major bleeding). Because the durations of anticoagulation therapy were widely different between the two groups, we constructed Cox's proportional hazard model incorporating status of anticoagulation during the follow-up period as a time-varying covariate. Also, because the incidences of death were strikingly different between the two groups due to the difference in the prevalence of active cancer, we used Fine-Gray's subdistribution hazard model in the presence of competing risks. We incorporated clinically relevant factors into these two models as covariates (10 factors for recurrent VTE and 11 for major bleeding).

Results

The statin group was significantly older than the non-statin group (statin 71.2±11.8 vs. non-statin 66.5±15.8, P<0.001). The prevalence of active cancer in the statin group was less than one-half of that in the non-statin group (12% vs. 25%, P<0.001), and the cumulative 3-year incidence of death was significantly lower in the statin group than in the non-statin group (12.8% vs. 26.1%, log-rank P<0.001). The table shows the adjusted HRs of the statin group relative to the non-statin group. The HRs of the statin group relative to non-statin group for recurrent VTE were significantly low, but those for major bleeding were insignificant.

Adjusted hazard ratios Outcome measures Model 1 P value Model 2 P value Adjusted HR [95% CI] Adjusted HR [95% CI] Recurrent VTE 0.59 [0.36–0.98] 0.042 0.53 [0.32–0.89] 0.02 Major bleeding 0.87 [0.60–1.24] 0.43 0.997 [0.69–1.43] 0.99 Model 1 derived from Cox's model with time-varying covariate of anticoagulation status. Model 2 derived from Fine-Gray's model.

Study flowchart

Conclusions

Prescription of satin was associated with significantly low risks for recurrent VTE, whereas that was not for major bleeding events. Statin could be a potential treatment option for secondary prevention of VTE.

P1029Catheter ablation outcome and heart failure hospitalization in atrial fibrillation patients: insights from the Kansai plus atrial fibrillation (KPAF) registry

Background

Heart failure (HF) is the leading cause of death in patients with atrial fibrillation (AF). Radiofrequency catheter ablation (RFCA) for AF is effective to maintain sinus rhythm.

Purpose

We sought to clarify whether AF ablation outcome influenced incidence of HF hospitalization after the procedures.

Methods

We conducted a large-scale, prospective, multicenter, observational study. A total of 5010 consecutive patients who underwent an initial RFCA for AF in 26 centers were enrolled (average age, 64±10 years; non-paroxysmal AF, 35.6%). The median follow-up duration was 2.9 years.

Results

The 3-year cumulative incidence of AF recurrence after a single procedure was 40.2%. The 3-year incidence of hospitalization for HF was observed in 92 patients (1.8%) and was significantly higher in patients with AF recurrence than those without it (3.3% vs 0.84%, log-rank p<0.001). After adjustment by advanced age,(≥65 years), reduced left ventricular ejection fraction (≤50%), low estimated glomerular filtration rate (≤60ml/min), and history of HF, all of which were statistically associated with a risk of HF hospitalization (p<0.1, respectively), AF recurrence after the index RFCA was an independent predictor of HF hospitalization (hazard ratio [HR]; 3.17, 95% confidence interval [CI]; 2.06–5.04, p<0.001).Even after multiple procedures (1425 re-ablation sessions in 1274 patients [25.4%]), AF recurrence after the last procedure was an independent predictor of HF hospitalization (HR; 2.83, 95% CI; 1.89–4.24, p<0.001).

Conclusions

Among AF patients receiving RFCA, those with AF recurrence were at greater risk of heart failure hospitalization than were patients without AF recurrence. These differences should be noted when treating AF patients in actual clinical practice.

Acknowledgement/Funding

This study was supported by the Research Institute for Production Development in Kyoto, Japan.

