Performance of a modified three-level classification in stratifying open liver resection procedures in terms of complexity and postoperative morbidity

BACKGROUND

Traditional classifications for open liver resection are not always associated with surgical complexity and postoperative morbidity. The aim of this study was to test whether a three-level classification for stratifying surgical complexity based on surgical and postoperative outcomes, originally devised for laparoscopic liver resection, is superior to classifications based on a previously reported survey for stratifying surgical complexity of open liver resections, minor/major nomenclature or number of resected segments.

METHODS

Patients undergoing a first open liver resection without simultaneous procedures at MD Anderson Cancer Center (Houston cohort) or the University of Tokyo (Tokyo cohort) were studied. Surgical and postoperative outcomes were compared among three grades: I (wedge resection for anterolateral or posterosuperior segment and left lateral sectionectomy); II (anterolateral segmentectomy and left hepatectomy); III (posterosuperior segmentectomy, right posterior sectionectomy, right hepatectomy, central hepatectomy and extended left/right hepatectomy).

RESULTS

In both the Houston (1878 patients) and Tokyo (1202) cohorts, duration of operation, estimated blood loss and comprehensive complication index score differed between the three grades (all P < 0·050) and increased in stepwise fashion from grades I to III (all P < 0·001). Left hepatectomy was associated with better surgical and postoperative outcomes than right hepatectomy, extended right hepatectomy and right posterior sectionectomy, although these four procedures were categorized as being of medium complexity in the survey-based classification. Surgical outcomes of minor open liver resections also differed between the three grades (all P < 0·050). For duration of operation and blood loss, the area under the curve was higher for the three-level classification than for the minor/major or segment-based classification.

CONCLUSION

The three-level classification may be useful in studies analysing open liver resection at Western and Eastern centres.

P3771Validation of risk scoring system predicting for progression of atrial fibrillation: the Fushimi AF Registry

Background

Atrial fibrillation (AF) increases the risks of thromboembolism and death. Progression from paroxysmal to sustained types (persistent or permanent) of AF is sometimes seen in clinical practice. We recently reported that progression of AF was associated with increased risk of clinical adverse events in Japanese AF patients. However, risk stratification schemes of predicting the progression of AF has not been fully established.

Methods

The Fushimi AF Registry, a community-based prospective survey, was designed to enroll all of the AF patients in Fushimi-ku, Kyoto, which is a typical urban district of Japan with a population of 283,000. Follow-up data were available for 4,454 patients. We investigated the risk factors of AF progression and validated the performance of various risk scoring systems predicting for progression of AF, such as APPLE, BASE-AF2, HATCH, and MB-LATER score, using data from 995 paroxysmal AF patients (mean age; 72.6±11.4 years, female; 42.2%, mean CHA2DS2-VASc score; 3.26±1.67) whose echocardiogram data were obtained at baseline.

Results

Of 995 AF patients, during the median follow-up of 1,477 days, progression from paroxysmal to sustained AF occurred in 160 patients (16.1%; 4.0 per 100 person-years). On a multivariate model, we indicated that history of AF ≥2 years (odds ratio [OR] 1.83; 95% confidence interval [CI] 1.28–2.61), left atrial diameter ≥40 mm (OR 1.45; 95% CI 1.02–2.08), daily drinker (OR 1.56; 95% CI 1.24–2.81), and cardiomyopathy (OR 2.58; 95% CI 1.17–5.69) were significantly associated with higher incidence of AF progression. Our model had better predictive potential for AF progression (area under curve [AUC] 0.612; 95% CI 0.566–0.658) than the APPLE (AUC 0.553; 95% CI 0.508–0.598; p=0.06), BASE-AF2 (AUC 0.571; 95% CI 0.526–0.617; p=0.04), CHADS2 (AUC 0.508; 95% CI 0.462–0.554; p<0.01), CHA2DS2-VASc (AUC 0.501; 95% CI 0.453–0.548; p<0.01), HATCH (AUC 0.502; 95% CI 0.456–0.548; p<0.01), and MB-LATER (AUC 0.528; 95% CI 0.483–0.572; p<0.01) score.

Conclusion

We identified 4 risk factors which may be useful to predict for progression of AF in Japanese patients. External validation of our model in other cohorts is needed.

Acknowledgement/Funding

Boehringer, Bayer, Pfizer, Bristol-Myers, Astellas, AstraZeneca, Daiichi Sankyo, Novartis, MSD, Sanofi and Takeda. Japan Agency for Medical Research

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.

P5431The relationship between pulse rate and the risk of cardiac events in patients with atrial fibrillation: the Fushimi AF registry

Background

Relationship between pulse rate (PR) and cardiac events in patients with sustained (persistent and permanent) atrial fibrillation (AF) in routine clinical practice remains unclear.

Methods

The Fushimi AF Registry is a community-based prospective survey of the AF patients in Fushimi-ku, Kyoto. Follow-up data were available for 4,454 patients, and we obtained PR at baseline in 2,209 patients of 2,248 sustained AF patients. We divided these patients into four groups based on their PR; G1 (PR≥100 bpm, n=249), G2 (80 bpm≤PR<100 bpm, n=821), G3 (60 bpm≤PR<80 bpm, n=986), and G4 (PR<60 bpm, n=153), and examined the relationship between PR and cardiac events (composite of cardiovascular death and hospitalization for heart failure (HF)).

