Prediction of bortezomib-induced peripheral neuropathy with the R-R interval variation of the electrocardiogram in plasma cell myeloma: a retrospective study

Bortezomib-induced peripheral neuropathy (BIPN) is a key dose-limiting toxicity in patients with plasma cell myeloma (PCM). This study examined 56 patients with PCM treated with bortezomib to determine the possible predisposing factors to BIPN with the R-R interval variation (RRIV) of the electrocardiogram (ECG). Of all, 17 patients developed Clinically obvious BIPN, grades 2-4 or grade worsening from the baseline neuropathy per the National Cancer Institute's Common Terminology Criteria for Adverse Events (v5.0). In the receiver operating characteristic curve analysis, the optimal RRIV cutoff value to distinguish patients with and without risk to develop BIPN was 1.391. A lower RRIV before bortezomib treatment independently correlated with the onset of Clinically obvious BIPN (p = .002) and the time to the onset of Clinically obvious BIPN (p < 0.001). A lower RRIV of the ECG before the bortezomib treatment is a predictive factor for BIPN in PCM.

P1761Distal transradial approach for primary percutaneous coronary intervention for patients with acute myocardial infarction: a multicentre study

Background

The distal transradial approach (dTRA) for coronary catheterisation is a newly introduced alternative to the conventional transradial approach. This technique is expected to decrease the incidence of haemorrhagic complications and improve patient comfort. However, limited data are available regarding the application of this technique in patients with acute myocardial infarction (AMI). This study investigated the feasibility and safety of the dTRA for primary percutaneous coronary intervention (PCI) in patients with AMI.

Methods

This study included patients with AMI who underwent primary PCI via the distal radial artery across 3 Japanese hospitals between January 2018 and January 2019. Patients' background, procedural characteristics, and clinical outcomes including the incidence of haemorrhagic complications were analysed.

Results

This study enrolled 95 consecutive patients with AMI, including 68 patients (71.6%) with ST-segment elevation myocardial infarction (STEMI), in whom distal radial artery puncture was attempted for primary PCI. The patients included 70 men (73.7%), and the mean age was 72.2±12.4 years. Among these patients, cannulation was successfully performed in 89 patients (93.7%). A 5-, 6-, or 7-French sheath (conventional or slender) was used in this study. Cannulation was performed using a forearm radial artery approach in patients in whom dTRA failed.

PCI was successfully performed in all patients. The meantime to achieve haemostasis was 6.3±5.3 hours, and no major bleeding complications occurred. Based on The Early Discharge After Transradial Stenting of Coronary Arteries trial haematoma scale, grade I, II, and III subcutaneous haemorrhages were observed in 16 (16.8%), 4 (4.2%), and 1 patient (1.1%), respectively. No patient developed a haematoma > grade IV.

In patients with STEMI, the mean door-to-balloon time was 39.4±31.9 min, and the mean puncture-to-balloon time was 19.7±14.2 min.

Conclusions

The distal radial approach is feasible and safefor primary PCI in selected patients with AMI.The application of the dTRA may serve as a less invasive strategy for the treatment of patients with AMI.

P794Long-term prognostic value of the combination of AHEAD score and wasting syndrome in patients admitted for acute decompensated heart failure with reduced or preserved LV ejection fraction

Background

Comorbidities are associated with poor clinical outcome in heart failure patients (pts). AHEAD (A: atrial fibrillation; H: hemoglobin; E: elderly; A: abnormal renal parameters; D: diabetes mellitus) score has been related to clinical outcomes in acute decompensated heart failure (ADHF) pts. On the other hand, heart failure is one of a number of disorders associated with the development of wasting syndrome. Previous studies have reported reduced mortality rates in heart failure patients with increased body mass index (BMI), so-called, obesity paradox. We sought to investigate the prognostic value of the combination of AHEAD score and the cachectic state in ADHF pts, relating to reduced or preserved LVEF (HFrEF or HFpEF).

Methods and results

We studied 303 pts admitted for ADHF and discharged with survival (HFrEF (LVEF <50%); n=163, HFpEF (LVEF ≥50%; n=140). We evaluated AHEAD score (range 0–5, atrial fibrillation, hemoglobin <13 mg/dL for men and 12 mg/dL for women, age >70 years, creatinine >130 μmol/L, and diabetes mellitus) and wasting syndrome was defined as BMI <20 kg/m2 and serum albumin level (Alb) <3.2 g/dl at the discharge. During a follow-up period of 5.1±4.2 years, 121 pts died. At multivariate Cox analysis, AHEAD score and wasting syndrome was significantly and independently associated with the total mortality, in pts with not only HFrEF but also HFpEF. Pts with both high AHEAD score (≥3: AUC 0.625 [0.542–0.709] in HFrEF and ≥3: AUC 0.611 [0514–0.708] in HFpEF, by ROC curve analysis) and wasting syndrome had a higher risk of mortality than those with either and none of them in HFrEF (71% vs 51% vs 40%, p<0.0001, respectively) and HFpEF (78% vs 33% vs 24%, p<0.0001, respectively).

