Ketone body levels and its associations with cardiac markers following an acute myocardial infarction: a post hoc analysis of the EMMY trial

BACKGROUND

Sodium-glucose co-transporter 2 inhibitors (SGLT2i) have been suggested to exert cardioprotective effects in patients with heart failure, possibly by improving the metabolism of ketone bodies in the myocardium.

METHODS

This post hoc analysis of the EMMY trial investigated the changes in serum β-hydroxybutyrate (3-βOHB) levels after acute myocardial infarction (AMI) in response to 26-week of Empagliflozin therapy compared to the usual post-MI treatment. In addition, the association of baseline and repeated measurements of 3-βOHB with cardiac parameters and the interaction effects of Empagliflozin were investigated. Cardiac parameters included N-terminal pro-B-type natriuretic peptide (NT-proBNP), left ventricular ejection fraction (LVEF), left ventricle end-systolic volume (LVESV), left ventricle end-diastolic volume (LVEDV), and left ventricular filling pressure (E/é ratio).

RESULTS

The mean 3-βOHB levels increased from baseline (46.2 ± 3.0 vs. 51.7 ± 2.7) to 6 weeks (48.8 ± 2.2 vs. 42.0 ± 2.3) and 26 weeks (49.3 ± 2.2 vs. 35.8 ± 1.9) in the Empagliflozin group compared to a consistent decline in placebo over 26 weeks (pinteraction < 0.001). Baseline and longitudinal measurements of 3-βOHB were not significantly associated with NT-proBNP and E/é ratio. Baseline 3-βOHB value was negatively associated with LVEF (coefficient: - 0.464, 95%CI - 0.863;- 0.065, p = 0.023), while an increase in its levels over time was positively associated with LVEF (0.595, 0.156;1.035, 0.008). The baseline 3-βOHB was positively associated with LVESV (1.409, 0.186;2.632, 0.024) and LVEDV (0.640, - 1.170;- 2.449, 0.488), while an increase in its levels over time was negatively associated with these cardiac parameters (LVESV: - 2.099, - 3.443;- 0.755, 0.002; LVEDV: - 2.406, - 4.341;- 0.472, 0.015). Empagliflozin therapy appears to modify the association between 3-βOHB, LVEF (pinteraction = 0.090), LVESV (pinteraction = 0.134), and LVEDV (pinteraction = 0.168), particularly at 26 weeks; however, the results were not statistically significant.

CONCLUSION

This post hoc analysis showed that SGLT2i increased 3-βOHB levels after AMI compared to placebo. Higher baseline 3-βOHB levels were inversely associated with cardiac function at follow-up, whereas a sustained increase in 3-βOHB levels over time improved these markers. This highlights the importance of investigating ketone body metabolism in different post-MI phases. Although more pronounced effect of 3-βOHB on cardiac markers was observed in the SGLT2i group, further research is required to explore this interaction effect.

The Prognostic Value of Right Ventricular Function in Patients with Chronic Heart Failure-A Prospective Study

Background: In patients with stable chronic heart failure with a reduced ejection fraction (HFrEF), left ventricular ejection fraction (LVEF) provides limited prognostic value, especially in patients with moderately to severely reduced LVEF. Echocardiographic parameters of right ventricular function may be associated with adverse clinical events in these patients. Therefore, we analyzed 164 patients with HFrEF in a prospective single-center cohort study to evaluate whether the parameters of right ventricular function are associated with worsening heart failure (WHF) hospitalizations, cardiovascular and all-cause deaths and combined endpoints. Methods: Echocardiographic cine loops were analyzed using vendor-independent post-processing software. Multivariate Cox regression analyses were performed, which were then adjusted for clinical characteristics and left ventricular functional parameters. Results: In these models, higher tricuspid annular plane systolic excursion (TAPSE) was significantly associated with lower rates of WHF hospitalizations (HR 0.880, 95%CI 0.800-0.968, p = 0.008), a composite endpoint of WHF hospitalizations and cardiovascular death (HR 0.878, 95%CI 0.800-0.964, p = 0.006), and a composite endpoint of WHF hospitalization and all-cause death (HR 0.918, 95%CI 0.853-0.988, p = 0.023). These associations were more pronounced in patients with LVEF ≤ 35%. Conclusions: In conclusion, in patients with HFrEF, TAPSE is an independent prognosticator for adverse clinical outcomes, warranting further studies to elucidate whether incorporating TAPSE into established risk scores improves their diagnostic accuracy.

