Insulin Suppresses Ubiquitination via the Deubiquitinating Enzyme Ubiquitin-Specific Protease 14, Independent of Proteasome Activity in H4IIEC3 Hepatocytes

Ubiquitin-proteasome dysfunction contributes to obesity-related metabolic disorders, such as diabetes and fatty liver disease. However, the regulation of ubiquitin-proteasome activity by insulin remains to be elucidated. Here, we show that prolonged insulin stimulation activates proteasome function even though it reduces the ubiquitinated proteins in H4IIEC3 hepatocytes. Looking for a pathway by which insulin inhibits ubiquitination, we found that hepatic expression of ubiquitin-specific protease 14 (USP14) was upregulated in the liver of patients with insulin resistance. Indeed, the USP14-specific inhibitor IU1 canceled the insulin-mediated reduction of ubiquitinated proteins. Furthermore, insulin-induced endoplasmic reticulum (ER) stress, which was canceled by IU1, suggesting that USP14 activity is involved in insulin-induced ER stress. Co-stimulation with insulin and IU1 for 2 hours upregulated the nuclear translocation of the lipogenic transcription factor, sterol regulatory element binding protein-1c (SREBP-1c), upregulated the expression of the lipogenic gene, fatty acid synthase (Fasn), and repressed the gluconeogenic genes. In conclusion, insulin activates proteasome function even though it inhibits protein ubiquitination by activating USP14 in hepatocytes. USP14 activation by insulin inhibits mature SREBP-1c while upregulating ER stress and the expression of genes involved in gluconeogenesis. Further understanding mechanisms underlying the USP14 activation and its pleiotropic effects may lead to therapeutic development for obesity-associated metabolic disorders, such as diabetes and fatty liver disease. SIGNIFICANCE STATEMENT: This study shows that insulin stimulation inhibits ubiquitination by activating USP14, independent of its effect on proteasome activity in hepatocytes. USP14 also downregulates the nuclear translocation of the lipogenic transcription factor SREBP-1c and upregulates the expression of genes involved in gluconeogenesis. Since USP14 is upregulated in the liver of insulin-resistant patients, understanding mechanisms underlying the USP14 activation and its pleiotropic effects will help develop treatments for metabolic disorders such as diabetes and fatty liver.

Analysis of microRNAs by the Stem-Loop Real-Time Quantitative Reverse Transcription Polymerase Chain Reaction Using A Double Quencher Probe

Introduction/Objective

We created a universal probe that can be used with mature micro RNAs (miRNAs) using a double quencher incorporating the ZEN quencher into the hydrolysis probe required for miRNA analysis by the real- time quantitative polymerase chain reaction (RT-qPCR) using a stem-loop primer. The main purpose of this approach was to improve sensitivity and convenience.

Methods/Case Report

We conducted studies on miR-21, miR-30a and miR-200c. To assess the relationship between the sequence interval and reactivity between the miRNA-specific sequence on the stem-loop primer and detection probe, various sequence patterns were examined using miRNA from K562 cells. The sensitivity and reactivity of the designed primers and probes were examined using each synthetic miRNA and transurethral resection of bladder tumor (TURBT) samples. The synthetic RNA was serially diluted in 10% increments. Twenty-seven TURBT cases were examined. The prepared samples were extracted with the FastGene RNA Basic Kit and FastGene miRNA Enhancer. After extraction, cDNA was prepared using FastGene Scriptase II. We performed quantitative analysis by the RT-qPCR using a ZEN double quencher probe. The samples were analyzed with the Taq Man miRNA assay.

Results (if a Case Study enter NA)

The probe and miRNA-specific sequences of the stem-loop primer showed better reactivity when the design contained less space within the sequences. Serial dilution of the samples using synthetic miRNA showed that linearity depended on the addition amount, and occurred at a concentration of log 7 or more. In the TURBT samples, the Δ of the mean Cp value, and the correlation coefficients of miR-21, miR-30a, and miR-200c, were 3.13 and 0.966; 1.10 and 0.991; and 0.39 and 0.997, respectively, compared with the TaqMan miRNA assay.

Conclusion

This demonstrates that our method has the same or higher sensitivity than the TaqMan miRNA assay. Overall, these findings suggest that the analysis of miRNA with a stem-loop primer using the double quencher probe is useful.

A myocardial extraction method using deep learning for 99mTc myocardial perfusion SPECT images: A basic study to reduce the effects of extra-myocardial activity

AIM

The purpose of this study was to automatically extract myocardial regions from transaxial single-photon emission computed tomography (SPECT) images using deep learning to reduce the effects of extracardiac activity, which has been problematic in cardiac nuclear imaging.

METHOD

Myocardial region extraction was performed using two deep neural network architectures, U-Net and U-Net ++, and 694 myocardial SPECT images manually labeled with myocardial regions were used as the training data. In addition, a multi-slice input method was introduced during the learning session while taking the relationships to adjacent slices into account. Accuracy was assessed using Dice coefficients at both the slice and pixel levels, and the most effective number of input slices was determined.

RESULTS

The Dice coefficient was 0.918 at the pixel level, and there were no false positives at the slice level using U-Net++ with 9 input slices.

CONCLUSION

The proposed system based on U-Net++ with multi-slice input provided highly accurate myocardial region extraction and reduced the effects of extracardiac activity in myocardial SPECT images.

Prognostic value of the combination of pulmonary-systemic pressure ratio and a new systemic inflammation-nutrition index in patients admitted for acute decompensated heart failure

Background

Concomitant presence of pulmonary hypertension in heart failure (HF) 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 HF. On the other hand, systemic inflammation plays a critical role in the outcomes of heart failure, and malnutrition is also associated with poor outcome in heart failure patients It has been recently reported that advanced lung cancer inflammation index (ALI), which is calculated as body mass index × serum albumin / neutrophil to lymphocyte ratio (NLR), is an independent prognostic marker in several types of cancer. However, there is no information available on the prognostic value of the combination of MPS ratio and ALI in patients with acute decompensated HF (ADHF).

Methods and results

We studied 219 patients admitted for ADHF, who underwent right heart catheterization at the admission and were discharged with survival. During a follow up period of 5.1±4.2 yrs, 57 had cardiovascular death (CVD). MPS ratio was significantly greater (0.401±0.107 vs 0.346±0.105, p=0.0009) and ALI was significantly smaller (34.2±18.7 vs 52.0±27.1, p<0.0001) in patients with than without CVD At multivariate Cox analysis, MPS ratio and ALIwere significantly associated with CVD, independently of eGFR and prior heart failure hospitalization, after the adjustment with left ventricular end-diastolic dimension and serum sodium level. The patients with both greater MPS ratio>0.350 (AUC 0.652 [0.569–0.735]) and smaller ALI <35.767 (AUC 0.714 [0.636–0.792]) had a significantly increased risk of CVD than those with either greater MPS or smaller ALI and none of them (67% vs 22% vs 11%, p<0.0001, respectively).

Conclusion

The combination of MPS ratio and ALI might be useful for stratifying ADHF patients at higher risk for CVD.

Funding Acknowledgement

Type of funding sources: None.