Conclusion

The combination of AHEAD score and wasting syndrome would be useful for stratifying patients at risk for the mortality in ADHF pts, regardless of HFrEF or HFpEF.

P787Long-term prognostic value of the combination of fibrosis-4 index and acute kidney injury in patients with admitted for acute decompensated heart failure

Background

Liver dysfunction in patients with heart failure (HF) is caused by liver congestion, which is related to liver stiffness. It was reported that liver stiffness assessed by non-invasive fibrosis marker such as Fibrosis-4 (FIB4) index (based on age, aspartate aminotransferase [AST] and alanine aminotransferase [ALT] levels, and platelet counts) predicts mortality in HF pts. Acute kidney injury (AKI) during HF treatment is associated with poor outcome in pts admitted for acute decompensated heart failure (ADHF). However, there is no information available on the long-term prognostic significance of the combination of FIB4 index and AKI in ADHF pts.

Methods and results

We studied 299 ADHF pts with survival discharge. FIB4 index was calculated by the formula: age (yrs) × AST[U/L]/(platelets [103/μL] × (ALT[U/L])1/2). AKI during ADHF treatment was defined according to AKI Network criteria (stage 1: mild, stage 2: moderate, stage 3: severe). During a follow-up period of 4.3±3.3 yrs, 94 pts died. At multivariate Cox analysis, FIB4 index and stage2/3 AKI, but not stage1 AKI, significantly associated with total mortality, independently of prior HF hospitalization and serum sodium and blood urea nitrogen levels after adjustment with BMI, systolic blood pressure, hemoglobin, serum creatinine and albumin levels, left ventricular end-diastolic and left atrial dimension indexes. Pts with both greater FIB4 index (&gt;2.674: median) and stage 2/3 AKI had a significantly higher risk of total mortality than those with none of them. Adjusted hazard ratio in pts with both greater FIB4 index and stage 2/3 AKI was 3.5 (95% CI 1.6–7.7), which was two-fold of that in pts with either of them (1.7 [95% CI 1.1–2.7]).

Conclusion

The combination of FIB4 index and moderate to severe AKI might identify higher risk subset for total mortality in ADHF pts.

P4512Impact of pulmonary artery catheter on all-cause death of patients with acute heart failure with preserved ejection fraction: Short-term results from the PURSUIT-HFpEF registry

Background

Appropriate pulmonary artery catheter (PAC) use may effectively decrease mortality in acute heart failure patients. The concept that the pulmonary artery catheter (PAC) is a valuable tool for hemodynamic monitoring when used in appropriately selected patients and by physicians trained well to interpret and apply the data correctly provided has not been evaluated adequately yet in acute heart failure patients with preserved ejection fraction (HFpEF).

Methods

The PERSUIT-HFpEF Registry is a prospective, observational, multicenter cohort study on prognosis of HFpEF in Japan. Patients hospitalized for heart failure (diagnosed by using Framingham criteria) who met both of the following criteria were enrolled: 1) a left ventricular ejection fraction of 50% or more as measured at the local site by echocardiography; 2) an elevated level of N terminal pro brain natriuretic peptide (NT proBNP) (400 pg per milliliter or more) or brain natriuretic peptide (BNP) (100 pg per milliliter or more). In the present study, we evaluated the impact of PAC on all-cause death of the patients with HFpEF. PAC use was left at the discretion of attending physicians.

Results

The PERSUIT-HFpEF Registry enrolled 486 patients (81±9 years, 259 females, mean follow-up duration 198±195 days). Of these, data of PAC usage was available in 434 patients. Patients were further stratified according to use of a PAC: PAC 153 patients vs. non-PAC 281 patients. Length of hospitalization was numerically shorter in the PAC group than in the non-PAC group [20.3±14.7 vs. 22.5±17.4 days, p=0.182]. Kaplan-Meier estimated 1-year all-cause death rate was significantly lower in the PAC group than in the non-PAC group (9.5% vs. 19.1%, p=0.019). PAC use was associated with significant risk reduction of all-cause death [hazard ratio (HR) 0.425, 95% confidence interval (CI), 0.203–0.890, p=0.023] in the crude analysis. The significant risk reduction still existed after multivariate adjustment including potential confounders [HR 0.427, 95% CI, 0.185–0.984, p=0.046]

Kaplan Meier analysis

Conclusions

In the real-world Asian registry data, PAC use was associated with the improved all-cause death rate, suggesting that the PAC might be a useful guidance tool for treatment of the patients with HFpEF.

Acknowledgement/Funding

Roche diagnostics FUJIFILM Toyama Chemical

P321A single factor related to left atrial pressure overload is useful for prognosis in elderly patients with heart failure with preserved ejection fraction: PURSUIT HFpEF study

Background

E/e' and the ratio of diastolic elastance (Ed)/arterial elastance (Ea) = (E/e')/(0.9 × systolic blood pressure), indices of left atrial (LA) pressure overload, are elevated in elderly women with heart failure with preserved ejection fraction (HFpEF). The severity of diastolic dysfunction is assessed by a combination of several indices of LA volume and pressure overload. However, which overload is more important as a single factor for the prognosis of these patients remains undefined.