Results

Proportion of female and symptomatic AF were more in G1 group, and diastolic blood pressure was higher in G1 group, despite that systolic blood pressure was similar between the four groups. Prevalence of anemia was higher in G1 group, and that of chronic kidney disease was higher in G4 group. Prevalence of HF and left ventricular dysfunction tended to be higher in G1 group but not statistically significant. Beta-blockers and non-dihydropyridine calcium blockers were more often prescribed in G1 group. During the median follow-up of 1,449 days, cardiac events occurred in 399 patients (358 hospitalization for HF and 41 cardiovascular death). In Kaplan-Meier analysis, the incidence of cardiac events were comparable between the four groups (p=0.3). The incidence of all cause death (p=0.06) and stroke or systemic embolism (p=0.4) was also similar between the four groups. The incidence of cardiac events did not differ between the four groups when we divided the patients based on the presence of HF at baseline, and the incidence of cardiac events was also comparable between the four groups after adjusting potential confounders. However, when we examined the impact of PR according to 10 bpm increment, patients with very low PR (<50 bpm) (hazard ratio [95% confidence intervals], 2.22 [1.04–4.15]) and very high PR (≥110 bpm) (hazard ratio [95% confidence intervals], 1.67 [1.00–2.64]) had higher incidence of cardiac events than patients with PR of 70–79 bpm (Figure). Furthermore, we acquired the annual follow-up data of PR. Mean PR during the follow-up periods was not different between patients with cardiac events and those without (with vs without, 79.5±15.3 bpm vs 79.7±12.7 bpm; p=0.8), whereas maximum PR was less in patients with cardiac events (85.2±17.5 bpm vs 89.3±16.2 bpm; p<0.0001). Patients with maximum PR<60 bpm showed higher incidence of cardiac events, and the incidence of cardiac events was the lowest in patients with maximum PR of 80 to 99 bpm (maximum PR<60 bpm: 31.3%, 60–79 bpm: 24.5%, 80–99 bpm: 14.5%, 100 bpm: 16.1%; P<ehz746.03881).

Conclusion

PR did not appear to have strong impact on cardiac events in patients with sustained AF. However, low PR might be a risk for developing cardiac events.

Acknowledgement/Funding

Japan Agency for Medical Research and Development, AMED (15656344, 16768811), Boehringer Ingelheim, Bayer Healthcare, Pfizer, Bristol-Myers Squibb

P1645Vascular endothelial growth factor-D and mortality in suspected or known coronary heart disease patients with a history of heart failure: a subanalysis of the ANOX study

Background

Vascular endothelial growth factor-D (VEGF-D) is a secreted glycoprotein that can act as lymphangiogenic and angiogenic growth factors through binding to its specific receptors, VEGFR-3 (Flt-4) and VEGFR-2 (KDR/Flk-1). VEGF-D signaling via VEGFR-3 plays an important role in lipoprotein metabolisms which may contribute to coronary heart disease (CHD). Recent studies suggest that VEGF-D appears to be a biomarker of pulmonary congestion and heart failure in both dyspnea patients and the general population. However, the prognostic value of VEGF-D in suspected or known CHD patients with a history of heart failure is unknown.

Methods

Serum VEGF-D levels were measured in 253 suspected or known CHD patients with a history of heart failure undergoing elective coronary angiography, enrolled in the development of novel biomarkers related to angiogenesis or oxidative stress to predict cardiovascular events (ANOX) study, and followed up for 3 years. The primary outcome was all-cause death. The secondary outcomes were cardiovascular death, and major adverse cardiovascular events (MACE) defined as a composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke.

Results

During the follow-up, 54 patients died from any cause, 24 died from cardiovascular disease, and 35 developed MACE. After adjustment for established risk factors, VEGF-D levels were significantly associated with all-cause death (hazard ratio [HR] for 1-SD increase, 1.44; 95% confidence interval [CI], 1.18–1.75), cardiovascular death (HR, 1.73; 95% CI, 1.32–2.25), and MACE (HR, 1.49; 95% CI, 1.14–1.89). Even after incorporation of N-terminal pro-brain natriuretic peptide, contemporary sensitive cardiac troponin-I, and high-sensitivity C-reactive protein into a model with established risk factors, the addition of VEGF-D levels further improved the prediction of all-cause death (continuous net reclassification improvement [NRI], 0.471; 95% CI, 0.176–0.766; P=0.002; integrated discrimination improvement [IDI], 0.036; 95% CI, 0.008–0.064; P=0.011) and cardiovascular death (NRI, 0.722; 95% CI, 0.326–1.118; P<0.001; IDI, 0.063; 95% CI, 0.005–0.122; P=0.033), but not that of MACE (NRI, 0.453; 95% CI, 0.100–0.805; P=0.012; IDI, 0.028; 95% CI, −0.007–0.063; P=0.116).

Conclusions

In suspected or known CHD patients with a history of heart failure undergoing elective coronary angiography, elevated VEGF-D levels may predict all-cause and cardiovascular mortality independent of established risk factors and cardiovascular biomarkers.

Acknowledgement/Funding

The ANOX study is supported by a Grant-in-Aid for Clinical Research from the National Hospital Organization.

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.

P3639Vascular endothelial growth factor-C and mortality in patients with suspected but no history of coronary heart disease: a subanalysis of the ANOX study

Background

The lymphatic system has been suggested to play an important role in cholesterol metabolism and cardiovascular disease. Recently, we demonstrated that serum levels of vascular endothelial growth factor-C (VEGF-C), a central player of lymphangiogenesis, are inversely and independently associated with the risk of all-cause mortality in patients with suspected or known coronary heart disease (CHD). However, the prognostic value of VEGF-C in patients with suspected but no history of CHD is still unclear.