P1607Epigenetic modifications via histone acetylation by p300 are changed during the transition from cardiac hypertrophy to heart failure

Background

An intrinsic histone acetyltransferase (HAT), p300, is required for acetylation and the transcriptional activity of GATA4, as well as pathological left ventricular hypertrophy (LVH) and the development of heart failure (HF) in vivo. Recently, studies of histone modification have been performed within the flexible tails, such as H3K9 and H3K14. Although most previously studied histone modifications are within the flexible tails of histones, H3K122 is reportedly a novel site of the histone globular domain acetylated by p300, and its acetylation activates gene transcriptions by destabilizing histone-DNA binding and increasing the accessibility of transactional factors to DNA. However, little is known about the extent histone modifications directly affect LVH and HF.

Hypothesis

We hypothesized that p300 could induce epigenetic changes by acetylation of the globular domain as well as tail domain of histone during the development of LVH and HF.

Methods

First, to investigate whether the acetylation of H3K122 in the globular domain of histones as well as those of H3K9 and H3K14 in the tail domain of histones increased in cardiomyocytes hypertrophy, western blotting and chromatin-immunoprecipitation (ChIP) assays were performed using neonatal rat cultured cardiomyocytes with phenylephrine (PE) stimulus. Second, neonatal rat cultured cardiomyocytes were treated with p300 knockdown by siRNA or curcumin, a p300-specific HAT inhibitor. Third, to investigate the role of p300 HAT activity in histone acetylation in vivo, we utilized mice overexpressing p300 in the heart, which induced LVH. Final, to investigate whether these acetylation changes during the development of LVH and HF, in vivo ChIP assay was performed using hypertensive heart disease model of Dahl salt-sensitive rats.

Results

Western blotting indicated that treatment with PE increased the acetylation of H3K122 as well as those of H3K9 and H3K14 in cardiomyocytes hypertrophy. ChIP assay demonstrated that PE increased the recruitment of acetylated H3K122 and H3K9 onto ANF and BNP promoters containing the GATA element and peaks of acetylation of these domains were 4 hours after PE stimulation. Next, these acetylations were significantly inhibited by p300 knockdown by siRNA or treatment with curcumin. Conversely, in vivo ChIP assays in mice overexpressing p300 indicated that p300 overexpression increased recruitment of acetylated H3K122 and H3K9 onto ANF and BNP promoters containing the GATA element. Next, in hypertensive heart disease model of Dahl salt-sensitive rats, in vivo ChIP assays reviled that acetylation of H3K9 was increased around ANF and BNP promoters containing the GATA element at the LVH stage but that of H3K122 was increased at the HF stage.

Conclusion

Our data indicate that acetylation of H3K122 in globular domain of histones by p300 is the key event of the transition from LVH to HF.

P5592Thrombolysis with tissue plasminogen activator for patients with acute pulmonary embolisms in the real world: from the COMMAND VTE Registry

Background/Introduction

There is still uncertainty about the optimal usage of thrombolysis for acute pulmonary embolisms (PEs), leading to widely varying usage of thrombolysis in the real world. However, these have not been fully evaluated yet.

Purpose

We sought to evaluate the management strategies and clinical outcomes of thrombolysis for acute PEs in the real world.

Methods

The COMMAND VTE Registry is a multicenter registry enrolling 3,027 consecutive patients with acute symptomatic venous thromboembolisms in Japan between January 2010 and August 2014. The present study population consisted of 1,549 patients with PEs who received tissue plasminogen activator (t-PA) thrombolysis (N=180, 12%), or those who did not (N=1,369). The effectiveness outcome was all-cause death. The safety outcome was major bleeding. We used a multivariable logistic regression analysis to estimate the odds ratio (OR) and 95% confidence intervals (CI), to adjust clinically relevant confounders (age, sex, history of major bleeding, active cancer, and anemia). Additionally, we conducted stratified analysis by clinical severity, and we also evaluated clinical outcomes according to dosages of t-PA.