Methods

We enrolled patients with HFpEF showing sinus rhythm (n=145; left ventricular ejection fraction >50%; men/women, 56/89; mean age, 80.5 years). Blood examination and transthoracic echocardiography were performed before discharge. All-cause mortality and admission for cardiac events were evaluated after more than 1 year (mean, 370 days).

Results

The all-cause mortality rate was 11% (16/145). There were significant differences in age (p=0.005), serum N-terminal pro-brain natriuretic peptide (NT-proBNP) level (p<0.001), LA volume index (p=0.018), E/e' (p=0.022), and Ed/Ea (p=0.016) between patients with and without all-cause mortality. When cutoff points for mortality by receiver operating characteristic curve analysis were examined, the area under the curve in LA volume index (0.564) was slightly smaller than that in age (0.734), NT-proBNP level (0.732), E/e' (0.695), and Ed/Ea (0.709). Kaplan-Meier survival analysis clearly showed that age >85 years (p<0.001), NT-proBNP level >888 pg/mL (p=0.003), E/e' >14.4 (p=0.020), and Ed/Ea >0.153 (p<0.001) were determinant factors for mortality. Cox hazard ratios were also significant in these indices (p=0.002, p=0.012, p=0.028, and p=0.001, respectively). In the case of all-cause mortality or admission for cardiac events, the results were nearly similar as those in the case of all-cause mortality. Ed/Ea exhibited a larger Cox hazard ratio for prognosis than E/e' in the multivariate analysis.

Conclusions

LA pressure overload compared to volume overload was a useful marker for prognosis in elderly patients with HFpEF. As a single index for LA pressure overload in noninvasive echocardiographic findings, Ed/Ea may be more suitable than E/e'.

P897Diagnostic utility of tissue biopsy in transthyretin cardiac amyloidosis diagnosed by non-invasive diagnostic criteria

Background

In the recent past, transthyretin cardiac amyloidosis (TTR-CA) is recognized as an important cause of heart failure with preserved ejection fraction, and diagnostic utility of 99mTc-pyrophosphate (99mTc-PYP) scintigraphy in TTR-CA has been established. However, pathological evaluation is still the basis to confirm diagnosis. Subcutaneous tissue and gastrointestinal tract biopsy are useful examinations alternative to endomyocardial biopsy. Nevertheless, the positive ratio of amyloid deposition in these organs is not fully evaluated based on recent non-invasive diagnostic criteria.

Purpose

Our aim was to evaluate the diagnostic sensitivity of tissue biopsy in TTR-CA patients diagnosed by 99mTc-PYP scintigraphy.

Methods

We retrospectively evaluated 124 consecutive TTR-CA patients [wild-type (ATTRwt): 90, hereditary (hATTR): 34] who were diagnosed by positive findings of 99mTc-PYP scintigraphy (visual score 2 or 3) between June 2002 and January 2019 at our institute.

Results

A total of 114 patients underwent tissue biopsy at least one organ. Amyloid was detected on Congo red staining of subcutaneous tissue (43/97: 44%), gastrointestinal tract (52/78: 67%) and heart (78/79: 99%), respectively. Among 70 patients who underwent both subcutaneous tissue and gastrointestinal tract biopsy, amyloid was detected at least one specimen in 57/70 (81%). Compared to hATTR CA patients, ATTRwt CA patients had lower positive ratio of subcutaneous tissue (81% vs. 27%) and gastrointestinal tract (73% vs. 63%) biopsy.

Conclusion

Non-invasive diagnostic criteria of TTR-CA had excellent sensitivity of amyloid deposition in heart. The diagnostic sensitivity of subcutaneous tissue and gastrointestinal tract biopsy was lower in ATTRwt CA compared to hATTR CA. Combination of subcutaneous tissue and gastrointestinal tract biopsy was useful for pathological confirmation of amyloid deposition without endomyocardial biopsy.

P762Usefulness of 2-year iodine-123 metaiodobenzylguanidine-based risk model for the post-discharge risk stratification in patients with acute decompensated heart failure

Background

A four-parameter risk model including cardiac iodine-123 metaiodobenzylguanidine (MIBG) imaging and readily available clinical parameters has been recently developed for the prediction of 2-year cardiac mortality risk in patients with chronic heart failure (CHF) using a Japanese CHF database consisting of 1322 patients. On the other hand, the Acute Decompensated Heart Failure National Registry (ADHERE) and Get With The Guidelines-Heart Failure (GWTG-HF) risk scores, simple tools to predict risk of in-hospital mortality, have been reported to be predictive of post-discharge outcome in patients with acute decompensated heart failure (ADHF). However, there is no information available on the usefulness of 2-year MIBG-based cardiac mortality risk score for the prediction of post-discharge prognosis in ADHF patients and its comparison with the ADHERE and GWTG-HF risk scores.