Prognostic value of sarcopenia and malnutrition in patients admitted for acute decompensated heart failure with reduced or preserved left ventricular ejection fraction

Background

Sarcopenia and malnutrition are associated with poor clinical outcome in patients with chronic heart failure. However, there is little information available on the prognostic significance of the combination of sarcopenia and malnutrition in patients with acute decompensated heart failure (ADHF), relating to reduced or preserved left ventricular ejection fraction (HFrEF or HFpEF).

Methods

We prospectively studied 543 consecutive ADHF patients who survived to discharge (HFrEF [LVEF <45%] n=245 and HFpEF [LVEF≥45%] n=298). At the discharge, sarcopenia and malnutrition was evaluated by free-fat mass index (FFMI) and geriatric nutrition risk index (GNRI), respectively. FFMI was calculated as follows: FFMI = (7.38 + 0.02908 × urinary creatinine [mg/day])/ (height in meter)2. Sarcopenia was defined as FFMI <17 kg/m2 in men and <15 kg/m2 in women. GNRI was calculated as follows: 14.89 × serum albumin (g/dl) + 41.7 × BMI/22, and malnutrition was defined as GNRI<92. The endpoint was all-cause death.

Results

During a follow-up period of 2.8±1.4 years, 161 patients had all-cause death. Multivariate Cox analysis showed that both FFMI and GNRI were independently associated with all-cause death in both HFrEF (p=0.0064 and p<0.0001, respectively) and HFpEF patients (p=0.0140 and p=0.0007, respectively) after adjustment for relevant baseline clinical and study characteristics. In HFrEF, patients with both sarcopenia and malnutrition had a significantly higher risk of the total mortality than those with either or none of them. On the other hand, in HFpEF, patients with both and either sarcopenia or malnutrition had a significantly higher risk of the total mortality than those with none of them, while there was no significant difference in the risk between both and either sarcopenia or malnutrition.

Conclusions

Sarcopenia or malnutrition at discharge was associated with all-cause death even in ADHF patients, irrespective of reduced or preserved LVEF. The combination of sarcopenia and malnutrition could provide prognostic information in ADHF patients with reduced LVEF.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Prognostic value of simple risk index and plasma volume status in patients with acute decompensated heart failure

Background

Increased heart rate (HR) and low systolic blood pressure (SBP) are associated with adverse clinical outcomes in patients admitted for acute decompensated heart failure (ADHF), and simple risk index (SRI) based on easily assessed clinical characteristics (age, HR, and SBP) provides prognostic information. On the other hand, plasma volume (PV) expansion plays an essential role in heart failure, and PV status is has been reported to be associated with adverse outcomes in ADHF patients. However, there is no information available on the value of the combination of SRI and PV status in patients admitted for ADHF.

Methods and results

We studied 301 patients admitted for ADHF. At the admission, SRI was calculated as (HR x [age/10]2)/SBP. 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 patients had all-cause death (ACD) and 68 patients had cardiovascular death (CVD). At multivariate Cox analysis, SRI and PV status were significantly associated with ACD and CVD, independently of the prior history of heart failure hospitalization and serum creatinine and sodium levels, after the adjustment with serum albumin level and anemia. Patients with both greater SRI (≥35.1 by ROC analysis; AUC 0.599 [0.524–0.674]) and greater PV status (≥8.1% by ROC analysis; AUC 0.625 [0.550–0.700]) had a significantly higher risk of ACD and CVD than those with either or none of them (ACD: 49% vs 27% vs 24%, p<0.0001, CVD: 39% vs 18% vs 15%, p<0.0001,respectively).

Conclusion

The combination of SRI and PV status might be useful for stratifying patients at risk for the total mortality and cardiovascular death in patients with ADHF.

Funding Acknowledgement

Type of funding sources: None.

The impact of substrate and trigger ablation for reduction of functional mitral regurgitation in patients with persistent atrial fibrillation

Background

Functional mitral regurgitation (FMR) is not uncommon in atrial fibrillation (AF) patients. Left atrial (LA) substrate remodeling and corresponding mitral valve annulus dilation has been reported as the most possible cause of FMR. Percutaneous catheter ablation (CA) is an effective treatment for AF. Although significant FMR could be improved by sinus restoration, patients with mitral regurgitation were more likely to experience recurrent AF post ablation, especially those with significant mitral regurgitation. There is no information available on the efficacy of CA for persistent AF in patients with FMR.

Purpose

The purpose of this study is to investigate the predictors of FMR improvement by CA and to determine the efficacy of substrate and trigger CA for persistent AF in patients with FMR.

Methods

We prospectively studied 512 consecutive patients admitted for persistent AF ablation from the EARNEST-PVI (Prospective Multicenter Randomized Study of Effect of Extensive Ablation on Recurrence in Patients with Persistent Atrial Fibrillation Treated with Pulmonary Vein Isolation) trial.

On admission, enrolled patients were randomly assigned in a 1:1 ratio to pulmonary vein isolation (PVI) or PVI-plus additional ablation (linear ablation or/and CFAE ablation). Of the 512 patients, we studied 94 patients with preoperative echocardiography showing moderate or greater baseline FMR. FMR grades were classified into 5 grades (0/1/2/3/4). The FMR improvement group (FMRI(+)) was defined as a case in which the FMR was improved by two or more grades compared the preoperative echocardiography and the one year follow-up examination.

Results

Of the 94 patients, 42 were in the PVI group and 52 were in the PVI-plus additional ablation group. There were 30 cases in the FMRI(+) group and 64 cases in the FMRI(−) group. There were no significant baseline differences in age, sinus rhythm maintenance, plasma B-type natriuretic peptide (BNP) level, left ventricular diastolic dimension, or left atrium dimension between the FMRI(+) and FMRI(−) groups. AF duration was significantly shorter in the FMRI(+) group than FMRI(−) groups (5.8±9.4 months vs 12.4±15.4 months, p<0.0001). In addition, significantly more additional ablation cases were observed in the FMRI(+) group than in the FMRI(−) group (73.3% vs 46.8%, p=0.016). In multivariate analyses, only additional ablation was an independent predictor of FMRI (odds ratio 0.226 95% CI 0.081–0.626; p=0.004).

Conclusions

Catheter ablation is a valid option for the treatment of AF in patients with functional MR and additional substrate and trigger ablation were the only independent predictor of FMR improvement.

Funding Acknowledgement

Type of funding sources: None.

Prognostic value of a new systemic inflammation-nutrition index in patients admitted with acute decompensated heart failure; a comparison with malnutrition

Background

Systemic inflammation plays a critical role in the outcomes of heart failure. Malnutrition is also associated with poor outcome in heart failure patients. It has been recently reported that advanced lung cancer inflammation index (ALI), which is calculated as body mass index × serum albumin / neutrophil to lymphocyte ratio (NLR), is an independent prognostic marker in several types of cancer. However, there is no information available on the prognostic impact of ALI in patients admitted with acute decompensated heart failure (ADHF), especially in comparison with malnutrition.