Methods

Serum VEGF-C levels were measured in 1,717 patients with suspected but no history of CHD undergoing elective coronary angiography, enrolled in the development of novel biomarkers related to angiogenesis or oxidative stress to predict cardiovascular events (ANOX) study, and followed up for 3 years. The primary outcome was all-cause death. The secondary outcomes were cardiovascular death, and major adverse cardiovascular events (MACE) defined as a composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke.

Results

During the follow-up, 161 patients died from any cause, 50 died from cardiovascular disease, and 104 developed MACE. After adjustment for established risk factors, VEGF-C levels were significantly and inversely associated with all-cause death (hazard ratio [HR] for 1-SD increase, 0.69; 95% confidence interval [CI], 0.58–0.83) and cardiovascular death (HR, 0.72; 95% CI, 0.52–0.998), but not with MACE (HR, 0.91; 95% CI, 0.74–1.13). Even after incorporation of N-terminal pro-brain natriuretic peptide, contemporary sensitive cardiac troponin-I, and high-sensitivity C-reactive protein into a model with established risk factors, the addition of VEGF-C levels further improved the prediction of all-cause death (continuous net reclassification improvement [NRI], 0.282; 95% CI, 0.121–0.443; P<0.001; integrated discrimination improvement [IDI], 0.009; 95% CI, 0.003–0.016; P=0.005), but not that of cardiovascular death (NRI, 0.178; 95% CI, r=−0.103–0.458; P=0.214; IDI, 0.004; 95% CI, r=−0.002–0.009; P=0.194) or MACE (NRI, 0.037; 95% CI, r=−0.162–0.235; P=0.717; IDI, 0.000; 95% CI, r=−0.0004–0.0005; P=0.872).

Conclusions

In patients with suspected but no history of CHD undergoing elective coronary angiography, a low VEGF-C value may predict all-cause mortality independent of established risk factors and cardiovascular biomarkers.

Acknowledgement/Funding

The ANOX study is supported by a Grant-in-Aid for Clinical Research from the National Hospital Organization

5195Growth differentiation factor-15 and mortality in suspected or known coronary heart disease patients with diabetes: a subanalysis of the ANOX study

Background

Diabetes is a risk factor for coronary heart disease (CHD), but further risk stratification in patients with diabetes is necessary to improve the prediction and prevention of cardiovascular events and deaths. Growth differentiation factor-15 (GDF-15) is a stress-responsive cytokine, which plays an important role in the regulation of the inflammatory response, growth and cell differentiation. Elevated GDF-15 was found in various diseases including diabetes and stable CHD, and was reported to predict mortality and cardiovascular events in general or established CHD population. However, the prognostic value of GDF-15 in suspected or known CHD patients with diabetes is unknown.

Methods

Serum GDF-15 levels were measured in 1,087 suspected or known CHD patients with diabetes undergoing elective coronary angiography, enrolled in the development of novel biomarkers related to angiogenesis or oxidative stress to predict cardiovascular events (ANOX) study, and followed up for 3 years. The primary outcome was all-cause death. The secondary outcomes were cardiovascular death, and major adverse cardiovascular events (MACE) defined as a composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke.

Results

During the follow-up, 147 patients died from any cause, 47 died from cardiovascular disease, and 94 developed MACE. After adjustment for established risk factors, GDF-15 levels were significantly associated with all-cause death (hazard ratio [HR] for 1-SD increase, 1.66; 95% confidence interval [CI], 1.48–1.86), cardiovascular death (HR, 1.63; 95% CI, 1.34–1.99), and MACE (HR, 1.41; 95% CI, 1.20–1.65). Even after incorporation of N-terminal pro-brain natriuretic peptide, contemporary sensitive cardiac troponin-I, and high-sensitivity C-reactive protein into a model with established risk factors, the addition of GDF-15 levels further improved the prediction of all-cause death (continuous net reclassification improvement [NRI], 0.344; 95% CI, 0.172–0.517; P<0.001; integrated discrimination improvement [IDI], 0.049; 95% CI, 0.026–0.072; P<0.001), but not that of cardiovascular death (NRI, −0.013; 95% CI, −0.300–0.274; P=0.931; IDI, 0.023; 95% CI, 0.003–0.043; P=0.026) or MACE (NRI, 0.059; 95% CI, −0.151–0.268; P=0.583; IDI, 0.005; 95% CI, −0.004–0.015; P=0.244).

Conclusions

In suspected or known CHD patients with diabetes undergoing elective coronary angiography, elevated GDF-15 levels may predict all-cause mortality independent of established risk factors and cardiovascular biomarkers.

Acknowledgement/Funding

The ANOX study is supported by a Grant-in-Aid for Clinical Research from the National Hospital Organization.

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.

P5529Vascular endothelial growth factor-D and mortality in suspected or known coronary heart disease patients with diabetes: a subanalysis of the ANOX study

Background

Diabetes is a risk factor for coronary heart disease (CHD), but further risk stratification in patients with diabetes is necessary to improve the prediction and prevention of cardiovascular events and deaths. Vascular endothelial growth factor-D (VEGF-D) is a secreted glycoprotein that can act as lymphangiogenic and angiogenic growth factors through binding to its specific receptors, VEGFR-3 (Flt-4) and VEGFR-2 (KDR/Flk-1). VEGF-D signaling via VEGFR-3 plays an important role in lipoprotein metabolisms which may contribute to CHD. VEGF-D signaling has been used as a therapeutic target of human diseases such as lymphangioleiomyomatosis and refractory angina. Furthermore, in clinical settings, the VEGF-D level is already established as a diagnostic biomarker for lymphangioleiomyomatosis. However, the prognostic value of VEGF-D in suspected or known CHD patients with diabetes is unknown.