Results

Patients with t-PA thrombolysis were younger, and more frequently had higher body weight, but less frequently had active cancer, history of major bleeding, and anemia. More than half of patients with t-PA thrombolysis were patients with mild PEs, and the proportions of t-PA thrombolysis varied widely across the participating centers. More than half of patients received low-dose of t-PA (<20,000 IU/kg). As for the effectiveness, 9 (5.0%) patients in the t-PA thrombolysis group and 95 (6.9%) patients in the non t-PA thrombolysis group died at 30 days (Crude OR, 0.71; 95% CI 0.35–1.42, P=0.33). As for the safety, 7 (3.9%) patients in the t-PA thrombolysis group and 22 (1.6%) patients in the non t-PA thrombolysis group experienced major bleeding events at 10 days (Crude OR, 2.48; 95% CI 1.04–5.88, P=0.04). T-PA thrombolysis group had a significantly higher risk for 10-day major bleeding (Adjusted OR, 4.01; 95% CI 1.57–10.2, P=0.004), but not a lower risk for 30-day mortality (Adjusted OR, 1.10; 95% CI 0.53–2.28, P=0.79), although the risk for 30-day mortality was significantly lower in those with severe PEs (Adjusted OR, 0.36; 95% CI 0.15–0.88, P=0.02). After adjusting confounders, the 10-day major bleeding risk of the low-dose of t-PA group relative to the standard-dose of t-PA group tended to be lower (Adjusted OR, 0.07; 95% CI 0.004–1.05, P=0.05).

Conclusions

In the present real-world registry, relatively large number of patients received t-PA thrombolysis with wide variation across the participating centers. T-PA thrombolysis was significantly associated with a higher risk for major bleeding, but not a lower risk for mortality, although there appeared to be a benefit of t-PA thrombolysis in decreasing the risk for mortality in patients with severe PEs.

Acknowledgement/Funding

Research Institute for Production Development, Mitsubishi Tanabe Pharma Corporation

P6461The long-term clinical comparisons of symptomatic patients of pulmonary embolism with and those without deep vein thrombosis: from the COMMAND VTE Registry

Background

Venous thromboembolism (VTE), including pulmonary embolism (PE) and deep vein thrombosis (DVT), has significant morbidity and mortality. Acute PE, in particular, is fatal if we miss it, and symptomatic patients of PE sometimes have concomitant DVT.

Purpose

This study compared the risk of mortality in symptomatic patients of PE with and those without DVT in the long term.

Methods

The COMMAND VTE Registry is a multicenter registry enrolling consecutive 3027 patients with acute symptomatic VTE objectively confirmed by imaging examination or by autopsy among 29 centers in Japan between January 2010 and August 2014. Patients with both PE and DVT (N=1334) were regarded as PE patients, and the current study population consisted of 1715 PE patients and 1312 DVT patients.

Results

There were 1203 symptomatic patients of PE, including 381 without and 822 with DVT. In our cohort, the mean age was 67.9±14.9 years, 63% was female, 44% had hypertension, 12% diabetes mellitus, 5% history of VTE. There were 20% of active cancer. Baseline characteristics were well matched except for dyslipidemia (18% vs. 23%, p=0.021) and atrial fibrillation (8% vs. 5%, p=0.045). Patients without DVT had a more severe clinical presentation compared to those with DVT, including hypoxemia, shock and arrest. Moreover, Initial parenteral anticoagulation therapy in the acute phase was administered less frequently in patients without DVT (89% vs. 96%, P=0.0001). Two groups received thrombolysis (20% vs. 26%, P=0.18) and mechanical supports (Ventilator 14% vs. 5%, p<0.001, PCPS 5% vs. 3%, p<0.001, respectively). During follow-up, 93 (8%) patients experienced recurrent VTE events and 98 (8%) major bleeding events, and 323 (27%) patients died. The most frequent cause of death was cancer (11%). There were a significant differences in the cumulative incidences of all-cause death between the groups (32% vs. 24%, P=0.006), whereas there was significant difference in VTE-related death (13% vs. 4%, p<0.001). Estimated freedom rates from death for patients of PE without and those with DVT were as follows: 88% vs 99% at 10-day, 86% vs 95% at 1-month, 75% vs 83% at 1-year, and 64% vs 71% at 5-year, respectively.

Landmark analysis

Conclusions

In symptomatic patients of PE, there was a difference in mortality between groups, but no difference in recurrent VTE. Patients without DVT had a more severe clinical presentation compared to those with DVT, and many VTE-related deaths in the acute phase. The one-month mortality rate differed statistically between groups, but there was no significant difference in long-term survival beyond one month. Most of deaths were due to underlying diseases, mainly cancer, and less commonly due to VTE in the long term.