Methods and results

We studied 263 ADHF patients discharged with survival. At the discharge, we measured ALI. Malnutrition was assessed by prognostic nutritional index (PNI) and controlling nutritional status score (CONUT). During a follow up period of 5.1±4.3 yrs, 67 patients had cardiovascular death (CVD). ALI was significantly smaller in patients with than without CVD (32.5±18.2 vs 52.2±30.2, p<0.0001). At multivariate Cox regression analysis, ALI was significantly associated with CVD, independently of prior heart failure hospitalization, systolic blood pressure and eGFR, although PNI and CONUT showed the association with CVD at unvariate analysis. By receiver-operator curve analysis, AUC of ALI was 0.733 (0.664–0.803), which was significantly greater than that of PNI (0.664 [0.590–0.739]) and CONUT (0.591 [0.509–0.672]). Patients with lowest tertile of ALI (<32.0) had a increased risk of mortality than middle tertile (NLR=32.0–53.6; HR 2.06 [1.15–3.71]) and highest tertile (ALI>53.6: HR 5.80 [2.60–12.94]) (48% vs 21% vs 9%, p<0.0001, respectively).

Conclusion

ALI, a systemic inflammation-nutrition index, is more useful prognostic marker than malnutrition in patients admitted with ADHF.

Funding Acknowledgement

Type of funding sources: None.

Long-term prognostic value of the combination of malnutrition and fib-4 index in patients admitted with acute decompensated heart failure

Background

Malnutrition is associated with increased mortality risk in patients with acute decompensated heart failure (ADHF). Cardiohepatic interactions have been a focus of attention among heart failure. It was reported that liver stiffness assessed by non-invasive fibrosis marker such as Fibrosis-4 (FIB4) index provide prognostic information in ADHF patients. However, there is no information available on the long-term prognostic value of the combination of malnutrition and FIB4 index in patients admitted for ADHF.

Methods and results

We studied 294 patients admitted for ADHF, who were discharged with survival. Nutritional status was evaluated by Geriatric Nutritional Risk Index (GNRI) calculated as follows: 14.89 × serum albumin (g/dl) + 41.7 × BMI/22, and malnutrition was defined as GNRI <92. FIB4 index was calculated by the formula: age (yrs) × AST[U/L] / (platelets [103/μL] × (ALT[U/L])1/2), and abnormal FIB4 index was defined as >2.67. During a mean follow-up period of 4.3±3.3 yrs, 94 patients had all-cause death. At multivariate Cox regression analysis, GNRI and FIB4 index were significantly associated with the total mortality, independently of prior heart failure hospitalization, systolic blood pressure, and serum creatinine level. Patients with malnutrition and abnormal FIB4 index had a significantly higher risk of the total mortality than those with either and none of them (49% vs 32% vs 20%, p<0.0001, respectively).

Conclusions

The combination of malnutrition and FIB4 index might be useful for stratifying ADHF patients at higher risk for the total mortality.

Funding Acknowledgement

Type of funding sources: None.

Changing methods of education during a pandemic: questionnaire survey about examinations for nuclear medicine technology at educational institutions in Japan

Coronavirus disease 2019 (COVID-19) has spread around the world. Its effects go far beyond health care: education has to be conducted so as to prevent infection among students and faculty. Accordingly, changes have occurred in Japan’s educational institutions, including methods of preparing students for examinations for nuclear medicine. To assess the quality of training for radiologic technologists, we investigated the related changes undertaken at educational institutions. We investigated the lecture format for teaching nuclear medicine technology at Japanese institutions during COVID-19 and efforts to ensure the quality of conventional education. Methods: We sent a questionnaire to 19 Japanese institutions. It addressed the lecture format and initiatives in examinations for nuclear medicine technology in the first and second semesters of 2020. Results: We obtained responses from 17 institutions. In the first semester of 2020, the lecture format for nuclear medicine technology included remote, hybrid (combination of remote and face-to-face), and video-on-demand lectures. To reinforce the effect of the new teaching formats, institutions adopted various methods, such as enhancing the possibility of allowing students to ask questions, increasing the number of quizzes during lectures, delivering lectures to YouTube, and introducing an e-learning system. In the second semester of 2020, the lecture format included face-to-face, remote, hybrid, and video-on-demand lectures. In that second semester, the number of institutions providing face-to-face lectures while taking thorough measures against infection showed a marked increase. Conclusion: The institutions introduced various educational techniques and initiatives. They prioritized students’ understanding of lecture content and applied what they considered the best teaching methods. Sharing information about the changes adopted at different institutions should help promote good radiologic technologists—even during a pandemic.

[Validation of Simulation Codes for Nuclear Imaging Using Digital Phantoms]

Validation study of simulation codes was performed based on the measurement of a sphere phantom and the National Electrical Manufacturers Association (NEMA) body phantoms. SIMIND and Prominence Processor were used for the simulation. Both source and density maps were generated using the characteristics of ^99mTc energy. A full width at half maximum (FWHM) of the sphere phantom was measured and simulated. Simulated recovery coefficient and the background count coefficient of variation were also compared with the measured values in the body phantom study. When the two simulation codes were compared with actual measurements, maximum relative errors of FWHM values were 3.6% for Prominence Processor and -10.0% for SIMIND. The maximum relative errors of relative recovery coefficients exhibited 11.8% for Prominence Processor and -2.0% for SIMIND in the body phantom study. The coefficients of variation of the SPECT count in the background were significantly different among the measurement and two simulation codes. The simulated FWHM values and recovery coefficients paralleled measured results. However, the noise characteristic differed among actual measurements and two simulation codes in the background count statistics.

LECT2 as a hepatokine links liver steatosis to inflammation via activating tissue macrophages in NASH

It remains unclear how hepatic steatosis links to inflammation. Leukocyte cell-derived chemotaxin 2 (LECT2) is a hepatokine that senses fat in the liver and is upregulated prior to weight gain. The aim of this study was to investigate the significance of LECT2 in the development of nonalcoholic steatohepatitis (NASH). In human liver biopsy samples, elevated LECT2 mRNA levels were positively correlated with body mass index (BMI) and increased in patients who have steatosis and inflammation in the liver. LECT2 mRNA levels were also positively correlated with the mRNA levels of the inflammatory genes CCR2 and TLR4. In C57BL/6J mice fed with a high-fat diet, mRNA levels of the inflammatory cytokines Tnfa and Nos2 were significantly lower in Lect2 KO mice. In flow cytometry analyses, the number of M1-like macrophages and M1/M2 ratio were significantly lower in Lect2 KO mice than in WT mice. In KUP5, mouse kupffer cell line, LECT2 selectively enhanced the LPS-induced phosphorylation of JNK, but not that of ERK and p38. Consistently, LECT2 enhanced the LPS-induced phosphorylation of MKK4 and TAB2, upstream activators of JNK. Hepatic expression of LECT2 is upregulated in association with the inflammatory signature in human liver tissues. The elevation of LECT2 shifts liver residual macrophage to the M1-like phenotype, and contributes to the development of liver inflammation. These findings shed light on the hepatokine LECT2 as a potential therapeutic target that can dissociate liver steatosis from inflammation.