Methods

Serum VEGF-D levels were measured in 1,087 suspected or known CHD patients with diabetes undergoing elective coronary angiography, enrolled in the development of novel biomarkers related to angiogenesis or oxidative stress to predict cardiovascular events (ANOX) study, and followed up for 3 years. The primary outcome was all-cause death. The secondary outcomes were cardiovascular death, and major adverse cardiovascular events (MACE) defined as a composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke.

Results

During the follow-up, 147 patients died from any cause, 47 died from cardiovascular disease, and 94 developed MACE. After adjustment for established risk factors, VEGF-D levels were significantly associated with all-cause death (hazard ratio [HR] for 1-SD increase, 1.34; 95% confidence interval [CI], 1.21–1.47), cardiovascular death (HR, 1.40; 95% CI, 1.18–1.62), and MACE (HR, 1.22; 95% CI, 1.07–1.40). Even after incorporation of N-terminal pro-brain natriuretic peptide, contemporary sensitive cardiac troponin-I, and high-sensitivity C-reactive protein into a model with established risk factors, the addition of VEGF-D levels further improved the prediction of all-cause death (continuous net reclassification improvement [NRI], 0.258; 95% CI, 0.088–0.429; P=0.003; integrated discrimination improvement [IDI], 0.013; 95% CI, 0.002–0.024; P=0.022), but not that of cardiovascular death (NRI, 0.046; 95% CI, −0.245–0.336; P=0.759; IDI, 0.013; 95% CI, −0.005–0.031; P=0.146) or MACE (NRI, 0.064; 95% CI, −0.146–0.274; P=0.552; IDI, 0.001; 95% CI, −0.002–0.004; P=0.557).

Conclusions

In suspected or known CHD patients with diabetes undergoing elective coronary angiography, elevated VEGF-D levels may predict all-cause mortality independent of established risk factors and cardiovascular biomarkers.

Acknowledgement/Funding

The ANOX study is supported by a Grant-in-Aid for Clinical Research from the National Hospital Organization

P5526Vascular endothelial growth factor-D and mortality in suspected or known coronary heart disease patients with chronic kidney disease: a subanalysis of the ANOX study

Background

Chronic kidney disease (CKD) is an independent risk factor for the development and progression of coronary heart disease (CHD). Vascular endothelial growth factor-D (VEGF-D) is a secreted glycoprotein that can act as lymphangiogenic and angiogenic growth factors through binding to its specific receptors, VEGFR-3 (Flt-4) and VEGFR-2 (KDR/Flk-1). VEGF-D signaling via VEGFR-3 plays an important role in lipoprotein metabolisms which may contribute to CHD. VEGF-D signaling has been used as a therapeutic target of human diseases such as lymphangioleiomyomatosis and refractory angina. Furthermore, in clinical settings, the VEGF-D level is already established as a diagnostic biomarker for lymphangioleiomyomatosis. However, the prognostic value of VEGF-D in suspected or known CHD patients with CKD is unknown.

Methods

Serum VEGF-D levels were measured in 999 suspected or known CHD patients with CKD undergoing elective coronary angiography, enrolled in the development of novel biomarkers related to angiogenesis or oxidative stress to predict cardiovascular events (ANOX) study, and followed up for 3 years. The primary outcome was all-cause death. The secondary outcomes were cardiovascular death, and major adverse cardiovascular events (MACE) defined as a composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke.

Results

During the follow-up, 154 patients died from any cause, 61 died from cardiovascular disease, and 96 developed MACE. After adjustment for established risk factors, VEGF-D levels were significantly associated with all-cause death (hazard ratio [HR] for 1-SD increase, 1.41; 95% confidence interval [CI], 1.27–1.56), cardiovascular death (HR, 1.48; 95% CI, 1.28–1.71), and MACE (HR, 1.34; 95% CI, 1.18–1.53). Even after incorporation of N-terminal pro-brain natriuretic peptide, contemporary sensitive cardiac troponin-I, and high-sensitivity C-reactive protein into a model with established risk factors, the addition of VEGF-D levels further improved the prediction of all-cause death (continuous net reclassification improvement [NRI], 0.272; 95% CI, 0.100–0.445; P=0.002; integrated discrimination improvement [IDI], 0.015; 95% CI, 0.003–0.027; P=0.013), but not that of cardiovascular death (NRI, 0.230; 95% CI, −0.029 to 0.488; P=0.082; IDI, 0.012; 95% CI, −0.007 to 0.031; P=0.207) or MACE (NRI, 0.102; 95% CI, −0.106 to 0.310; P=0.337; IDI, 0.005; 95% CI, −0.005 to 0.015; P=0.337).

Conclusions

In suspected or known CHD patients with CKD undergoing elective coronary angiography, elevated VEGF-D levels may predict all-cause mortality independent of established risk factors and cardiovascular biomarkers.

Acknowledgement/Funding

The ANOX study is supported by a Grant-in-Aid for Clinical Research from the National Hospital Organization

P5641Impact of lethal arrhythmias on medical castration in patients with prostate cancer

Background

Prostate cancer is the most common non-cutaneous malignancy in men and has been steadily rising in an aging society. Medical castration had been widely applied as a treatment for prostate cancer. Sex steroid hormones regulate cardiac ion channels. However, the proarrhythmic properties of medical castration have not been reported.