Purpose

We sought to validate the predictability of the 2-year MIBG-based cardiac mortality risk score for post-discharge clinical outcome in ADHF patients, and to compare its prognostic value with those of ADHERE and GWTG-HF risk scores.

Methods

We studied 297 consecutive patients who were admitted for ADHF, survived to discharge, and had definitive 2-year outcomes. Venous blood sampling was performed on admission, and echocardiography and cardiac MIBG imaging were performed just before discharge. In cardiac MIBG imaging, the cardiac MIBG heart-to-mediastinum ratio (HMR) was measured from the chest anterior view images obtained at 20 and 200 min after isotope injection. The 2-year cardiac mortality risk score was calculated using four parameters, including age, left ventricular ejection fraction, NYHA functional class, and HMR on delayed image. The patients were stratified into three groups based on the 2-year cardiac mortality risk score: low- (<4%), intermediate- (4–12%), and high-risk (>12%) groups. The ADHERE and GWTG-HF risk scores were also calculated from admission data as previously reported. The predictive ability of the scores was compared using receiver operating characteristic curve analysis. The endpoint was a composite of all-cause mortality and unplanned hospitalization for worsening heart failure.

Results

During a follow-up period, 110 patients reached the primary endpoint. There was significant difference in the rate of primary endpoint among the three groups stratified by 2-year cardiac mortality risk score (low-risk group: 18%, intermediate-risk group: 36%, high-risk group: 64%, Figure 1A). The 2-year cardiac mortality risk score demonstrated a greater area under the curve for the primary endpoint compared to the ADHERE and the GWTG-HF risk scores (Figure 1B).

Figure 1

Conclusions

The 2-year MIBG-based cardiac mortality risk score is also useful for the prediction of post-discharge clinical outcome in ADHF patients, and its prognostic value is superior to those of the ADHERE and the GWTG-HF risk scores.

P786Plasma volume status is associated with the change in nutritional status during hospitalization in acute decompensated heart failure patients with preserved left ventricular ejection fraction

Introduction

Plasma volume (PV) expansion has an essential role in heart failure (HF). PV can be estimated by a simple formula using hematocrit and body weight, and PV status (PVS) provides prognostic information in patients (pts) with chronic HF. Nutritional status (NS) based on the prognostic nutritional index (PNI) and NS change during hospitalization have been shown to predict prognosis in pts admitted with acute decompensated HF (ADHF).

Purpose

We sought to assess the hypothesis that PVS is associated with NS change during hospitalization in pts with HF with preserved LVEF (HFpEF) who are admitted with ADHF.

Methods

We prospectively studied 411 pts who were admitted for ADHF with LVEF ≥50% and survived to discharge. Body weight measurement and venous blood sampling were performed on admission and at discharge. PVS was defined as follows: actual PV = (1 − hematocrit) × [a + (b × body weight)] (a=1530 in males and a=864 in females, b=41.0 in males and b=47.9 in females); ideal PV = c × body weight (c=39 in males and c=40 in females); and PVS = [(actual PV − ideal PV)/ideal PV] × 100 (%). PNI was calculated as 10 × serum albumin (g/dL) + 0.005 × total lymphocyte count (per mm3). The pts were divided into 3 groups by PNI: normal (>38), moderate malnutrition (35–38), and severe malnutrition (<35). During admission, pts who remained in the moderate or severe malnutrition group or whose NS worsened were defined as no improvement in NS. Follow-up data was obtained in 203 cases. They were followed for up to 18 months, and the incidence of all-cause death was evaluated.

Results

On admission, PVS in the moderate (n=71, 13.3±13.9%) or severe malnutrition group (n=69, 14.8±10.8%) was significantly higher than in the normal PNI group (n=271, 5.4±10.8%, p<0.001). During hospitalization, 123 pts had no NS improvement. Admission PVS was significantly higher in pts with no NS improvement than in pts with improved NS (13.9±11.2% vs 5.9±12.8%, p<0.0001). In multivariate logistic regression analysis, admission PVS was independently associated with no NS improvement during hospitalization (OR 1.06, 95% CI 1.03–1.08, p<0.0001). Receiver operating characteristics curve analysis revealed that the optimal cut-off value of admission PVS for predicting no NS improvement was 9.4% (sensitivity: 72%, specificity: 63%). The area under the curve for predicting no NS improvement using admission PVS was significantly greater than for other independent factors (Figure 1A). During the follow-up period (median 12.4 months), 68 of 203 patients had all-cause death. Kaplan-Meier analysis showed that the patients with no NS improvement had a significantly higher risk of all-cause death (Figure 1B).

Figure 1

Conclusions

In this multicenter study, admission PVS was shown to be associated with poor improvement in NS during hospitalization in HFpEF pts admitted for ADHF.

Acknowledgement/Funding

Roche diagnostics, FUJIFILM Toyama Chemical

P4552The prognostic impact of worsening and improved renal function in acute decompensated heart failure with and without plasma volume expansion

Background

Recent studies showed that both worsening renal function (WRF) and improved renal function (IRF) during hospitalization are associated with poor prognosis in patients with acute decompensate heart failure (ADHF). On the other hand, plasma volume (PV) expansion plays an essential role in ADHF. However, there is little information about the difference of prognostic impact of WRF and IRF in ADHF patients, relating to PV status (PVS).