A prospective, randomized, comparison of the coronary vasomotion associated with drug-coated balloon versus drug-eluting stent

Background

It is widely known that even new-generation drug-eluting stent (DES) induce coronary vasomotion abnormality. On the other hand, recent studies reported that drug-coated balloon (DCB) for native coronary artery was non-inferior to DES in medium term outcomes. However, there is no available information about vasomotion after treatment with DCB.

Purpose

The aim of this study was to prospectively compare coronary vasomotion in patients treated with DCB versus new-generation DES.

Methods

Twenty-seven patients were randomly treated with angioplasty with DCB (n=12) versus implantation of bioabsorbable polymer everolimus-eluting stent (BP-EES, n=15) after successful predilation. At 8 months after treatment, endothelium-dependent and -independent vasomotion were evaluated by intracoronary infusion of incremental doses of acetylcholine (for right coronary artery: low-dose 5μg, high-dose 50μg and for left coronary artery: low-dose 10μg, high-dose 100μg) and nitroglycerine (200μg). Mean luminal diameter of the distal segments, beginning 5 mm and ending 15 mm distal to the edge of the treated segment was quantitatively measured by angiography.

Results

Clinical and procedural characteristics were not different between two groups. Vasoconstriction after acetylcholine infusion was less pronounced in the DCB group than the BP-EES group (low-dose: 4±13% vs −4±14%, p=0.158, high-dose: −2±14% vs −28±30%, p=0.013). The response to nitroglycerin was not different between two groups (17±13% vs 18±24%, p=0.838).

Conclusion

Vasoconstriction after acetylcholine infusion in the peri-treated region was more pronounced in the BP-EES group than in the DCB group, which suggests that endothelial function of coronary vessel treated by DCB can be more preserved than new-generation DES.

Figure 1

Funding Acknowledgement

Type of funding source: None

Predictors of silent cerebral infarction associated with catheter ablation for atrial fibrillation

Introduction

Cather ablation (CA) has been identified as an effective and safe treatment option for patients with atrial fibrillation (AF). One of the serious complications associated AF is cerebral infarction (CI). Recent studies reported that CA was associated with lower incidence of ischemic stroke in patients with AF. However, CA for AF itself has a potential risk of CI. Several previous studies showed that the incidence of silent CI (SCI) assessed by magnetic resonance imaging (MRI) of the brain occurred 5 to 18% during CA for AF. Recently, CA for AF made a remarkable progress in technology. However, there are few information available that the impact of 3-dimensional electroanatomical mapping system on the incidence of SCI. This study aimed to clarify the prevalence and predictors of SCI during CA for AF.

Methods

We enrolled 893 consecutive patients (male 534, age 71±10 years), who underwent CA for AF and MRI of brain 1 day after the procedure. We collected patients data such as physical examinations, blood sampling, echo cardiography, and CA data. A brain MRI was performed the next day following the procedure to identify any CIs. One-hundred and forty-six of patients used the Rhythmia® mapping system catheter, and the other mapping system such as CARTO or EnSite system used in the remaining 747 patients.

Results

The MRI depicted acute micro-CIs in 144 (16%) patients, but neither symptoms nor abnormal neurological findings were present in these patients. Patients with SCI had significantly higher prevalence of persistent AF (60 vs 43%, p=0.0002), CHADS2 Score (2 (1–3) vs 1 (1–2), p=0.0001), higher prevalence of previous stroke (19 vs 12%, p=0.02), larger left atrial (LA) diameter (43.2±6.4 vs 41.7±6.5mm, p=0.01), lower left ventricular ejection fraction (LVEF) (59.0±13.2 vs 64.2±11.3%, p≤0.0001), higher B-type natriuretic peptide level (221±236 vs 163±225 pg/dl, p≤0.0001), more Rhythmia® mapping system use (30 vs 8%, p<0.0001), and longer procedure time (129±46 vs 108±39 min, p≤0.0001) than those without SCI, while there were no significant differences in age, LA appendage flow velocity, kind of anti-coagulant agent between the two groups. Multivariate regression analysis identified Rhythmia® use [odds ratio (OR) 4.26, (95% CI 2.32–7.84), p=0.0001], LVEF (OR 1.02, p=0.0059), CHADS2 score (OR 1.27, p=0.009), and procedure time (OR 1.005, p=0.04) as independent risk factors of acute SCI during CA for AF.

Conclusion

Acute SCI occurred about 16% after CA for AF. Rhythmia® mapping system use exhibited a higher incidence of acute SCI after catheter ablation for AF than the other mapping system use. Rhythmia® mapping system use, LVEF, CHADS2 score, and procedure time are associated with SCI relating CA for AF.

Funding Acknowledgement

Type of funding source: None

Impact of simple nutrition index on the long-term mortality of acute decompensated heart failure patients with preserved left ventricular ejection fraction: insight from PURSUIT-HFpEF registry

Background

The novel nutrition index; triglyceride (TG) × total cholesterol (TG) × body weight (BW) index (TCBI) has been reported to be an easy and useful predictor for patients with coronary artery disease. However, there is no information available on the prognostic value of TCBI in patients with heart failure with preserved LVEF (HFpEF) who admitted with acute decompensated heart failure (ADHF).

Methods and results

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 recorded clinical, echocardiographic, and outcome data of ADHF pts with HFpEF. We enrolled consecutive 757 HFpEF patients who admitted with ADHF from June 2016 to June 2019. TCBI was calculated by the formula; TG × TC × BW / 1000 at the discharge. After we excluded patients with in-hospital death or without sufficient data, we analyzed 419 patients. The primary endpoint was all-cause mortality. During a median follow up period of 1.1 (0.9–1.9) years, 59 patients died. ROC analysis revealed that TCBI at discharge was a fair discriminator for predicting all-cause mortality (AUC 0.676, sensitivity 53%, specificity 78%). Multivariate Cox proportional analysis showed that TCBI (p=0.002) was an independent predictor for all cause death after adjustment with major confounders such as age, gender, NT-proBNP, hemoglobin and serum creatinine level. We divided patients into 4 groups according to quartiles of TCBI. Kaplan-Meier analysis showed a significantly higher risk of all-cause death in relation to the decrease in TCBI.

Conclusion

TCBI, a simple and novel nutrition index, is a useful and strong long-term prognostic indicator in ADHF patients with HFpEF.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Roche Diagnositics K.K.; Fuji Film Toyoma Chemical Co. Ltd.

Effect of empagliflozin as add-on therapy on transtubular potassium concentration gradient in patients with type 2 diabetes hospitalized for acute decompensated heart failure

Background

The transtubular potassium concentration gradient (TTKG) has been reported to be a marker of renal aldosterone bioactivity, and has been shown to be a surrogate of arterial underfilling in patients with acute decompensated heart failure (ADHF). Moreover, high TTKG at discharge has been shown to be associated with poor prognosis in ADHF patients. Empagliflozin, one of the sodium glucose cotransporter 2 inhibitors, has been shown to reduce the risk of cardiovascular mortality in patients with type 2 diabetes mellitus (T2D) and cardiovascular disease. However, little is known about the effect of empagliflozin as add-on therapy on TTKG in T2D patients with ADHF.

Purpose

We sought to elucidate the effect of empagliflozin as add-on therapy on TTKG in T2D patients with ADHF.