Low-grade systemic inflammation and left ventricular dysfunction in hypertensive compared to non-hypertensive hypertrophic cardiomyopathy

BACKGROUND

Arterial hypertension (HTN) is associated with excess mortality in hypertrophic cardiomyopathy (HCM), but underlying mechanisms are largely elusive. The objective of this study was to investigate the association between HTN and markers of left ventricular (LV) dysfunction and low-grade systemic inflammation in a HCM cohort.

METHODS

This was a single-center cross-sectional case-control study comparing echocardiographic and plasma-derived indices of LV dysfunction and low-grade systemic inflammation between 30 adult patients with HCM and HTN (HTN+) and 30 sex- and age-matched HCM patients without HTN (HTN-). Echocardiographic measures were assessed using post-processing analyses by blinded investigators.

RESULTS

Mean age of the study population was 55.1 ± 10.4 years, 30% were women. Echocardiographic measures of systolic and diastolic dysfunction, including speckle-tracking derived parameters, did not differ between HTN+ and HTN-. Moreover, levels of N-terminal pro B-type natriuretic peptide were balanced between cases and controls. Compared with HTN-, HTN+ patients exhibited a higher white blood cell count [8.1 ± 1.8 109/l vs. 6.4 ± 1.6 109/l; p < 0.001] as well as higher plasma levels of interleukin-6 [2.8 pg/ml (2.0, 5.4) vs. 2.1 pg/ml (1.5, 3.4); p = 0.008] and high-sensitivity C-reactive protein [2.6 mg/l (1.4, 6.5) vs. 1.1 mg/l (0.9, 2.4); p = 0.004].

CONCLUSION

This study demonstrates that HTN is associated with indices of low-grade systemic inflammation among HCM patients. Moreover, this analysis indicates that the adverse impact of HTN in HCM patients is a consequence of systemic effects rather than alterations of cardiac function, as measures of LV systolic and diastolic dysfunction did not differ between HTN+ and HTN-.

Prevalence and prognostic impact of bone disease in chronic heart failure with reduced ejection fraction

AIMS

Chronic heart failure is associated with a bone-catabolic state and increases the risk of osteoporosis and fractures. Prospective studies investigating the clinical relevance of bone disease in heart failure are lacking. We aimed to assess the prevalence and prognostic impact of osteoporosis and vertebral fractures (VFs) in chronic heart failure with reduced ejection fraction (HFrEF).

METHODS AND RESULTS

Symptomatic outpatients with chronic heart failure and a previous diagnosis of overtly reduced left ventricular ejection fraction < 40% on stable, optimal HFrEF therapy and left ventricular ejection fraction < 50% at enrolment were included into a prospective single-centre study. Osteoporosis was determined with dual-energy X-ray absorptiometry and defined as a T-score ≤ 2.5 at any site. VFs were assessed using X-ray of both thoracic and lumbar spine applying the semiquantitative Genant score. We enrolled 205 patients (22% women), with a median age of 66 (IQR 58-74) years. Median left ventricular ejection fraction was 37 (IQR 30-43) % and median N-terminal pro B-type natriuretic peptide was 964 (IQR 363-2173) pg/mL. Osteoporosis, as defined by bone mineral density, and at least one VF were prevalent in 31 (15%) and 29 patients (14%). Osteoporosis or VF were present in 55 patients (27%) and 5 patients (2%) had both osteoporosis and a VF. During a median follow-up of 4.7 (IQR 4.0-5.3) years, 18 patients (9%) died due to cardiovascular (CV) cause, and 46 patients (22%) had a worsening heart failure (WHF) hospitalization. In multivariate Cox regression analyses, presence of VF independently predicted CV death (HR 2.82, 95% CI 1.04-7.65, P = 0.042), WHF hospitalizations (HR 2.39, 95% CI 1.18-4.82, P = 0.015), and a composite endpoint of CV death and WHF hospitalizations (HR 2.44, 95% CI 1.23-4.82, P = 0.011). Osteoporosis was not significantly associated with CV events.

