5950Lymphocyte-to-monocyte ratio could predict adverse clinical outcomes in patients with heart failure with preserved ejection fraction

Background

Heart failure with preserved ejection fraction (HFpEF) is increasing with aging of the population, whereas the mechanisms of HFpEF remain poorly understood. It was reported that systemic inflammation is associated with pathophysiology of HFpEF. Lymphocyte-to-monocyte ratio (LMR) is a marker of systemic inflammation, which predicts clinical outcomes in various cancers. However, the prognostic value of LMR has not yet been elucidated in patients with HFpEF.

Purpose

The aim of this study was to investigate the impact of LMR on clinical outcomes in patients with HFpEF.

Methods and results

We prospectively analyzed 414 consecutive patients with HFpEF. Preserved EF was defined as an EF ≥50%. During a median follow-up period of 740 days, there were 111 major adverse cardiovascular events (MACE). When patients were divided into tertiles according to LMR, Kaplan-Meier analysis demonstrated that the low LMR was associated with the greatest risk for MACE. Multivariate Cox proportional hazard regression analysis showed that the low LMR was significantly associated with MACE after adjustment for confounding factors.

Conclusions

Low LMR could predict poor clinical outcomes in patients with HFpEF. LMR is a feasible marker for predicting MACE in patients with HFpEF.

129Elevated plasma xanthine oxidoreductase activity predicts cardiovascular events in patients with heart failure with preserved ejection fraction

Background

The pathophysiology of heart failure with preserved ejection fraction (HFpEF) remains poorly understood, although reactive oxygen species (ROS) is reportedly involved in underlying mechanisms. Xanthine oxidoreductase (XOR) is the rate-limiting enzyme of purine metabolism that plays an important role in producing uric acid, and also generates the ROS. However, the impact of plasma XOR activity on the clinical outcomes in patients with HFpEF remains unclear.

Purpose

The aim of this study was to assess whether plasma XOR activity predicts cardiovascular events in patients with HFpEF.

Methods and results

We measured plasma XOR activity in 257 patients with HFpEF. The patients were divided into 3 groups based on XOR activity: low XOR group (<33 pmol/h/mL, n=45), normal XOR group (33 - 120 pmol/h/mL, n=160), and high XOR group (≥120 pmol/h/mL, n=52). During a median follow-up period of 809 days, there were 74 major adverse cardiovascular events (MACEs). Kaplan-Meier analysis demonstrated that the patients with high XOR activity were at greatest risk for MACEs. A multivariate Cox proportional hazard regression analysis showed that high XOR activity was significantly associated with MACEs after adjustment for confounding factors. Furthermore, we divided the patients into 4 groups according to the presence of high XOR activity and/or hyperuricemia. Cox multivariate hazard regression analysis revealed that the patients with high XOR activity were associated with cardiovascular events in patients with HFpEF, regardless of whether hyperuricemia was present or not.

Conclusions

Elevated plasma XOR activity is significantly associated with adverse clinical outcomes in patients with HFpEF. Inhibition of XOR could be a potential therapy for HFpEF.

P1626MicroRNA-21 deteriorates left ventricular reverse remodeling by promoting cardiac fibrosis in non-ischemic cardiomyopathy

Background

Left ventricular reverse remodeling (LVRR) contributes to better outcomes in patients with non-ischemic cardiomyopathy (NICM). It is reported that LVRR is associated with progression of cardiac fibrosis. MicroRNAs (miRs) have emerged as powerful regulators of post-transcriptional gene expression. We focused on miR-21, which plays a key role in pathogenesis of fibrosis in multiple organs. The aim of this study was to clarify the effect of miR-21 on cardiac fibrosis and LVRR in patients with NICM.

Methods

We measured plasma miR-21 levels in 16 patients with NICM. LVRR was defined as increased LVEF by ≥10% and decreased LV end-diastolic diameter index by ≥10% from baseline data after optimal medication treatment at 1-year of follow-up. Further, we examined miR-21 expression and its potential role in cardiac fibrosis induced by transverse aortic constriction (TAC) in mice and angiotensin II (Ang II) stimulation in neonatal rat cardiomyocytes (NRCMs).

Results

There were 12 patients without LVRR and 4 patients with LVRR. Plasma miR-21 levels were significantly higher in patients without LVRR compared with those with LVRR. In TAC mice heart, miR-21 levels were significantly increased and programmed cell death 4 (PDCD4), a main target of miR-21, was decreased. In vitro, miR-21 levels were significantly increased and its upstream transcriptional factor, activator protein 1 (AP-1), was activated by Ang II stimulation in NRCMs. After transfection of miR-21 specific inhibitor, PDCD4 levels were upregulated. Furthermore, AP-1 activity, expression of collagen type I, and α-smooth muscle actin levels were significantly decreased after miR-21 inhibition.