Methods

We enrolled 58 consecutive T2D patients admitted for ADHF. On admission, enrolled patients were randomly assigned in a 1:1 ratio to either empagliflozin add-on therapy (EMPA(+)) or conventional glucose-lowering therapy (EMPA(−)). All patients in EMPA(+) group received empagliflozin (10 mg/day) throughout the study period. Left ventricular ejection fraction (LVEF) was measured at baseline using echocardiography. Body weight and vital signs, such as blood pressure and heart rate, were measured, and blood and urine samples were collected at baseline and 1, 2, 3 and 7 days after randomization. The TTKG was measured using the first morning urine samples collected on each day. TTKG was calculated according to the following equation: TTKG = (Ku/Ks)×(plasma osmolality/urine osmolality), where Ku is urine potassium concentration and Ks is serum potassium concentration, as previously reported.

Results

Thirty patients were assigned to the EMPA(+) group, and 28 patients were assigned to the EMPA(−) group. There were no significant baseline differences in LVEF, plasma B-type natriuretic peptide (BNP) level, body mass index, or serum creatinine level between the EMPA(+) and EMPA(−) groups. TTKG did not significantly differ between the two groups at baseline. However, seven days after randomization, plasma BNP level was significantly lower in the EMPA(+) group than in the EMPA(−) group (median 227 [IQR 114–381] pg/mL vs 362 [227–554] pg/mL, p=0.0294). Furthermore, TTKG of the EMPA(+) group was significantly lower at 2, 3 and 7 days after randomization (Figure).

Conclusions

This study demonstrated that empagliflozin as add-on therapy can lower TTKG in T2D patients with ADHF.

Figure 1

Funding Acknowledgement

Type of funding source: None

Role of diuretics on long-term mortality may differ in volume status in patients with acute myocardial infarction

Background

Diuretics has been reported to have a potential for an activation of the renin-angiotensin-aldosterone system and the sympathetic nervous system, leading to a possibility of poor clinical outcome in patients with cardiovascular disease. However, few data are available on clinical impact of diuretics on long-term outcome in patients with acute myocardial infarction (AMI) based on plasma volume status.

Methods

To address the issue, a total of 3,416 survived patients with AMI who were registered to a large database of the Osaka Acute Coronary Insufficiency Study (OACIS) were studied. Plasma volume status was assessed with the estimated plasma volume status (ePVS) that was calculated at discharge 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 ePVS = [(actual PV − ideal PV)/ideal PV] × 100 (%). Multivariable Cox regression analysis and propensity score matching were performed to account for imbalances in covariates. The endpoint was all-cause of death (ACD) within 5 years.

Results

During a median follow-up period of 855±656 days, 193 patients had ACD. In whole population, there was no significant difference in long-term mortality risk between patients with and without diuretics in both multivariate cox regression model and propensity score matching population. When patients were divided into 2 groups according to ePVS with a median value of 4.2%, 46 and 147 patients had ACD in groups with low ePVS and high ePVS, respectively. Multivariate Cox analysis showed that use of diuretics was independently associated with an increased risk of ACD in low ePVS group, (HR: 2.63, 95% confidence interval [CI]: 1.22–5.63, p=0.01), but not in high ePVS group (HR: 0.70, 95% CI: 0.44–1.10, p=0.12). These observations were consistent in the propensity-score matched cohorts; the 5-year mortality rate was significantly higher in patients with diuretics than those without among low ePVS group (4.7% vs 1.7%, p=0.041), but not among high ePVS group (8.0% vs 10.3%, p=0.247).

Conclusion

Prescription of diuretics at discharge was associated with increased risk of 5-year mortality in patients with AMI without PV expansion, but not with PV expansion. The role of diuretics on long-term mortality may differ in plasma volume status. Therefore, prescription of diuretics after AMI may be considered based on plasma volume status.

Funding Acknowledgement

Type of funding source: None

Comparative prognostic impact of ACCI and AHEAD risk score in heart failure with reduced, mid-range and preserved left ventricular ejection fraction admitted for acute decompensated heart failure

Background

Comorbidities are strongly associated with poor clinical outcome in heart failure patients (pts). The Age-adjusted Charlson comorbidity index (ACCI), which is well-known widely used comorbidity index, recently has been used as a robust prognostic model in heart failure pts. On the other hand, AHEAD risk score has been recently reported as a useful long-term risk stratification score in acute decompensated heart failure (ADHF) pts. Recently, a new group of heart failure pts with mid-range ejection fraction (HFmrEF) has been defined, separated from reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF). We sought to compare the prognostic value of ACCI and AHEAD score in ADHF pts, relating to HFrEF, HFmrEF and HFpEF.

Methods

We prospectively studied 410 consecutive ADHF pts (HFrEF [n=143], HFmrEF [n=99] and HFpEF [n=168]) with survival discharge. ACCI contains 19 issues which was weighted according to their potential influence on mortality. AHEAD risk score is a simple index, which is 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. The endpoint of this study was all cause death (ACD).

Results

During a follow-up period of 2.4±1.4 years, 119 pts had ACD (42, 29 and 48 pts in HFrEF, HFmrEF and HFpEF, respectively). At univariate Cox analysis, ACCI and AHEAD risk score were significantly associated with ACD in each subgroup. At multivariate Cox analysis, in HFrEF pts, ACCI, but not AHEAD risk score, showed the significant and independent association with ACD. In HFmrEF, both ACCI and AHEAD risk score was significantly and independently associated with ACD and ROC analysis showed AUC of ACCI was greater than that of AHEAD risk score (0.778 [0.683–0.855] vs 0.637 [0.572–0.764], p=0.07). On the other hand, in HFpEF pts, AHEAD risk score, but not ACCI, showed the significant and independent association ACD.

Conclusion

ACCI provides more prognostic value in HFrEF pts, and AHEAD risk score has more prognostic value in HFpEF pts. In HFmrEF pts, both ACCI and AHEAD score might have prognostic values, although ACCI tends to be more associated with ACD than AHEAD score.

Funding Acknowledgement

Type of funding source: None

Prognostic significance of cardiac 123I-MIBG SPECT imaging in patients with acute decompensated heart failure with preserved left ventricular ejection fraction

Background

Cardiac sympathetic nerve dysfunction, which is assessed by I-123 metaiodobenzylguanidine (MIBG) imaging, is associated with the poor outcomes in patients with heart failure (HF). Most of the literature on the use of 123I-MIBG imaging is based on planar images in patients with chronic HF and reduced left ventricular ejection fraction (HFrEF), because It is technically challenging to conduct precise 123I-MIBG SPECT analysis in globally denervated heart, which is frequently observed in HFrEF patients. There was no information available on cardiac sympathetic nerve dysfunction evaluated by cardiac MIBG SPECT imaging in acute decompensated HF (ADHF) patients with preserved left ventricular ejection fraction (HFpEF).

Purpose

We aimed to clarify the prognostic significance of 123I-MIBG SPECT myocardial imaging in ADHF patients with HFpEF.