CONCLUSIONS

In a prospective study, bone disease affected every fourth patient with HFrEF, and patients with VF at baseline had a two-fold risk of subsequent CV death or WHF hospitalization. Prevalent bone disease, particularly VF, should be considered as a clinically relevant comorbidity in HFrEF.

Effects of empagliflozin in women and men with acute myocardial infarction: An analysis from the EMMY trial

OBJECTIVE

Women have a higher comorbidity burden and a lower survival rate after acute myocardial infarction (AMI) than men. This analysis aimed to investigate the impact of sex on the effect of treatment with the sodium glucose cotransporter 2 inhibitor (SGLT2i) empagliflozin immediately after an AMI.

METHODS

Participants were randomized to either empagliflozin or placebo and followed for 26 weeks after initiating the treatment no later than 72 hours after a percutaneous coronary intervention following an AMI. We analyzed the impact of sex on the beneficial effects of empagliflozin observed for heart failure biomarkers as well as structural and functional cardiac parameters.

RESULTS

Women had higher NT-proBNP levels at baseline (median 2117pg/mL, IQR 1383-3267 pg/mL versus 1137 pg/mL, IQR 695-2050 pg/mL; p < 0.001) and were older than men (median 61y, IQR 56-65y versus 56y, IQR 51-64y, p = 0.005). The beneficial effects of empagliflozin on NT-proBNP levels (Pinteraction = 0.984), left ventricular ejection fraction (Pinteraction = 0.812), left ventricular end systolic volume (Pinteraction = 0.183), or left ventricular end diastolic volume (Pinteraction = 0.676) were independent of sex.

CONCLUSIONS

Empagliflozin exhibited similar benefits in women and men when administered immediately after an AMI.

Impact of the evaluation method on 4D flow-derived diastolic transmitral and myocardial peak velocities: Comparison with echocardiography

PURPOSE

To compare agreement of different evaluation methods of magnetic resonance (MR) 4D flow-derived diastolic transmitral and myocardial peak velocities as well as their ratios, using echocardiography as reference.

METHODS

In this prospective study, 60 subjects without symptoms of cardiovascular disease underwent echocardiography and non-contrast 3 T MR 4D flow imaging of the heart. Early- (E) and late-diastolic (A) transmitral peak filling velocities were evaluated from 4D flow data using three different strategies: 1) at the mitral valve tips in short-axis orientation (SA-method), 2) between the mitral valve tips in 4-chamber orientation (4-chamber-method), and 3) as maximal velocities in the transmitral inflow volume (max-velocity-method). Septal, lateral and average early-diastolic myocardial peak velocities (e') were derived from the myocardial tissue in the vicinity of the mitral valve. 4D flow parameters were compared with echocardiography by correlation and Bland-Altman analysis.

RESULTS

All 4D flow-derived E, A and E/A values correlated with echocardiography (r = 0.65-0.73, 0.75-0.83 and 0.74-0.86, respectively). While the SA- and 4-chamber-methods substantially underestimated E and A compared to echocardiography (p < 0.001), the max-velocity-method provided E (p = 0.13) and E/A (p = 0.07) without significant bias. Septal, lateral and average e' from 4D flow as well as the max-velocity-method-derived E/e' correlated with echocardiographic measurements (r = 0.64-0.81) and showed no significant bias (p = 0.26-0.54).

CONCLUSION

MR 4D flow imaging allows precise and accurate evaluation of transmitral and myocardial peak velocities for characterization of LV diastolic function without significant bias to echocardiography, when transmitral velocities are assessed from the transmitral inflow volume. This enables the use of validated echocardiography threshold values.