Acknowledgement/Funding

Research Institute for Production Development, Mitsubishi Tanabe Pharma Corporation

P2770Clinical characteristics and outcomes of venous thromboembolism according to patients with versus without atrial fibrillation: from the COMMAND VTE Registry

Background/Introduction

Oral anticoagulants are widely used for the treatment and second prevention of venous thromboembolism (VTE) and stroke prevention in atrial fibrillation (AF). VTE and AF are common diseases and these sometimes might coexist. However, there are few reports about the relationship between VTE and AF.

Purpose

We sought to evaluate the clinical characteristics and outcomes in VTE patients with AF.

Methods

The COMMAND VTE Registry is a multicenter registry enrolling consecutive 3027 patients with acute symptomatic VTE objectively confirmed by imaging examination or by autopsy among 29 centers in Japan between January 2010 and August 2014. The current study population consisted of 129 patients with AF (AF group) and 2898 patients without AF (non-AF group). We compared the clinical characteristics, management strategies and long-term outcomes between the 2 groups.

Results

The AF group was older (mean age: 75.3 vs. 66.8 years, P<0.001), and more often had co-morbidities such as hypertension (54.3% vs. 37.7%, P<0.001), diabetes mellitus (20.2% vs. 12.4%, P=0.01), chronic kidney disease (28.7% vs. 18.5%, P=0.004), heart failure (28.7% vs. 18.5%, P=0.004), history of stroke (20.2% vs. 8.4%, P<0.001), and history of major bleeding (12.4% vs. 7.4%, P=0.04) compared with the non-AF group, whereas there were no significant differences in the proportions of active cancer at diagnosis (18.6% vs. 23.2%, P=0.23) and pulmonary embolism at presentation (64.3% vs. 56.3%, P=0.07). The proportion of anticoagulation therapy beyond acute phase was not significantly different (94% vs. 93%, P=0.60), while the cumulative discontinuation rates of anticoagulation therapy was significantly lower in the AF group (26.9% vs. 43.4% at 3 years, Log-rank P=0.03). The cumulative 5-year incidences of recurrent VTE and major bleeding were not significantly different (Recurrent VTE: 7.6% vs. 10.6%, Log-rank P=0.89; Major bleeding: 18.6% vs. 11.8%, Log-rank P=0.07). After adjusting for potential confounders, the risks of the AF group relative to the non-AF group for recurrent VTE and major bleeding remained insignificant (HR 1.19, 95% CI 0.54–2.28, P=0.64; HR 1.28, 95% CI 0.73–2.06, P=0.37). The cumulative 5-year incidence of all-cause death was significantly higher in the AF-group (49.1% vs. 28.6%, Log-rank P<0.001). After adjusting for potential confounders, the risks of the AF group relative to the non-AF group for all-cause death remained significant (HR 1.63, 95% CI 1.23–2.15, P<0.001). The proportion of deaths due to cancer was lower in the AF group (30% vs. 55%, P<0.001), while the proportion of cardiac deaths was higher in the AF group (16.1% vs. 4.0%, P<0.001).

The outcomes of VTE patients with AF

Conclusions

The risks for recurrent VTE between patients with AF and those without AF were not significantly different, although patients with AF received longer-term anticoagulation therapy, whereas the risks for major bleeding tended to be higher in patients with AF.