Methods

We enrolled 183 patients who were admitted for ADHF with HFpEF, discharged with survival. All patients underwent cardiac MIBG imaging at the timing of discharge. The cardiac MIBG heart to mediastinum ratio (H/M) was calculated on the early image and the delayed image (late H/M). We studied 156 patients after excluding 27 patients whose MIBG SPECT reconstruction was difficult due to too low MIBG uptake or extracardiac accumulation interference. SPECT analysis on the delayed image was conducted by using CardioBull, a fully automated software for the quantification of I-123 MIBG SPECT. All of 17 regional tracer uptake were compared with normal control database. A scoring algorithm for the evaluation of low uptake employs a 5-point scoring system as 0–4 for normal, mildly abnormal, moderately abnormal, severe abnormal, and perfusion defect, respectively. The summed severity (SSS) scores were obtained by summing the score for all segments. SSS could range from 0 to 68. The endpoint of this study is cardiac events defined as the composite of unplanned heart failure hospitalization and cardiac death.

Results

During a mean follow up period of 2.4±1.6 years, 60 patients reached cardiac events. SSS was significantly high in patients with than without cardiac events (20 [10–27] vs 7 [4–16], p<0.0001). SSS (p<0.0001) was significantly associated with cardiac events after multivariable Cox adjustment of age, sex, creatinine and log-transformed BNP level, although late H/M showed the significant association with the endpoint at the univariate Cox analysis. Kaplan-Meier analysis showed that patients with high SSS (>10, defined by median) had significantly greater risk of cardiac event (56% vs 21%, Hazard ratio: 3.56 (2.00–6.33, p<0.0001). ROC curve analysis showed that area under the curve (AUC) of SSS was 0.746 [95% CI:0.670, 0.812], which was significantly higher than that of late H/M (0.618 [95% CI:0.537, 0.695]) (p=0.0159).

Conclusion

Cardiac MIBG SPECT imaging was useful for risk stratification in ADHF patients with HFpEF.

Funding Acknowledgement

Type of funding source: None

Impact of comorbidity on the predictive value of cystatin-C in patients admitted for acute decompensated heart failure: insights from a prospective study

Background

Comorbidities are strongly associated with poor clinical outcome in heart failure patients. The Age-adjusted Charlson comorbidity index (ACCI), which is well-known widely used comorbidity index, recently has been used as a robust prognostic model in heart failure patients. On the other hand, Cystatin C, as a novel and important biomarker of renal function, has been recently reported as a useful long-term risk stratification score in heart failure patients. However, there is no information available on the impact of comorbidities on the prognostic value of cystatin-C in patients admitted for acute decompensated heart failure (ADHF).

Methods

We prospectively studied 458 consecutive ADHF patients with survival discharge. Patients with hemodialysis were excluded. Echocardiography and venous blood sampling were performed just before discharge and serum cystatin-C level was measured. Comorbidity was measured with the Age-adjusted Charlson comorbidity index (ACCI). ACCI was commonly used for the evaluation of the comorbid condition which is weighted and scored, with additional points added for age. The endpoint was all-cause death (ACD).

Results

During a follow-up period of 2.8±1.5 years, 132 patients had ACD. At multivariate Cox analysis, ACCI (p=0.0015) and cystatin-C level (p=0.0145) were significantly and independently associated with ACD. Patients with high ACCI (≥6: determined by ROC analysis) had a significantly greater risk of ACD (37.2% vs 17.8%, p<0.0001, HR 2.45 [1.61–3.70]). In the subgroup of higher ACCI, patients with higher cystatin-C level (≥1.56: determined by ROC analysis) had a significantly higher risk of ACD (50.3% vs 23.4%). Furthermore, in the subgroup of lower ACCI, patients with higher cystatin-C level had also significantly higher risk of ACD (34.2% vs 12.1%).

Conclusions

The prognostic value of cystatin-C is not affected by comorbidities and cystatin-C provide prognostic information even in patients admitted for ADHF, irrespective of comorbid burden.

All-cause death-free rate in ADHF pts

Funding Acknowledgement

Type of funding source: None

Prognostic value of nutritional status in patients with heart failure with preserved ejection fraction, with and without atrial fibrillation: insights From PURSUIT-HFpEF Registry

Background

Malnutrition is one of the most important comorbidities among heart failure (HF) patients, and serum cholinesterase (CHE) has been reported to be a prognostic factor in HF patients. On the other hand, atrial fibrillation (AF) is frequently observed in patients with HF with preserved ejection fraction (HFpEF). However, there is little information available on the prognostic value of nutritional status in HFpEF patients, with and without AF. We sought to clarify the prognostic value of CHE in HFpEF with and without AF and compare it with that of other nutrition indices such as gastric nutritional risk index (GNRI), controlling nutritional status (CONUT), and the prognostic nutritional index (PNI).

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, which is a prospective multicenter observational registry for acute decompensated heart failure patients with left ventricular ejection fraction ≥50% in Osaka. We analyzed 380 patients (median age: 80 [75–87] years, male: 46%) after exclusion of patients with in-hospital death, missing follow-up data, or missing data to calculate nutritional indices. On admission, 155 patients had AF. Laboratory data were obtained at discharge. During a mean follow up period of 1.1±0.6 years, 131 patients had a composite endpoint (CE) of all-cause death and hospitalization for worsening heart failure or cerebrovascular disorder. In multivariate Cox analysis, in patients with AF, CHE was significantly associated with CE independently of age, gender and body mass index after the adjustment with serum albumin, total cholesterol levels and total lymphocyte count, while it was not significantly associated with CE in patients without AF. C-index of CHE (0.708) was higher than that of GNRI (0.555, p=0.0028), CONUT (0.651, p=0.208) and PNI (0.635, p=0.208) in AF patients, while there were no significant differences in those nutritional indices in patients without AF. Kaplan-Meier curve analysis revealed that AF patients with lower CHE (<208 U/L = median value) had higher risk of CE than those with higher CHE (44% vs 18%, adjusted HR 3.26 95% CI [1.66–6.67], p=0.0005), while there was no significant difference in the occurrence rate of CE between patients with and without higher CHE in non-AF group (42% vs 31%, adjusted HR 1.28 95% CI [0.78–2.13], p=0.33).

Conclusions

Prognostic value of CHE would be stronger than other nutritional indices in HFpEF patients with AF, while it would be weak in HFpEF patients without AF.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Roche Diagnostics K.K.; Fuji Film Toyama Chemical Co. Ltd.

Long-term serial changes of cardiac sympathetic nerve dysfunction in acute decompensated heart failure patients with reduced, mid-range and preserved left ventricular ejection fraction

Background

Cardiac sympathetic nerve dysfunction, which is assessed by I-123 metaiodobenzylguanidine (MIBG) imaging, is associated with the poor outcomes in patients with chronic heart failure (CHF). Serial evaluation of cardiac MIBG imaging was shown to be useful for predicting adverse outcome in CHF. However, there was no information available on long-term serial changes of cardiac sympathetic nerve dysfunction after discharge of acute decompensated heart failure (ADHF) hospitalization.

Purpose

We aimed to clarify the serial change of cardiac MIBG imaging parameter in long-term after discharge of heart failure hospitalization, especially relating to HFrEF (LVEF<40%), HFmrEF (40%≤LVEF<50%) and HFpEF (LVEF≥50%).