Conclusions

These findings suggested that miR-21/PDCD4/AP-1 feedback loop pathway was involved in LVRR in patients with NICM by promoting cardiac fibrosis. MiR-21 can be the therapeutic target in NICM.

P3355Stress-induced left ventricular dyssynchrony predicts future cardiac events in patients with known or suspected coronary artery disease

Background

Prognostic value of stress induced left ventricular (LV) dyssynchrony has not been fully understood.

The aim of this study was to evaluate the possible impact between cardiovascular events and stress induced worsening LV dyssynchrony.

Methods and results

One hundred and eighty consecutive subjects with known or suspected coronary artery disease (CAD) (142 men, mean age 68±12 years) underwent both gated myocardial single photon emission computed tomography (SPECT) with 99mTc-sestamibi or tetrofosmin according to a standard same day stress-rest protocol and coronary angiography or coronary computed tomography. The summed difference score (SDS) was calculated in every subjects. LV ejection fraction (EF) and phase Entropy at after stress and rest were determined by cardioREPO software. We determined %ΔEntropy = (stress Entropy - rest Entropy)/rest Entropy x100, as an indicator of stress-induced LV dyssynchrony. In the study population, the mean SDS was 2.7±3.9 and LVEF was 58±16%, stress and rest Entropy were 0.62±0.15 and 0.57±0.13, respectively.

%ΔEntropy was higher in patients with CAD than in those without CAD (3.3±11.5 vs. 10.2±15.0, respectively). Moreover, there was a strict correlation between the presence of CAD and %ΔEntropy, indicator of stress induced LV dyssynchrony (non-CAD vs. CAD and/or 1 vessel disease vs. multivessel disease: 4.3±12.5 vs. 8.8±15.6 vs. 12.7±14.3, respectively. p<0.05)

We examined all study subjects and they were divided into 2 groups by cut off value of the %ΔEntropy constructed with receiver operating characteristic curve (=15.4). Kaplan-Meier analysis revealed that future cardiovascular event rate was significantly higher in %ΔEntropy >15.4 group (20/57) than in %ΔEntropy <15.4 group (24/123) (Log-rank p<0.01). On the other hand, summed stress score and SDS were no significant differences between 2 groups.

However, SDS was higher in patients with future cardiovascular event than in those without cardiovascular event (4.4±5.4 vs. 2.2±3.2, respectively. p=0.001).

Conclusion

In patients with known or suspected CAD, stress-induced worsening LV dyssynchrony may predict the presence of CAD and future cardiac events.

Acknowledgement/Funding

None

P2677A combination of HEART score and a 0-hour/1-hour algorithm for early and safe triage tool for patients in observe zone

Background

The European Society Cardiology guidelines recommend that a 0-hour/1-hour (0–1hr) algorithm using high sensitivity cardiac troponin T (hs-cTnT) improves the early triage of patients with suspected non-ST elevation acute coronary syndrome (NSTE-ACS). However, diagnostic uncertainty remains in the 25–30% of patients assigned to “observe” group.

Purpose

To establish a step wise risk score system using HEART score and 0-hour/1-hour algorithm to identify the low risk group from observation group.

Methods

This study was a prospective, multi-center, observational study of patients with suspected NSTE-ACS admitted to five hospitals in Japan and Taiwan from 2014 to 2018, respectively. We applied the algorithm and calculated HEART score simultaneously. Patients were divided into three groups according to the algorithm: hs-cTnT below 12 ng/L and delta 1 hour below 3 ng/L were the “rule out” group; hs-cTnT at least 52 ng/L or delta 1 hour at least 5 ng/L were in the “rule in” group; the remaining patients were classified as the “observe” group. All patients underwent a clinical assessment the included medical history, physical examination, 12-lead ECG, continuous ECG monitoring, pulse oximetry, standard blood test, chest radiography, cardiac and abdominal ultrasonography. Patients presenting with congestive heart failure, terminal kidney disease on hemodialysis state, arrhythmia, or infection disease (which causes to increase troponin level) were excluded. Thirty-day MACE was defined as acute myocardial infarction, unstable angina (UA), or death.

Results

Of the 1,332 patients enrolled, 933 patients were analyzed after exclusion. NSTE-ACS was the final diagnosis for 122 (13.1%) patients and none of death. The HEART score less than 4 points in observation groups identified as very low risk with a negative predictive value (NPV) of 98.1% (95% confidential interval (CI); 90.1%-100%) and sensitivity of 98.0% (95% CI; 89.6%-100%). There were only one patient (0.5%) with AMI. In case of the HEART score less than 5 points, it could also identify as very low risk with a NPV of 96.7% (95% CI; 90.8%-99.3%%) and sensitivity of 94.1% (95% CI; 83.8%-98.8%). There were only three patients (1.2%) with AMI.