Methods

This prospective observational study consisted of 149 patients (75±6 years) who underwent hormonal therapy using gonadotropin-releasing hormone with or without anti-androgen for prostate cancer. The changes of electrocardiogram (ECG) findings during the therapy and the associations of ECG findings with lethal arrhythmias were studied.

Results

QT (394±32 to 406±39 ms, p<0.001) and QTc intervals (416±27 to 439±31 ms, p<0.001) significantly prolonged during the therapy as compared to baseline. Heart rate significantly increased during the therapy as compared to baseline (68±11 to 71±14 / min, p=0.006). PQ interval and QRS duration were similar before and during the therapy. During the hormonal therapy, 2 patients (1.3%) presented with torsades de pointes and ventricular fibrillation. The first patient was 71 year-old and the second patient was 70 year-old. The period of the therapy was 6 and 45 months, respectively. Both patients had no structural heart disease. The magnitude of QTc interval change during the therapy as compared to baseline (Δ QTc interval) was significantly greater in patients with VF than those without (p<0.001), however the magnitude of Δ heart rate, Δ PQ interval, and Δ QRS duration were similar between the 2 groups.

Conclusions

Medical castration significantly prolonged QT/QTc interval and could be a trigger of lethal arrhythmias in patients with prostate cancer.

P3765Low vascular endothelial growth factor-C was a predictor for cardiovascular events in patients with atrial fibrillation and suspected or known coronary artery disease: a subanalysis of the ANOX study

Background

Lymphatic system has been considered to play an important role in cardiovascular disease. We recently reported that vascular endothelial growth factor-C (VEGF-C), a central player in lymphangiogenesis, predicted all-cause mortality in patients with suspected or known coronary artery disease (CAD). However, relationship between VEGF-C and atrial fibrillation (AF) remains unclear.

Methods

The ANOX study is a multicenter, prospective cohort study of 2,418 patients with suspected CAD, to determine the predictive value of possible novel biomarkers related to angiogenesis or oxidative stress for major adverse cardiovascular events (MACE) among patients undergoing elective angiography. Blood samples were collected from the arterial catheter sheath at the beginning of coronary angiography. Serum levels of VEGF-C, as well as N-terminal pro-brain natriuretic peptide (NT-proBNP), high-sensitivity troponin-I (cTnI), and high-sensitivity C-reactive protein (hsCRP), were measured. The outcome was a MACE defined as a composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke.

Results

Of a total of 2,418 patients, 261 patients had AF at baseline. AF group were older, and had more chronic kidney disease, history of heart failure, and history of stroke, but less diabetes, dyslipidemia, and CAD. The median level of NT-proBNP, cTnI, and hsCRP were higher in AF group [AF vs non-AF: NT-proBNP, 1048 pg/ml vs 162 pg/ml (p<0.0001); cTnI, 0.0003 ng/ml, vs 0.0 ng/ml (p<0.0001); hsCRP, 1.43 ug/ml vs 0.88 ug/ml (p=0.0005)], whereas median level of VEGF-C was lower in AF group [3107 pg/ml vs 3590 pg/ml (p<0.0001)]. AF was associated with lower VEGF-C and higher hsCRP after adjustment for potential confounders. During the 3-year follow-up, 29 (11.1%) patients in AF group and 136 (6.3%) patients in non-AF group developed MACE (p=0.007). Incidence of stroke was higher in AF group (17 (6.5%) vs 52 (2.4%); p<0.0009), despite that the incidence of cardiovascular death and myocardial infarction were similar between the groups. We divided the entire cohort into two groups based on the lowest quartile of VEGF-C or highest quartile of other biomarkers, lowest quartile of VEGF-C (log rank p=0.0004), as well as highest quartile of cTnI (log rank p=0.0009), were significantly associated with MACE in AF group. After adjustment for established risk factors and these biomarkers, both lowest quartile of VEGF-C (HR, 2.73; 95% CI, 1.27–6.06) and highest quartile of cTnI (HR, 2.54; 95% CI, 1.08–6.09) were significantly associated with MACE in AF group.

Conclusions

AF was associated with lower level of VEGF-C, and low VEGF-C as well as high cTnI might serve as an independent predictor of MACE in patients with AF and suspected or known CAD.

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.

P3780Clinical characteristics and outcomes in Japanese atrial fibrillation patients with valvular heart disease: the Fushimi AF registry

Background

Previous studies have suggested that valvular atrial fibrillation (VAF), defined as atrial fibrillation (AF) patients with prosthetic valve or rheumatic mitral stenosis, increased the risks of thromboembolism. However, clinical characteristics and outcomes of VAF and non-valvular AF (NVAF) patients with other valvular heart disease (VHD) has not been fully described.

Method

The Fushimi AF Registry was designed to enroll all of the AF patients. In the entire cohort (4,454 patients), follow-up data including echocardiography data were available for 3,566 patients. We compared clinical characteristics and outcomes between 131 VAF patients (3.7%), 583 NVAF with VHD (NVAF-VHD: 16.3%) and 2,852 without VHD (Non-VHD: 80.0%).