Methods

We studied 112 patients (HFrEF; n=44, HFmrEF; n=23 and HFpEF; n=45) who were admitted for ADHF, discharged with survival and without heart failure hospitalization during follow-up period. All patients underwent cardiac MIBG imaging at the timing of discharge, in 6–12 months and in 18–24 months after discharge. The cardiac MIBG heart to mediastinum ratio (H/M) was calculated on the early image and the delayed image (late H/M). The cardiac MIBG washout rate (WR) was calculated from the early and delayed planar images after taking radioactive decay of I-123 into consideration.

Results

In HFrEF patients, late H/M was significantly improved from discharge to 6–12 months data (1.60±0.24 vs 1.75±0.31, p<0.0001). Late H/M of HFmrEF patients was also significantly improved from discharge to 18–24 months data (1.71±0.27 vs 1.84±0.29 p=0.043). On the other hand, late H/M of HFpEF patients was not significantly changed. As for WR, WR in HFrEF and HFmrEF patients was significantly improved from discharge to 18–24 months data, although WR of HFpEF was not significantly changed.

Conclusion

The improvement in cardiac sympathetic nerve dysfunction was observed in patients with HFrEF and HFmrEF, not in HFpEF, after the discharge of acute heart failure hospitalization.

Funding Acknowledgement

Type of funding source: None

Long-term prognostic value of the combination of malnutrition and pulmonary-systemic pressure ratio in patients admitted with acute decompensated heart failure

Background

Malnutrition is associated with increased mortality risk 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 malnutrition and MPS ratio in pts admitted for ADHF.

Methods and results

We studied 248 pts admitted for ADHF, who underwent right heart catheterization at the admission and were discharged with survival. Malnutrition was assessed by geriatric nutritional risk index (GNRI), prognostic nutritional index (PNI) and controlling nutritional status score (CONUT). During a mean follow-up period of 5.2±4.4 yrs, 62 pts had cardiovascular death (CVD). MPS ratio was significantly greater in pts with than without CVD (0.408±0.114 vs 0.347±0.102, p=0.0001). GNRI and PNI were significantly lower, CONUT was significantly greater in pts with than without CVD. At multivariate Cox regression analysis, GNRI and MPS ratio were significantly associated with CVD, independently of prior heart failure hospitalization, eGFR, and serum sodium level and anemia, although PNI and CONUT showed the association with CVD at unvariate analysis. Pts with malnutrition (GNRI≤median value=96.5) and greater MPS ratio (≥median value=0.346) had a significantly higher CVD risk than those with either and none of them (51% vs 20% vs 12%, p<0.0001, respectively).

Conclusions

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

Funding Acknowledgement

Type of funding source: None

Plasma half-life and tissue distribution of leukocyte cell-derived chemotaxin 2 in mice

Leukocyte cell-derived chemotaxin 2 (LECT2) is a hepatokine that causes skeletal muscle insulin resistance. The circulating levels of LECT2 are a possible biomarker that can predict weight cycling because they reflect liver fat and precede the onset of weight loss or gain. Herein, to clarify the dynamics of this rapid change in serum LECT2 levels, we investigated the in vivo kinetics of LECT2, including its plasma half-life and tissue distribution, by injecting ¹²⁵I-labelled LECT2 into ICR mice and radioactivity tracing. The injected LECT2 was eliminated from the bloodstream within 10 min (approximate half-life, 5 min). In the kidneys, the radioactivity accumulated within 10 min after injection and declined thereafter. Conversely, the radioactivity in urine increased after 30 min of injection, indicating that LECT2 is mainly excreted by the kidneys into the urine. Finally, LECT2 accumulated in the skeletal muscle and liver until 30 min and 2 min after injection, respectively. LECT2 accumulation was not observed in the adipose tissue. These findings are in agreement with LECT2 action on the skeletal muscle. The present study indicates that LECT2 is a rapid-turnover protein, which renders the circulating level of LECT2 a useful rapid-response biomarker to predict body weight alterations.

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.

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.

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.

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.

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.

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.

P842Calculated plasma volume status provides additional prognostic value to global registry of acute coronary event (GRACE) score in patients with acute myocardial infarction

Background

Plasma volume status (PVS) has been shown to be a well-validated prognostic indicator which relate to morbidity and mortality in heart failure. However, it remains unclear whether PVS would have the prognostic significance in patients with acute myocardial infarction (AMI). Global Registry of Acute Coronary Events (GRACE) risk score is a powerful predictor of prognosis after acute coronary event, but there is no information available on the additional prognostic value of PVS to GRACE in AMI patients.

Methods

We retrospectively studied 3930 AMI patients. GRACE score and PVS was obtained on the admission. PVS was calculated 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 (%). The endpoint was All cause of death (ACD) within 5 years.

Results

During a mean follow-up period of 2.4±1.9 years, 406 patients had ACD. PVS was significantly greater in patients with ACD than without ACD (8.1±14.9% vs −1.7±13.3%, p<0.001). Each 5% increase in PVS was linked to a 27% estimated risk of 5-year mortality (p<0.001, HR: 1.05 [1.03–1.08]). PVS was still independently associated with ACD, after adjustment with GRACE score as a potential confounding factor. Kaplan-Meier analysis revealed that patients with PV expansion (PVS>0%) were significantly higher risk of ACD than those without PV expansion in patients both with high risk in GRACE score (>140) (28% (225/803) vs 19% (78/412), p=0.01, HR: 7.5) and with low risk in GRACE score (≤140) (6% (52/894) vs 3% (51/1821), p=0.009, HR: 6.2).

Survival rate curves

Conclusion

PVS, which represents intravascular compartment and congestion, could identify poor prognosis in patients with AMI. In addition, PVS would provide additional prognostic information to GRACE score.

P1031The impact of the duration of atrial fibrillation persistence for arrhythmia free survival in patients undergoing catheter ablation

Background

Catheter ablation (CA) for atrial fibrillation (AF) is a curable treatment option. However, AF recurrence after CA remains an important problem. Although the success rate has been improved after catheter ablation (CA) in patients with paroxysmal AF (PAF), outcome data after CA for persistent AF (PeAF) are highly variable. Previous studies showed the PeAF is one of independent predictors for AF recurrence in comparison to PAF. However, there are little information available on the prognostic significance of AF duration after CA for AF. The aim of this study is to evaluate the impact of AF duration on long-term outcomes of AF ablation in patients with PeAF compared with PAF.

Methods

We enrolled 778 consecutive patients, who were referred our institution between August 2015 and December 2017 for undergoing the first time CA for AF. We divided 5 groups (Group 1; PAF (n=442), Group 2; PeAF duration ≤6 months (n=198), Group 3; PeAF duration of 6 months to 2 years (n=87), Group 4; PeAF duration of 2–5 years (n=30) and Group 5; PeAF duration ≥5 years (n=21)). All patients followed up for at least 1 year. Outcome data on recurrence of AF after ablation were collected.