Methods

We prospectively studied 348 patients admitted for ADHF. PVS was defined as follows: actual PV = (1 - hematocrit) × [a + (b × body weight)] (a=1530 in males and a=864 in females, b=41.0 in males and b=47.9 in females); ideal PV = c × body weight (c=39 in males and c=40 in females); and PVS = [(actual PV - ideal PV)/ideal PV] × 100 (%). WRF and IRF were defined as an increase and a decrease in serum creatinine of ≥0.3 mg/dl from admission to discharge, respectively. The endpoint was readmission for worsening heart failure (WHF) within 1 year.

Result

Median PVS was 6.7% (IQR: −4.1%–16.7%). 43 and 21 patients had WHF in groups with high PVS (PVS ≥ median) and low PVS (PVS > median), respectively. In high PVS group, multivariate Cox analysis showed that IRF was independently and significantly associated with WHF (p=0.016, HR: 2.4 [1.2–4.8]), but WRF was not (p=0.55, HR: 0.7 [0.3–2.1]). On the other hand, in low PVS group, WRF was independently associated with WHF (p=0.035, HR: 3.0 [1.1–8.1]), but IRF was not (p=0.27, HR: 2.1 [0.6–8.0]). Kaplan-Meier analysis revealed that only patients with IRF had a significantly higher risk of WHF than those with stable renal function (SRF) in high PVS group, while patients with WRF had a significantly higher risk of WHF than those with SRF in low PVS group.

Worsening heart failure-free rate curves

Conclusion

In ADHF patients with PV expansion, IRF during hospitalization could predict poor outcomes, but WRF could not. On the other hand, in ADHF patients without PV expansion, not IRF but WRF could predict poor outcomes. PVS guided-therapy may be considered in secondary prevention for WHF.

P793Prediction of prognosis using combined objective nutritional score in the patients with acute decompensated heart failure

Background

It has been reported that the objective nutritional indices such as the Controlling Nutritional Status (CONUT) score, Geriatric Nutritional Risk Index (GNRI) and Prognostic Nutritional Index (PNI) are useful for the prediction of prognosis in patients with heart failure. However, there is no information available on the prognostic value of the combination of these objective nutritional indices in patients with acute decompensated heart failure (ADHF).

Purpose

We sought to assess the usefulness of the Combined Objective Nutritional Score for the prediction of post-discharge clinical outcome in ADHF patients.

Methods

We studied 361 consecutive patients who were admitted for ADHF and survived to discharge. Venous blood sampling, echocardiography, and measurement of body weight were performed just before discharge. CONUT score, GNRI and PNI were calculated as previously reported. We determined the Combined Objective Nutritional Score by assigning 1 point each for high CONUT score (2–12), low GNRI (≤98) or low PNI (≤38). Patients were followed-up for up to 5 years. The study endpoint was all-cause death.

Results

During a follow-up period of 2.4±1.3 years, 106 patients had all-cause death. Multivariate Cox analysis showed that the Combined Objective Nutritional Score was independently associated with all-cause death after adjustment for age, gender, history of coronary artery disease, left ventricular ejection fraction, brain natriuretic peptide level and estimate glomerular filtration rate (p<0.0001). When the patients were stratified into the three groups based on the Combined Objective Nutritional Score (normal nutritional status: 0 point, mild-to-moderate malnutrition: 1–2 points, severe malnutrition: 3 points), the incidence of all-cause death appeared to increase in relation to the Combined Objective Nutritional Score (normal: 0%, mild-to moderate: 23%, severe: 52%, p<0.0001, Figure). Patients with severe malnutrition showed 2.9 fold (95% CI 1.8–4.6) increase in the total mortality in comparison to patients with mild-to-moderate malnutrition.

Figure 1

Conclusion

This study showed that the Combined Objective Nutritional Score is a useful tool to risk stratify the patients hospitalized with ADHF.

P791Long-term prognostic value of pulmonary-systemic pressure ratio in patients admitted for acute decompensated heart failure with reduced or preserved left ventricular ejection fraction

Background

Concomitant presence of pulmonary hypertension in heart failure is associated with increased adverse events and may be related to interventricular uncoupling and impaired cardiac efficiency. It has recently been shown that an increased mean pulmonary artery pressure to mean systemic arterial pressure ratio (MPS ratio), a marker of interventricular coupling and efficiency, is associated with worse clinical outcomes in patients with advanced heart failure. However, there is little information available on the long-term prognostic value of MPS ratio in patients with acute decompensated heart failure (ADHF), relating to reduced or preserved left ventricular ejection fraction (HFrEF or HFpEF).