Result

Compared with Non-VHD, patients in VAF and NVAF-VHD were older (VAF vs. NVAF-VHD vs. Non-VHD: 74.3 vs. 76.9 vs. 72.9 years, respectively; p≤0.0001), more often female (56.5% vs. 51.1% vs. 36.9%, p≤0.0001), less in body weight (54.3 vs. 54.7 vs. 60.6 kg, p≤0.0001), more persistent/permanent type (64.1% vs. 65.4% vs. 45.8%, p≤0.0001), more likely to have heart failure (61.8% vs. 53.2% vs. 23.3%, p≤0.0001), had higher CHADS2 score (2.18 vs. 2.49 vs. 1.96, p≤0.0001) and CHA2DS2-VASc score (3.71 vs. 4.02 vs. 3.26, p≤0.0001), and received oral anticoagulant prescription more frequently (78.6% vs. 63.0% vs. 55.6%, p0.0001). NVAF-VHD was more likely to have previous stroke/systemic embolism (SE) than VHD or Non-VHD (14.5% vs. 23.5% vs. 19.6%, p=0.03). VAF or NVAF-VHD had larger left atrium than Non-VHD (50.5 vs. 47.2 vs. 42.4 mm, p<0.0001). Heart rate, diabetes mellitus and previous bleeding were comparable between the groups.

During the median follow-up of 1,471 days, the incidence rate of stroke/SE was not significantly different between three groups, however, NVAF-VHD showed modestly higher rate than Non-VHD (1.67 vs. 1.96 vs. 1.28 per 100 person-years, respectively, log rank p=0.054) (Figure). The incidence rates of all-cause death (4.62 vs. 5.74 vs. 3.21, p≤0.0001), cardiac death (1.07 vs. 1.01 vs. 0.44, p=0.0003), and those of hospitalization for heart failure (3.29 vs. 4.41 vs. 1.80, p≤0.0001) were higher in NVAF-VHD and VAF, than Non-VHD. After adjustment by relevant factors including the components of CHA2DS2-VASc score and oral anticoagulant use, NVAF-VHD, but not VAF, was an independent predictor for hospitalization for heart failure. Neither VAF nor NVAF-VHD was predictors for all-cause death, cardiac death or stroke/SE.

Figure 1. Incidence of stroke/SE

Conclusion

As compared with Non-VHD, the risk of stroke/SE in VAF and NVAF-VHD was not particularly high; although NVAF-VHD had modestly higher rate than Non-VHD. VAF and NVAF-VHD were associated with higher incidence rates of all-cause death, cardiac death and hospitalization for heart failure. NVAF-VHD was an independent predictor for hospitalization for heart failure in multivariate analysis.

Acknowledgement/Funding

Pfizer, Bristol-Myers Squibb, Boehringer Ingelheim, Bayer Healthcare and Daiichi Sankyo

P2434Digital zoom decreases radiation exposure dose up to 30% in percutaneous coronary intervention

Background

Interventional cardiology is gaining greater popularity worldwide with each passing year. Reduction of exposure dose is a very imminent and an important issue in cardiology procedure. Although a newer radiation reduction technique, device and procedure are very valuable and expected, we should consider about therapy technique, radiation technique, devices, and the way to protection. Digital zoom digitally enlarges images in real time by up to 2.5-fold at lower doses than those used with traditional field of view changes. In our phantom examination the average dose reduction of digital zoom was 27%.

Methods and results

This study is designated as single-center, retrospective, not-randomized, observation study. 2101 eligible cases were collected. We assigned the cases of PCI without the use of Digital zoom to the Conventional group and those involving the use of Digital zoom to the Digital zoom group. There were 806 patients in the Conventional group and 1195 in the Digital zoom group. Because we had begun using Digital zoom from January 2015 onwards, all patients in the Conventional group had undergone PCI from January 2013 to December 2014 and all patients in the Digital zoom group had undergone PCI from January 2015 to December 2016. In addition, we calculated the RAK/minute and DAP/minute for an accurate assessment. To minimize the difference of characteristics between two groups, propensity score including all baseline variables was performed. Furthermore, Predictors of radiation exposure were investigated using multivariable least square methods. Inter group differences were observed in DAP, RAK, DAP/min, and RAK/min (Digital zoom group vs conventional group: DAP, 16000 cGy cm2 [from 1st quartile to 3rd quartile; 10300–24400] vs 20700 [13400–29500], p<0.001; DAP/min, 557 cGy cm2/min [392–737] vs 782 [571–1010], p<0.01; RAK, 1590 Gy [990–2410] vs 1850 [1220–2720], p<0.01; RAK/min, 54.7 Gy/min [38.5–73.2] vs 71.2 [51.5–93.0], p<0.01). Even after propensity score matching, intergroup differences in DAP (810 cases), DAP/min (811 cases), RAK (746 cases), and RAK/min (744 cases) persisted. Furthermore, the least squares method showed that Digital zoom is an important predictor of DAP (β=0.17, p<0.01) and RAK (β=0.12, p<0.01).

Conclusion

Digital zoom is an old and cost-free technique, but one of most powerful reduction of exposure method. Propensity score adjustment and least square methods show that digital zoom is one of independent effective method.

P6339Sequential organ failure assessment score on admission predicts long-time mortality of the patients with acute heart failure

Background

Despite the remarkable advances in the treatment options of acute heart failure (HF), prognosis assessment remains an ongoing challenge. Previous studies revealed only a moderate accuracy of models predicting mortality. Sequential Organ Failure Assessment (SOFA) Score are widely used in the intensive care unit (ICU) to predict outcome and predicted higher long-time mortality in unselected patients in cardiac ICU. In addition, the American Heart Association Get With the Guidelines–Heart Failure (GWTG-HF) risk score allows for risk stratification of 30-day outcome for patients hospitalized with HF. The purpose of this study was to evaluate whether SOFA score on admission is useful for long-time mortality prediction in acute HF patients and also to assess the discriminative performance as compared with GWTG-HF risk score.