Results

There were no significant differences in baseline clinical characteristics before CA among 5 groups, except for the prevalence of congestive heart failure, left atrial diameter and left ventricular ejection fraction. During a mean follow-up period of 511±298 days, 217 patients had AF recurrence. Kaplan-Meier analysis revealed that AF recurrence was significantly higher in group 2 compared to group 1 (31% vs 20%, p=0.002) and in group 4 compared to group 3 (83% vs 30%, p<0.0001). However, AF recurrence was no significantly differences between groups 2 and 3 (31% vs 30%, p=0.76) and between groups 4 and 5 (83% vs 81%, p=0.45). Of 217 patients with AF recurrence, 154 patients had undergone multiple procedures. After last procedures, during a mean follow-up period of 546±279 days, 61 patients had AF recurrence. Kaplan-Meier analysis revealed that AF recurrence was significantly higher in group 2 compared to group 1 (10% vs 3%, P=0.0005) and in group 4 compared with group 3 (35% vs 10%, p=0.0001). However, AF recurrence was no significantly difference between groups 2 and 3 (10% vs 10%, p=0.91) and between groups 4 and 5 (47% vs 35%, p=0.47).

AF Free Survival Curve

Conclusion

Although patients with PeAF within 2 years had significantly higher AF recurrence compared to PAF, AF ablation might still be a good contributor as the first line approach to improve outcomes in patient with PeAF within 2 years.

P5413Effect of empagliflozin as add-on therapy on serum uric acid level in patients with type 2 diabetes hospitalized for acute decompensated heart failure: a prospective randomized controlled study

Background

Elevated serum uric acid (UA) level has been shown to be associated with reduced survival among patients (pts) with heart failure. Sodium glucose cotransporter 2 (SGLT2) inhibitors have been reported to lower serum uric acid level in pts with type 2 diabetes mellitus (T2D). Empagliflozin, one of the SGLT2 inhibitors, has been shown to reduce the risk of cardiovascular mortality in T2D pts with cardiovascular disease, and involvement of UA lowering effect by empagliflozin in the reduction of cardiovascular mortality has been suggested. However, little is known about the effect of empagliflozin as add-on therapy on serum UA level in T2D pts with acute decompensated heart failure (ADHF).

Purpose

We sought to elucidate the effect of empagliflozin as add-on therapy on serum UA level in T2D pts with ADHF.

Methods

We enrolled 38 consecutive T2D pts admitted for ADHF. On admission, enrolled pts were randomly assigned in a 1:1 ratio to either empagliflozin add-on therapy (EMPA(+)) or conventional glucose-lowering therapy (EMPA(−)). All pts in EMPA(+) group received empagliflozin (10 mg/day) throughout the study period. Left ventricular ejection fraction (LVEF) was measured at baseline using echocardiography. Body weight and vital signs, such as blood pressure and heart rate, were measured, and blood and urine samples were collected at baseline and 1, 2, 3 and 7 days after randomization. Renal handling of UA was evaluated by fractional excretion of UA (FEUA).

Results

Twenty pts were assigned to the EMPA(+) group, and 18 pts were assigned to the EMPA(−) group. There were no significant baseline differences in LVEF, plasma brain natriuretic peptide level, body mass index, or serum creatinine level between the EMPA(+) and EMPA(−) groups. In addition, prevalence rate of hyperuricemia, serum UA level, and FEUA did not significantly differ between the two groups at baseline. However, there was significant difference in the change in serum UA level from baseline at 2, 3 and 7 days after randomization between the two groups (Figure A). As a result, serum UA level was significantly lower in the EMPA(+) group than in the EMPA(−) group at 7 days after randomization (6.2±1.8 mg/dL vs 7.8±1.8 mg/dL, p=0.0127). Moreover, FEUN of the EMPA(+) group was significantly higher at 1, 2 and 7 days after randomization (Figure B), which suggested that serum UA level was lowered in the EMPA(+) group by increased urinary excretion of UA.

Figure 1

Conclusions

This study demonstrated that empagliflozin as add-on therapy can lower serum UA level in T2D pts with ADHF through the effect on the urinary excretion rate of UA.

4330Effect of empagliflozin as add-on therapy on decongestion and renal function in diabetic patients hospitalized for acute decompensated heart failure: a prospective randomized controlled study

Background

The mainstay of treatment of acute decompensated heart failure (ADHF) is decongestion by diuretic therapy. Empagliflozin has been shown to reduce the risk of hospitalization for heart failure in patients (pts) with type 2 diabetes mellitus (T2D) and cardiovascular disease. This may be explained by natriuresis and osmotic diuresis caused by empagliflozin, leading to plasma volume (PV) contraction and decongestion. However, little is known about the therapeutic effect of empagliflozin on decongestion and its association with renal function in T2D pts with ADHF.

Purpose

We sought to elucidate the effect of empagliflozin as add-on therapy on plasma B-type natriuretic peptide (BNP) level, hemoconcentration, PV contraction and renal function in T2D pts with ADHF.

Methods

We enrolled 38 consecutive T2D pts admitted for ADHF. On admission, enrolled pts were randomly assigned in a 1:1 ratio to either empagliflozin add-on therapy (EMPA(+)) or conventional glucose-lowering therapy (EMPA(−)). All pts in EMPA(+) group received empagliflozin (10mg/day) throughout the study period. Left ventricular ejection fraction (LVEF) was measured at baseline using echocardiography. Body weight and vital signs, such as blood pressure and heart rate, were measured, and blood and urine samples were collected at baseline and 1, 2, 3 and 7 days after randomization. Hemoconcentration was defined as a ≥3% absolute increase in hematocrit (Hct). Percent change in PV between admission and subsequent timepoints (%ΔPV) was calculated using the Strauss formula as follows: %ΔPV = ([(Hb1/Hb2) × ((100 − Hct2)/(100 − Hct1))] − 1) × 100 (%), where 1 = baseline values and 2 = subsequent values. Worsening renal function (WRF) was defined as an increase in serum creatinine ≥0.3 mg/dL above baseline within 7 days of randomization.

Results

Twenty pts were assigned to the EMPA(+) group, and 18 pts were assigned to the EMPA(−) group. There were no significant baseline differences in LVEF, plasma BNP level, Hct or serum creatinine level between the EMPA(+) and EMPA(−) groups. Seven days after randomization, plasma BNP level was significantly lower in the EMPA(+) group than in the EMPA(−) group (median 213 [IQR 116–360] pg/mL vs 362 [226–776] pg/mL, p=0.0437) and hemoconcentration was more frequently observed in the EMPA(+) group than in the EMPA(−) group (53% vs 12%, p=0.0105). The decrease in %ΔPV was larger in the EMPA(+) group than in the EMPA(−) group 2 days (−8.74±9.92% vs 1.14±14.71%, p=0.0228), 3 days (−11.28±10.65% vs −0.02±14.70%, p=0.0121) and 7 days after randomization (−10.62±14.89% vs 0.97±13.72%, p=0.0211). The incidence of WRF did not significantly differ between the EMPA(+) and EMPA(−) groups (15% vs 22%).

Conclusions

This study demonstrated that empagliflozin as add-on therapy can achieve effective decongestion without an increased risk of WRF in T2D pts with ADHF.