Methods and results

We studied 240 patients admitted for ADHF, who underwent right heart catheterization and were discharged with survival (HFrEF (LVEF≤40%); n=110, HFpEF (LVEF>40%); n=130). MPS ratio was obtained at the admission. During a mean follow-up period of 5.2±4.4 yrs, 59 patients had cardiovascular death (CVD). In both groups with HFrEF and HFpEF, MPS ratio was significantly greater in patients with than without CVD (HFrEF; 0.453±0.101 vs 0.382±0.116, p=0.0035, HFpEF; 0.374±0.118 vs 0.323±0.083, p=0.0091). At multivariate Cox regression analysis, MPS ratio was significantly associated with CVD, independently of eGFR and serum sodium level in HFrEF and HFpEF groups. Patients with high MPS ratio (>0.386 in HFrEF and >0.415 in HFpEF determined by ROC curve analysis) had a significantly increased risk of CVD than those with low MPS ratio in both groups.

Conclusions

MPS ratio could provide the long-term prognostic information in patients admitted for ADHF, regardless of reduced or preserved LVEF.

P5406Impact of the albumin level on the prognostic value of diuretic response in patients admitted for acute decompensated heart failure: a prospective study

Background

The reduced diuretic response (DR) has been shown to be associated with poor clinical outcome in patients with acute decompensated heart failure (ADHF). In addition, hypoalbuminemia, which is related to DR, has been also reported to predict poor prognosis in ADHF patients. However, there is no information available on the impact of albumin level on the prognostic value of DR in patients with ADHF.

Methods

We prospectively studied 296 consecutive patients who were admitted for ADHF and survived to discharge. The patients were divided into 2 groups according to the presence or absence of hypoalbuminemia at the admission, defined as the serum level of albumin at admission <3.5g/dl, and DR was defined as weight loss per 40mg intravenous dose and 80mg oral dose of furosemide up to day 4. The endpoint was a composite of all-cause mortality and unplanned hospitalization for worsening heart failure.

Results

There were 144 patients with hypoalbuminemia and 152 patients without hypoalbuminemia. During a mean follow-up period of 2.2±1.5 years, 88 patients with hypoalbuminemia and 53 patients without hypoalbuminemia reached the endpoint. In group with hypoalbuminemia, DR was significantly smaller in patients with than without the endpoint (0.85 [0.50–1.50] vs 1.60 [0.76–2.70] kg/40mg furosemide, p=0.003), while there was no significant difference in DR between them in group without hypoalbuminemia (1.17 [0.59–1.66] vs 1.07 [0.75–1.88] kg/40mg furosemide, p=0.381). At multivariate Cox analysis, in group with hypoalbuminemia, DR was significantly associated with the endpoint, independently of age, left ventricular ejection fraction, and serum creatinine and plasma BNP levels. On the other hand, in group without hypoalbuminemia, DR showed no significant association with the endpoint at univariate Cox analysis. Kaplan-Meier analysis showed that patients with poor DR (≤1.08 kg/40mg furosemide: median value) had a significantly higher risk of the endpoint in group with hypoalbuminemia, but not in group without hypoalbuminemia (Figure).

Figure 1

Conclusion

Our results suggested that prognostic value of DR in ADHF patients is affected by the presence or absence of hypoalbuminemia.

P6005Incidence and clinical characteristics of coronary artery spasm in patients with out-of-hospital cardiac arrest

Background

Substantial cases of out-of-hospital cardiac arrest (OHCA) due to acute coronary syndrome have been recognized thus far, but there have been few reports about the aetiology of patients with OHCA without the organic heart disease. Especially, coronary artery spasm would be one of the causes of OHCA.

Purpose

This study aimed to investigate causes of OHCA without the organic heart disease and to investigate the characteristics and angiographic findings of OHCA patients with vasospastic angina (VSA).

Methods

Between January 2010 and April 2018, 920 patients with OHCA caused by probable or definite cardiovascular disease were transferred to our hospital. Return of spontaneous contraction was successfully achieved in 151 patients, among whom diagnosis was made in 130 patients. First, we analysed the causes of OHCA in these patients. Second, we compared clinical and angiographic characteristics between the VSA group with OHCA (OHCA-VSA) and the VSA group without OHCA (stable VSA; n=72) from our database.

Results

Among the 130 patients, 95 (73%) had the organic heart disease; 72, acute coronary syndrome; 19, myocardial disease; 2, valvular heart disease; and 1, congenital heart disease. There were 35 patients (27%) without the organic heart disease. Nineteen patients had primary (i.e., Brugada syndrome, QT prolongation) or secondary arrhythmia (i.e. drug adverse effect). Electrocardiogram, coronary angiogram, and LV structure and function were normal in 35 patients. However, there were 16 patients (11%) with VSA defined by Japanese guideline. The OHCA-VSA group was significantly younger (50±14) than the stable VSA group (64±11, P=0.003). The incidence of diffuse-type spasm in the OHCA-VSA group (100%) was significantly higher than that in the stable VSA group (100% vs. 69%, P<0.05). In addition, the incidence of triple-vessel coronary spasm in the OHCA-VSA group was significantly higher than that in the stable VSA group (86% vs. 25%, P=0.003).