Acknowledgement/Funding

Research Institute for Production Development, Mitsubishi Tanabe Pharma Corporation

Downward Terrestrial Gamma-Ray Flash Observed in a Winter Thunderstorm

During a winter thunderstorm on 24 November 2017, a strong burst of gamma rays with energies up to ∼10  MeV was detected coincident with a lightning discharge, by scintillation detectors installed at the Kashiwazaki-Kariwa Nuclear Power Station at sea level in Japan. The burst had a subsecond duration, which is suggestive of photoneutron production. The leading part of the burst was resolved into four intense gamma-ray bunches, each coincident with a low-frequency radio pulse. These bunches were separated by 0.7-1.5 ms, with a duration of ≪1  ms each. Thus, the present burst may be considered as a "downward" terrestrial gamma-ray flash (TGF), which is analogous to upgoing TGFs observed from space. Although the scintillation detectors were heavily saturated by these bunches, the total dose associated with them was successfully measured by ionization chambers, employed by nine monitoring posts surrounding the power plant. From this information and Monte Carlo simulations, the present downward TGF is suggested to have taken place at an altitude of 2500±500  m, involving 8_{-4}^{+8}×10^{18} avalanche electrons with energies above 1 MeV. This number is comparable to those in upgoing TGFs.

Doublon-holon pairing mechanism via exchange interaction in two-dimensional cuprate Mott insulators

Coupling of charge and spin degrees of freedom is a critical feature of correlated electron oxides, as represented by the spin-related mechanism of a Cooper pair under high-T _c superconductivity. A doublon-holon pair generated on an antiferromagnetic spin background is also predicted to attract each other via the spin-spin interaction J, similar to a Cooper pair, while its evidence is difficult to obtain experimentally. Here, we investigate such an excitonic effect by electroreflectance spectroscopy using terahertz electric field pulses in undoped cuprates: Nd₂CuO₄, Sr₂CuO₂Cl₂, and La₂CuO₄. Analyses of the spectral changes of reflectivity under electric fields reveal that the splitting of odd-parity and even-parity excitons, a measure of doublon-holon binding energy, increases with J. This trend is reproduced by t-J-type model calculations, providing strong evidence of the spin-related doublon-holon pairing. Agreement with the calculations supports the s-wave symmetry of the doublon-holon pair in contrast to the d-wave Cooper pair in doped cuprates.

Abstract P3-10-19: Significance of baseline neutrophil-to-lymphocyte ratio for progression-free survival of patients with HER2-positive locally advanced and metastatic breast cancer treated with trastuzumab emtansine

Purpose The prognosis of human epidermal growth factor receptor 2 (HER2)-positive locally advanced or metastatic breast cancers (MBCs) has dramatically improved due to the introduction of trastuzumab, pertuzumab, and trastuzumab emtansine (T-DM1). The efficacy of T-DM1 is prolonged for some patients; however, the predictive factors remain unknown. There is a report that T-DM1 induced antitumor immunity in patients treated with neoadjuvant therapy, with tumor infiltrating lymphocytes (TILs) increasing after the administration of T-DM1. Based on these observations, the benefits of T-DM1 for prognosis may be mediated by an immune reaction against breast cancers, at least in part. As an indicator of cancer immunity, in addition to TILs, the neutrophil-to-lymphocyte ratio (NLR) has been established in early breast cancers. In the present study, we investigated the usefulness of the NLR for treatment efficacy of T-DM1 in HER2-positive MBCs. Methods Fifty-three advanced or metastatic breast cancers treated with T-DM1 were retrospectively recruited from three institutes. The NLR in the peripheral blood was measured at baseline (just before the start of T-DM1) and after one cycle (just before the start of cycle 2). The cutoff value of the NLR was set at 2.56 (median value) and progression-free survival (PFS) and overall survival (OS) according to NLR levels were evaluated. Results The PFS of patients with NLR-low at baseline (NLR&lt;2.56; n=26; median, not reached) was significantly better than that of patients with NLR-high (NLR≥2.56; n=27; median, 4.13 months; hazard ratio [HR], 0.226; 95% confidence interval [CI], 0.112-0.493; p=0.0001). There was a significant association between improved OS and a low NLR (HR, 0.384; 95% CI, 0.170-0.910; p=0.0296). In the subgroup analysis, patients with NLR-low consistently had improved PFS compared to those with NLR-high irrespective of the number of prior chemotherapy regimens, prior trastuzumab use, visceral metastasis, estrogen receptor status, and HER2 immunohistochemical staining score. According to univariable analysis of each clinical and biological factor for PFS, the NLR-low group was solely and significantly associated with favorable PFS compared with the NLR-high group (HR, 0.226; 95% CI, 0.112-0.493; p=0.0001). The NLR at baseline was significantly decreased (p=0.0010) and lymphocyte count was significantly increased after one cycle treatment (p=0.0005). Interestingly, the PFS of patients whose NLR was high at baseline but changed to low after one cycle (n=12; median PFS, 6.47 months) was better than that of patients with a consistently high NLR (n=14; median PFS, 3.27 months). Conclusion and Discussion A low baseline NLR was found to be significantly associated with improved PFS for patients treated with T-DM1. Interestingly, lymphocyte count was significantly increased in patients in the NLR-low group but not in the NLR-high group after one cycle treatment. Although detailed mechanisms remain unknown, the treatment efficacy of T-DM1 may be partly mediated by immunoreaction on the basis of present data. A low baseline NLR appears to be beneficial for treatment with T-DM1 in HER2-positive breast cancers.