Methods

This was a single-centre, retrospective cohort study. Between January 2007 and December 2016, we screened eligible 661 consecutive patients with acute HF administered at our hospital. SOFA score on admission of 294 patients was able to calculate retrospectively. We enrolled 269 patients who could complete follow up evaluation for more than 1 year. Endpoint was all-cause mortality after admission. Additive information of SOFA score was evaluated by area under the curve (AUC), net reclassification improvement (NRI), integrated discrimination improvement (IDI) and decision curve analysis (DCA).

Results

The 269 patients were included in this study (78.5±10.9 years; 136 men; left ventricular ejection fraction [EF], 49.8±16.6%) during a mean follow-up of 32.1±22.3 months. Patients with all-cause death had higher SOFA score (4.2±2.3 versus 2.8±1.8, p<0.001; AUC, 0.689) and GWTG-HF risk score (44.0±7.6 versus 38.1±7.9, P<0.001, AUC, 0.692).

Kaplan-Meier survival analysis demonstrated higher SOFA scores (P<0.001) and GWTG-HF risk scores (P<0.001) appears to be related to increase probabilities of all cause death. A multivariate Cox proportional hazard model were made with adjustment for SOFA score, GWTG-HF risk score, age, gender and ejection fraction. As a result, SOFA score (hazard ratio [HR] 1.227; 95% confidence interval [CI], 1.130 to 1.326; P<0.001), GWTG-HF (HR, 1.054; 95% CI, 1.029 to 1.078; P<0.001) and age (HR, 1.069; 95% CI 1.048 to 1.092; P<0.001) were independent predictors of all cause death and HR of SOFA score was the highest in these parameters. Incorporating SOFA score into GWTG-HF score yielded a significant NRI (0.528 (95% CI 0.291 to 0.765) and IDI (0.046 (95% CI 0.020 to 0.072). In DCA, compared with the reference model, the net benefit for SOFA score model was greater across the range of threshold probabilities.

Conclusions

The SOFA score, simple and validated mortality risk score can predict long-term all-cause mortality in patients with acute HF. Discriminative performance metrics such as NRI, IDI and DCA were improved on incorporation of the SOFA score for prediction of mortality.

P5663Impact of proteinuria on cardiovascular outcomes in Japanese diabetic patients with atrial fibrillation: the Fushimi AF Registry

Background

Previous studies have suggested that proteinuria is independently associated with clinical outcomes in diabetic patients, irrespective of the presence of renal dysfunction. However, data regarding the impact of proteinuria on clinical outcomes in diabetic patients with atrial fibrillation (AF) are limited.

Methods

The Fushimi AF Registry is a community-based prospective survey of AF patients in our city in Japan. Follow-up data were available in 4,454 patients, and 634 diabetic patients with available data of proteinuria and estimated glomerular filtration rate (eGFR) were examined. We compared the clinical background and outcomes between patients with proteinuria (n=251) and those without (n=383). Then, we divided the patients into 4 subgroups according to the presence of proteinuria and renal dysfunction, and compared the clinical outcomes between groups; group 1 (without proteinuria, eGFR ≥60 ml/min/1.73 m2; n=203), group 2 (with proteinuria, eGFR ≥60; n=96), group 3 (without proteinuria, eGFR <60; n=180), group 4 (with proteinuria, eGFR <60; n=155).

Results

Age was comparable between patients with or without proteinuria. Patients with proteinuria had higher prevalences of previous heart failure (HF), stroke/systemic embolism, hypertension and renal dysfunction. The prevalences of previous myocardial infarction, and major bleeding were similar between two groups. During the median follow-up of 1,505 days, the incidence rates of HF hospitalization (4.1/100 person-years vs. 2.5/100 person-years; p<0.01) and cardiovascular death (1.8/100 person-years vs. 0.4/100 person-years; p<0.01) were higher in patients with proteinuria. When we divided patients into 4 subgroups, the incidences of HF hospitalization (group 1: 1.8/100 person-years vs. group 2: 3.4/100 person-years vs. group 3: 3.8/100 person-years vs. group 4: 4.9/100 person-years; p<0.01) and cardiovascular death (group 1: 0.3/100 person-years vs. group 2: 1.8/100 person-years vs. group 3: 0.5/100 person-years vs. group 4: 2.2/100 person-years; p<0.01) tended to be higher in not only group 3 and group 4 but also group 2 than group 1 (Figure). Multivariate Cox proportional hazards regression analysis including female gender, age (≥75 years), hypertension, pre-existing HF, renal dysfunction (eGFR <60),low left ventricular ejection fraction (<40%) and proteinuria revealed that proteinuria was an independent determinant of both of HF hospitalization (adjusted hazard ratio [HR]: 1.57, 95% confidence interval [CI]: 1.05–2.34) and cardiovascular death (HR: 3.76, 95% CI: 1.59–8.88).

Figure 1

Conclusion

In Japanese diabetic patients with AF, proteinuria was associated with higher incidences of HF hospitalization and cardiovascular death, irrespective of the presence of renal dysfunction.

P3635Vascular endothelial growth factor-D and mortality in patients with suspected but no history of coronary heart disease: a subanalysis of the ANOX study

Background

Vascular endothelial growth factor-D (VEGF-D) is a secreted glycoprotein that can act as lymphangiogenic and angiogenic growth factors through binding to its specific receptors, VEGFR-3 (Flt-4) and VEGFR-2 (KDR/Flk-1). VEGF-D signaling via VEGFR-3 plays an important role in lipoprotein metabolisms which may contribute to coronary heart disease (CHD). VEGF-D signaling has been used as a therapeutic target of human diseases such as lymphangioleiomyomatosis and refractory angina. In clinical settings, the VEGF-D level is already established as a diagnostic biomarker for lymphangioleiomyomatosis. However, the prognostic value of VEGF-D in patients with suspected but no history of CHD is unknown.