Conclusion

OHCA patients without the organic heart disease had considerable cases of VSA, in addition to primary or secondary arrhythmia. Furthermore, the severity of spasm in the OHCA-VSA group was more serious and extensive than in comparison with the stable VSA group.

P5409Plasma volume status provides the additional prognostic information to the Get With the Guidelines-Heart Failure risk score in acute decompensated heart failure patients

Background

The Get with The Guidelines (GWTG) heart failure (HF) risk score was developed in the GWTG inpatient HF registry to predict in-hospital mortality and also reported to be associated with post-discharge long-term outcomes. Plasma volume (PV) expansion plays an essential role in HF. Recently, it has been reported that PV is estimated by a simple formula based on hematocrit and body weight, not using radioisotope assays, and PV status provides prognostic information in patients (pts) with acute decompensated heart failure (ADHF). However, there is no information available on the long-term prognostic value of the combination of PV status and GWTG-HF risk score in pts admitted for ADHF.

Methods and results

We studied 301 ADHF pts discharged with survival. Variables required for the GWTG-HF risk score were race, age, systolic blood pressure, heart rate, serum levels of blood urea nitrogen and sodium, and the presence of chronic obstructive pulmonary disease. PV status was calculated as the following: Actual PV = (1 − hematocrit) x [a + (b x body weight)] (a=1530 in males and a=864 in females, b=41 in males and b=47.9 in females), Ideal PV = c x body weight (c=39 in males and c=40 in females), and PV status = [(actual PV − ideal PV)/ideal PV] x 100(%). During a follow-up period of 4.3±3.2 yrs, 95 pts had all-cause death (ACD). At multivariate Cox analysis, GWTG-HF risk score and PV status were significantly associated with the total mortality, independently of eGFR and the prior history of heart failure hospitalization, after the adjustment with serum albumin level and anemia. Pts with both high GWTG-HF risk score (≥39 by ROC analysis; AUC 0.655 [0.586–0.724]) and greater PV status (≥8.1% by ROC analysis; AUC 0.624 [0.566–0.692]) had a significantly higher risk of ACD than those with either or none of them (58% vs 30% vs 21%, p<0.0001, respectively).

Conclusion

PV status would provide the additional long-term prognostic information to GWTG-HF risk score in ADHF pts.

P6356Comparisons of clinical outcomes in patients with heart failure with preserved ejection fraction with and without atrial fibrillation: results from a multicenter PURSUIT-HFpEF registry

Background

The presence of atrial fibrillation (AF) has been demonstrated to be associated with poor clinical outcomes in heart failure patients with reduced ejection fraction.

Objective

This study aimed to elucidate the impact of the presence of atrial fibrillation (AF) on the clinical characteristics, therapeutics, and outcomes in patients with heart failure and preserved ejection fraction (HFpEF).

Methods

PURSUIT-HFpEF is a multicenter prospective observational study including patients hospitalized for acute heart failure with left ventricular ejection fraction of >50%. Patients with acute coronary syndrome or severe valvular disease were excluded.

Results

Of 486 HFpEF patients (age, 80.8±9.0 years old; male, 47%) from 24 cardiovascular centers, 199 (41%) had AF on admission. Patients with AF had lower systolic blood pressures (142±27 vs. 155±35mmHg, p<0.0001) and higher heart rates (91±29 vs. 82±26bpm, p<0.0001) than those without. There was no difference in the usage of inotropes or mechanical ventilation between the 2 groups. A higher quality of life score (EQ5D, 0.72±0.27 vs. 0.63±0.30, p=0.002) was observed at discharge in patients with than without AF. In addition, AF patients tended to demonstrate lower in-hospital mortality rates (0.5% vs. 2.4%, p=0.09) and shorter hospital stays (20.3±12.1 vs. 22.6±18.4 days, p=0.09) than those without. During a mean follow up of 360±111 days, mortality (14.1% vs. 15.3) and heart failure re-hospitalization rates (13.1% vs. 13.9%) were comparable between the 2 groups.

Conclusion

In contrast to heart failure patients with reduced ejection fraction, AF on admission was not associated with poor long-term clinical outcomes among HFpEF patients. Several in-hospital outcomes were better in patients with AF than in those without.

Acknowledgement/Funding

None

P4523Impact of comorbiditity on the predictive value of acute kidney injury in patients admitted for acute decompensated heart failure: a prospective study

Background

Comorbidities are associated with poor clinical outcome in patients with chronic heart failure, and acute kidney injury (AKI) also provides prognostic information in patients with heart failure. However, there is no information available on the impact of comorbidities on the prognostic value of AKI in patients admitted for acute decompensated heart failure (ADHF).

Methods

We prospectively studied 357 consecutive ADHF patients with survival discharge. Patients with hemodialysis were excluded. Comorbidity was measured with the Age-adjusted Charlson comorbidity index (ACCI) which is commonly used for the evaluation of the comorbid condition which is weighted and scored, with additional points added for age. AKI was defined as an absolute increase in serum creatinine of 0.3mg/dl or more during hospitalization. The endpoint was all-cause death (ACD).