Citation Format: Imamura M, Morimoto T, Egawa C, Miyagawa Y, Miyoshi Y. Significance of baseline neutrophil-to-lymphocyte ratio for progression-free survival of patients with HER2-positive locally advanced and metastatic breast cancer treated with trastuzumab emtansine [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-10-19.

Spectral dynamics of shift current in ferroelectric semiconductor SbSI

Photoexcitation in solids brings about transitions of electrons/holes between different electronic bands. If the solid lacks an inversion symmetry, these electronic transitions support spontaneous photocurrent due to the geometric phase of the constituting electronic bands: the Berry connection. This photocurrent, termed shift current, is expected to emerge on the timescale of primary photoexcitation process. We observe ultrafast evolution of the shift current in a prototypical ferroelectric semiconductor antimony sulfur iodide (SbSI) by detecting emitted terahertz electromagnetic waves. By sweeping the excitation photon energy across the bandgap, ultrafast electron dynamics as a source of terahertz emission abruptly changes its nature, reflecting a contribution of Berry connection on interband optical transition. The shift excitation carries a net charge flow and is followed by a swing over of the electron cloud on a subpicosecond timescale. Understanding these substantive characters of the shift current with the help of first-principles calculation will pave the way for its application to ultrafast sensors and solar cells.

Imaging of local structures affecting electrical transport properties of large graphene sheets by lock-in thermography

The distribution of defects and dislocations in graphene layers has become a very important concern with regard to the electrical and electronic transport properties of device applications. Although several experiments have shown the influence of defects on the electrical properties of graphene, these studies were limited to measuring microscopic areas because of their long measurement times. Here, we successfully imaged various local defects in a large area of chemical vapor deposition graphene within a reasonable amount of time by using lock-in thermography (LIT). The differences in electrical resistance caused by the micrometer-scale defects, such as cracks and wrinkles, and atomic-scale domain boundaries were apparent as nonuniform Joule heating on polycrystalline and epitaxially grown graphene. The present results indicate that LIT can serve as a fast and effective method of evaluating the quality and uniformity of large graphene films for device applications.

Probing ultrafast spin-relaxation and precession dynamics in a cuprate Mott insulator with seven-femtosecond optical pulses

A charge excitation in a two-dimensional Mott insulator is strongly coupled with the surrounding spins, which is observed as magnetic-polaron formations of doped carriers and a magnon sideband in the Mott-gap transition spectrum. However, the dynamics related to the spin sector are difficult to measure. Here, we show that pump-probe reflection spectroscopy with seven-femtosecond laser pulses can detect the optically induced spin dynamics in Nd2CuO4, a typical cuprate Mott insulator. The bleaching signal at the Mott-gap transition is enhanced at ~18 fs. This time constant is attributable to the spin-relaxation time during magnetic-polaron formation, which is characterized by the exchange interaction. More importantly, ultrafast coherent oscillations appear in the time evolution of the reflectivity changes, and their frequencies (1400-2700 cm-1) are equal to the probe energy measured from the Mott-gap transition peak. These oscillations can be interpreted as the interference between charge excitations with two magnons originating from charge-spin coupling.