Methods

Serum VEGF-D levels were measured in 1,717 patients with suspected but no history of CHD undergoing elective coronary angiography, enrolled in the development of novel biomarkers related to angiogenesis or oxidative stress to predict cardiovascular events (ANOX) study, and followed up for 3 years. The primary outcome was all-cause death. The secondary outcomes were cardiovascular death, and major adverse cardiovascular events (MACE) defined as a composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke.

Results

During the follow-up, 161 patients died from any cause, 50 died from cardiovascular disease, and 104 developed MACE. After adjustment for established risk factors, VEGF-D levels were significantly associated with all-cause death (hazard ratio [HR] for 1-SD increase, 1.29; 95% confidence interval [CI], 1.17–1.42), cardiovascular death (HR, 1.37; 95% CI, 1.20–1.56), and MACE (HR, 1.22; 95% CI, 1.08–1.37). Even after incorporation of N-terminal pro-brain natriuretic peptide, contemporary sensitive cardiac troponin-I, and high-sensitivity C-reactive protein into a model with established risk factors, the addition of VEGF-D levels further improved the prediction of all-cause death (continuous net reclassification improvement [NRI], 0.165; 95% CI, 0.004–0.325; P=0.044; integrated discrimination improvement [IDI], 0.012; 95% CI, 0.002–0.023; P=0.013), but not that of cardiovascular death (NRI, 0.078; 95% CI, r=−0.203–0.359; P=0.586; IDI, 0.014; 95% CI, r=−0.009–0.037; P=0.235) or MACE (NRI, r=−0.011; 95% CI, r=−0.207–0.184; P=0.337; IDI, 0.003; 95% CI, r=−0.003–0.009; P=0.354).

Conclusions

In patients with suspected but no history of CHD undergoing elective coronary angiography, elevated VEGF-D levels may predict all-cause mortality independent of established risk factors and cardiovascular biomarkers.

Acknowledgement/Funding

The ANOX study is supported by a Grant-in-Aid for Clinical Research from the National Hospital Organization.

P3758Clinical characteristics and outcomes of atrial fibrillation patients with thrombocytopenia: the Fushimi AF Registry

Background

Thrombocytopenia is sometimes found in routine blood tests and is reported as a risk factor of major bleeding events and incidence of all-cause death after percutaneous coronary intervention. However, the influence of thrombocytopenia on clinical outcomes in patients with atrial fibrillation (AF) remains unknown.

Purpose

We aimed to investigate relationship between baseline platelet count and clinical outcomes such as all-cause death, hospitalization for heart failure, and the major bleeding event in AF patients.

Methods

The Fushimi AF Registry was designed to enroll all of the AF patients in Fushimi-ku, Kyoto. Fushimi-ku is densely populated with a total population of 283,000 and is assumed to represent a typical urban community in Japan. Follow-up data with baseline platelet counts were available in 4,179 patients from March 2011 to November 2018. We divided the entire cohort into 3 groups according to baseline platelet level: No thrombocytopenia (≥150,000/μL, n=3,323), Mild thrombocytopenia (100,000–149,999/μL, n=707), and Moderate/severe thrombocytopenia (≤99,999/μL, n=149).

Results

In the entire cohort, the mean age was 73 years, 40% were women, and the mean body weight and body mass index was 59 kg and 23.1 kg/m2, and the median platelet count were 192,000/μL (interquartile range 156,000 to 232,000/μL), respectively.

Compared to No thrombocytopenia, patients with thrombocytopenia were older (No vs. Mild vs. Moderate/severe; 73.3 years vs. 76.5 years vs. 75.8 years, p<0.0001), more likely to have heart failure (27.0% vs. 32.8% vs. 41.6%, p<0.0001), more likely to have chronic renal disease (35.7% vs. 42.6% vs. 57.7%, p<0.0001), and had higher CHADS2 score (2.05 vs. 2.17 vs. 2.34, p=0.0039) and CHA2DS2-VASc score (3.40 vs. 3.52 vs. 3.71, p=0.0416). Patients with thrombocytopenia had lower hemoglobin (13.0 vs. 12.8 vs. 11.6, p<0.0001) than No thrombocytopenia. However, prevalence of previous major bleeding events was comparable between three groups (4.66% vs. 4.67% vs. 5.37%, p=0.92)

On Kaplan-Meier analysis, the incidence of all-cause death was higher in Mild group (hazard ratio [HR] 1.51; 95% confidence interval [CI] 1.28–1.77) and Moderate/severe group (HR 2.97; 95% CI 2.28–3.80) than No group (Figure 1). The incidence of hospitalization for heart failure was higher in Mild group (HR 1.62; 95% CI 1.31–1.99) and Moderate/severe group (HR 2.64; 95% CI 1.76–3.81) than No group (Figure 2). The incidence of major bleeding event was higher in Mild group (HR 1.46; 95% CI 1.11–1.91) and Moderate/severe group (HR 2.45; 95% CI 1.41–3.91) than No group (Figure 3).

Conclusion

Thrombocytopenia in AF patients was associated with higher incidence of all-cause death, hospitalization for heart failure, and major bleeding event in the Fushimi AF Registry.

Acknowledgement/Funding

Pfizer, Bristol-Myers Squibb, Boehringer Ingelheim, Bayer Healthcare,and Daiichi-Sankyo