Conclusion

A combination of HEART score and the 0-hour/1-hour algorithm strategy rapidly identified the patient in observation group of 30-day MACE including UA where nor further cardiac testing would be needed.

Acknowledgement/Funding

JSPS KAKENHI Grant Number JP18K09554

5945Single nucleotide polymorphisms of PAR2 gene is associated with subclinical myocardial damage in the general population

Introduction

The protease activated receptor (PAR) 2 is a G protein-coupled receptor and expressed in cardiomyocytes, vascular cells, and leukocytes. Experimental studies demonstrated that PAR2 signaling is associated with adverse cardiac remodeling, heart failure, vascular inflammation and atherosclerosis. Recently, we and others demonstrated that subclinical myocardial damage is associated with cardiovascular mortality in general population. However, the impact of single nucleotide polymorphisms (SNPs) of PAR2 gene on subclinical myocardial damage in general population is unclear.

Purpose

The aim of this study was to investigate whether SNPs of PAR2 gene is associated with subclinical myocardial damage in general population.

Methods

The present study included 2,926 apparently healthy subjects (aged ≥40) who participated in a community-based health checkup. We investigated 639 SNPs and measured serum heart-type fatty acid binding protein (H-FABP) as markers of subclinical myocardial damage.

Results

We found the association of SNPs rs616235 within a PAR2 gene with subclinical myocardial damage. The homozygous A-allele (AA), heterozygous (AG), and homozygous G-allele (GG) carriers of rs616235 were identified in 2084 (71%), 791 (27%), and 51 (2%) subjects, respectively. The prevalence rates of subclinical myocardial damage were 29% in AA carriers, 23% in AG carriers, and 18% in GG carriers. Multivariate logistic analysis showed that the homozygous (AA) of rs616235 was independently associated with subclinical myocardial damage (odds ratio: 1.330, 95% confidence interval: 1.077–1.641, P=0.0080) after adjustment for conventional cardiovascular risk factors.

Conclusions

Genetic variant of PAR2 gene was independently associated with subclinical myocardial damage in the general population.

P2462Left atrial appendage wall velocity evaluated by transthoracic echocardiography is a feasible parameter for predicting cardiac prognosis in patients with heart failure

Background

It was reported that left atrial (LA) remodeling is occurred in patients with heart failure (HF), and increased LA volume index (LAVI) is a feasible predictor for poor prognosis of HF. It was reported that LA remodeling is associated with LA appendage (LAA) dysfunction. We previously reported that LAA wall motion velocity (LAWV) obtained by transthoracic echocardiography (TTE) can noninvasively evaluate LAA dysfunction. However, it remains to be determined whether LAWV is useful for predicting poor prognosis in patients with HF.

Purpose

We investigated whether LAA dysfunction assessed by LAWV is associated with poor prognosis in patients with HF.

Methods

We performed TTE at discharge in 217 consecutive patients who hospitalized for HF (126 males, 71±13 years) and prospectively followed them up. LAWV was measured using Doppler tissue imaging at the LAA tip from the parasternal short-axis view on TTE imaging.

Results

There were 86 patients with cardiac events including 14 cardiac deaths and 72 rehospitalizations for HF during a median follow-up period of 404 days (interquartile range 168–748 days). LAWV was significantly lower in patients with cardiac events than in those without. LAWV was significantly decreased with advancing left ventricular diastolic dysfunction grade. Kaplan-Meier analysis demonstrated that significantly higher cardiac event rate was observed in patients with low LAWV (log-rank test, P=0.004). Cox multivariate hazard analysis revealed that LAWV was an independent predictor for cardiac events after adjusting for confounding factors (hazard ratio 0.57, 95% confidence interval 0.40–0.82, P<0.05). Further, we categorized the patients into 3 groups based on the median of LAWV and left atrial volume index (LAVI), and Kaplan-Meier analysis showed that patients with both low LAWV and high LAVI had the highest rate of cardiac events among 3 groups (log-rank test, P<0.001; Figure).

Figure 1

Conclusion

LAWV may be a feasible parameter for predicting cardiac prognosis in patients with HF.

P2676Prospective validation of the 2015 ESC 0-hour/1-hour algorithm using high-sensitivity cardiac troponin T in Asian countries

Background/Introduction

Implementation of the 2015 ESC 0-hour/1-hour algorithm using high-sensitivity troponin (hs-cTn) T in Asian countries presents a challenge for clinical practice.

Purpose

We aimed to prospectively validate the 0-hour/1-hour algorithm in Asian countries.