Results

During a follow-up period of 2.2±1.4 years, 97 patients had ACD. At multivariate Cox analysis, ACCI (p<0.0001) and AKI (p=0.0061) were significantly and independently associated with ACD. Patients with high ACCI (≥5: determined by ROC analysis) had a significantly greater risk of ACD (39% vs 16%). In the subgroup of high ACCI, patients with AKI had a significantly higher risk of ACD (60% vs 35%), whereas there was no significant difference in the risk of ACD between with and without AKI (15% vs 16%) in the subgroup of low ACCI.

Conclusions

The presence of AKI was associated with the increased risk of mortality in ADHF patients with higher comorbidity burden but not in those without them.

P1649Prognostic significance of serum cholinesterase in patients with acute decompensated heart failure with preserved ejection fraction: insights from PURSUIT-HFpEF registry

Background

Comorbidities strongly influence the prognosis in heart failure with preserved ejection fraction (HFpEF). Malnutrition is one of the most important comorbidities among heart failure patients. Serum cholinesterase (CHE), one of the markers of malnutrition, was reported to be a prognostic factor in patients with chronic heart failure. In addition, we previously reported prognostic significance of CHE from a single center registry data of acute decompensated heart failure (ADHF). The aim of this study is to conduct external validation of the prognostic role of CHE using multi-center HFpEF registry.

Methods and results

Patients data were extracted from The Prospective mUlticenteR obServational stUdy of patIenTs with Heart Failure with Preserved Ejection Fraction (PURSUIT HFpEF) study. PURSUIT-HFpEF study is a prospective multicenter observational study in which collaborating hospitals in Osaka recorded clinical, echocardiographic, and outcome data of patients with ADHF and preserved ejection fraction. Between June 2016 and January 2018, 381 patients were enrolled and we excluded patients without sufficient laboratory data and in-hospital death. Finally, we analyzed 204 patients with survival discharge. Laboratory data including CHE and echocardiography were obtained just before discharge. The endpoint of this study is the composite of all-cause death and worsening heart failure re-admission (cardiac event). During a follow up period of 0.92±0.37 years, 49 patients had cardiac event. CHE was significantly lower in patients with than without cardiac event (183±67 vs 223±71 U/L, p<0.0001). At multivariate Cox analysis, CHE (p=0.0020) was significantly associated with cardiac event, independently of NT-pro BNP after adjustment of age, sex, eGFR and hemoglobin. ROC curve analysis showed that AUC of CHE for the prediction of cardiac event was 0.706 (95% CI 0.638–0.768). Kaplan-Meier analysis showed that patients with low CHE (<211U/L defined by median) had a significantly greater risk of cardiac event (35% vs 13% p=0.0002).

Figure 1

Conclusion

Serum cholinesterase level is the useful prognostic marker for the prediction of cardiac event in patients with ADHF with preserved ejection fraction.

Acknowledgement/Funding

Roche diagnostics, FUJIFILM Toyama Chemical

P795Long-term prognostic value of the combination of plasma volume status and pulmonary-systemic pressure ratio in patients admitted with acute decompensated heart failure

Background

Plasma volume (PV) expansion plays an essential role in heart failure and PV status provides prognostic information in patients (pts) with acute decompensated heart failure (ADHF). On the other hand, concomitant presence of pulmonary hypertension in heart failure is associated with increased adverse events and may be related to interventricular uncoupling and impaired cardiac efficiency. It has recently been shown that an increased mean pulmonary artery pressure to mean systemic arterial pressure ratio (MPS ratio), a marker of interventricular coupling and efficiency, is associated with worse clinical outcomes in patients with advanced heart failure. However, there is no information available on the long-term prognostic value of the combination of PV status and MPS ratio in pts admitted for ADHF.

Methods

We studied 248 pts admitted for ADHF, who underwent right heart catheterization at the admission and were discharged with survival. PV status and MPS ratio were obtained at the admission. PV status was calculated as the following: Actual PV = (1 − hematocrit) x [a + (b x body weight)] (a=1530 in males and a=864 in females, b=41 in males and b=47.9 in females), Ideal PV = c x body weight (c=39 in males and c=40 in females), and PV status = [(actual PV − ideal PV)/ideal PV] x 100(%). The study endpoint was cardiovascular death (CVD).

Results

During a mean follow-up period of 5.2±4.4 yrs, 62 pts had CVD. PV status (10.0±16.2 vs 5.0±15.3%, p=0.03) and MPS ratio (0.408±0.114 vs 0.347±0.102, p=0.0001) were significantly greater in patients with than without CVD. At multivariate Cox regression analysis, PV status and MPS ratio were significantly associated with CVD, independently of prior heart failure hospitalization, eGFR, and serum sodium level and anemia. Patients with greater PV status (> median value = 4.6%) and MPS ratio (> median value = 0.346) had a significantly higher CVD risk than those with either and none of them (44% vs 22% vs 14%, p<0.0001, respectively).

Conclusions

The combination of PV status and MPS ratio might be useful for stratifying patients at risk for CVD in patients with ADHF.