Methods

We conducted a prospective, multi-center, international cohort already utilizing 0-hour/1-hour algorithm using hs-cTnT for evaluation of patients with suspected of non-ST elevation acute coronary syndrome (NSTE-ACS). All patients underwent a clinical assessment the included medical history, physical examination, 12-lead ECG, continuous ECG monitoring, pulse oximetry, standard blood test, chest radiography, cardiac and abdominal ultrasonography. Patients presenting with congestive heart failure, terminal kidney disease on hemodialysis state, arrhythmia, or infection disease (which cause to increase troponin level) were excluded. Patients were divided into three groups according to the algorithm: hs-cTnT below 12 ng/L and delta 1 hour below 3 ng/L were the “rule out” group; hs-cTnT at least 52 ng/L or delta 1 hour at least 5 ng/L were in the “rule in” group; the remaining patients were classified as the “observational” group. The final diagnosis was then adjudicated by 2 independent cardiologists using all available information, including coronary angiography, coronary computed tomography, stress electrocardiography and follow-up data. The presence of acute myocardial infarction (AMI) was defined according to the Fourth Universal Definition of Myocardial Infarction.

Results

Of the 1,332 patients enrolled in 2014 to 2018, 933 patients were analyzed after exclusion. AMI was the final diagnosis for 122 (13.1%) patients. The algorithm ruled out AMI in 401 patients with a negative predictive value and sensitivity of 100% (95% confidential interval [CI], 98.6%-100%) and 100% (95% CI, 94.0%-100%), respectively, in the rule-out group. None of the patients were diagnosed with AMI. Among the 211 patients classified into the rule-in group, 90 were diagnosed as having AMI. The positive predictive value and specificity were 43.1% (95% CI, 36.2%-50.2%) and 78.3% (95% CI, 74.5%-81.7%), respectively. The median length of hospital stay was 159 min (142–180) in rule out group.

Conclusion(s)

Our findings suggest that the 0-hour/1-hour algorithm using hs-cTnT provides very high safety and efficacy for the triage toward rapid rule-out to rule-in of AMI.

Acknowledgement/Funding

JSPS KAKENHI Grant Number JP18K09554

P1615HECT-Type Ubiquitin E3 Ligase ITCH attenuates cardiac hypertrophy by suppressing Wnt signaling pathway

Background

The homologous to the E6-AP carboxyl terminus (HECT)–type ubiquitin E3 ligase ITCH is an enzyme that plays an important role in ubiquitin proteasomal protein degradation. Dishevelled proteins (Dvl1, Dvl2 and Dvl3), which are involved in canonical Wnt/β catenin signaling pathway, play a role in cardiac hypertrophy.

Purpose

The aim of this study was to examine whether ITCH interacts with Dvls and prevents cardiac hypertrophy induced by pressure overload.

Methods and results

We confirmed the protein interaction between ITCH and Dvls in cardiomyocytes. Overexpression of ITCH decreased protein expression levels of Dvls, phospho-GSK3β and β-catenin. Conversely, knockdown of ITCH using small interfering RNA augmented canonical Wnt/β catenin signaling pathway. Thoracic transverse aortic constriction (TAC) was performed in transgenic mice with cardiac-specific overexpression of ITCH (ITCH-Tg) and wild-type (WT) mice. The canonical Wnt/β catenin signaling pathway was inhibited and cardiac hypertrophy was attenuated in ITCH-Tg mice compared with WT mice after TAC.

Overexpression of ITCH in cardiomyocytes

Conclusion

We demonstrated that ITCH targets Dvls for ubiquitin-proteasome degradation in cardiomyocytes and ameliorates cardiac hypertrophy by suppressing canonical Wnt/β catenin signaling pathway.

Estimating the Net Utility Gains Among Donors and Recipients of Adult Living Donor Kidney Transplant

OBJECTIVES

Living donor kidney transplant relieves the disease burden of patients with end-stage renal disease but may shorten donor life expectancy; however, their quality of life (QOL) is preserved. Nevertheless, the magnitude of the net gain of this procedure is unknown. We evaluated the QOL of both donors and recipients concurrently and calculated the net utility gain.

METHODS

We recruited 210 subjects who visited the kidney transplantation clinic of a university hospital. Subjects were asked to complete the 5-level EQ-5D-based questionnaire, and patient characteristics were extracted from their medical records. We performed multivariate tobit models analysis to evaluate the QOL change caused by transplant surgery and subsequently ran computational simulations to determine the net utility gains of donors and recipients. We also performed sensitivity analyses.

RESULTS

After excluding 16 answers with missing data, we analyzed 203 answers in total. After the transplant surgery, recipients gained 0.07 in utility value while donors lost 0.04. In the net utility analysis, we found that the quality-adjusted life years gained ranged from 7.2 to 7.8 in the most favorable case observed in the combination of middle-aged recipients and elderly donors. Assuming no utility discount, the most favorable combination was that with older donors and younger recipients.

CONCLUSIONS

These findings indicated that the QOL improvement in recipients was larger than the loss among donors. When calculating the net utilities, a combination of middle-aged recipients and elderly donors yielded the largest net utility, but this was likely derived from assumption in the discount of QOL.