Non-eligibility for pivotal HFpEF/HFmrEF outcome trials and mortality in a contemporary heart failure cohort

Pivotal outcome trials targeting heart failure with preserved (HFpEF) and mildly-reduced ejection fraction (HFmrEF) may have excluded patients at highest risk of poor outcomes. We aimed to assess eligibility for HFpEF/HFmrEF outcome trials in an unselected heart failure cohort and its association with all-cause mortality. Among 32.028 patients presenting to a tertiary care center emergency unit for any reason between August 2018 and July 2019, we identified 407 admissions with evident HFpEF and HFmrEF. Eligibility criteria for pivotal trials CHARM-Preserved, I-PRESERVE, TOPCAT, PARAGON-HF, EMPEROR-Preserved and DELIVER were assessed by chart review. The proportions of admissions fulfilling HFpEF/HFmrEF trial eligibility criteria were 88% for CHARM-Preserved, 40% for I-PRESERVE, 35% for TOPCAT, 28% for PARAGON-HF, 51% for EMPEROR-Preserved, and 49% for DELIVER. During a median follow-up of 1.9 years, death-from-any-cause occurred in 121 cases (30%). Twenty-four-month overall survival estimates for non-eligible and eligible admissions were 53% vs. 76% for CHARM-Preserved (HR=2.32, 95% CI: 1.47-3.67, p<0.001), 62% vs. 87% for I-PRESERVE (HR=2.97, 1.85-4.77, p<0.001), 67% vs. 84% for TOPCAT (HR=2.04, 1.29-3.24, p = 0.002), 68% vs. 85% for PARAGONHF (HR=2.28, 1.33-3.90, p = 0.003), 64% vs. 81% for EMPEROR-Preserved (HR=1.90, 1.27-2.84, p = 0.002), and 65% vs. 80% for DELIVER (HR=1.71, 1.14-2.57, p = 0.010). Exclusion criteria independently predicting death were eGFR <20 ml/min/1.73 m2, COPD with home oxygen therapy, and severe valvular heart disease. Conclusively, in a contemporary HFpEF/HFmrEF cohort, non-eligibility for outcome trials predicted for strongly increased mortality. HFpEF/HFmrEF patients at highest mortality risk were likely underrepresented in previous outcome trials and their treatment remains an unmet medical need.

MR 4D flow-derived left atrial acceleration factor for differentiating advanced left ventricular diastolic dysfunction

OBJECTIVES

The magnetic resonance (MR) 4D flow imaging-derived left atrial (LA) acceleration factor α was recently introduced as a means to non-invasively estimate LA pressure. We aimed to investigate the association of α with the severity of left ventricular (LV) diastolic dysfunction using echocardiography as the reference method.

METHODS

Echocardiographic assessment of LV diastolic function and 3-T cardiac MR 4D flow imaging were prospectively performed in 94 subjects (44 male/50 female; mean age, 62 ± 12 years). LA early diastolic peak outflow velocity (vE), systolic peak inflow velocity (vS), and early diastolic peak inflow velocity (vD) were evaluated from 4D flow data. α was calculated from α = vE / [(vS + vD) / 2]. Mean parameter values were compared by t-test; diagnostic performance of α in predicting diastolic (dys)function was investigated by receiver operating characteristic curve analysis.

RESULTS

Mean α values were 1.17 ± 0.14, 1.20 ± 0.08, 1.33 ± 0.15, 1.77 ± 0.18, and 2.79 ± 0.69 for grade 0 (n = 51), indeterminate (n = 9), grade I (n = 13), grade II (n = 13), and grade III (n = 8) LV diastolic (dys)function, respectively. α differed between subjects with non-advanced (grade < II) and advanced (grade ≥ II) diastolic dysfunction (1.20 ± 0.15 vs. 2.16 ± 0.66, p < 0.001). The area under the curve (AUC) for detection of advanced diastolic dysfunction was 0.998 (95% CI: 0.958-1.000), yielding sensitivity of 100% (95% CI: 84-100%) and specificity of 99% (95% CI: 93-100%) at cut-off α ≥ 1.58. The AUC for differentiating grade III diastolic dysfunction was also 0.998 (95% CI: 0.976-1.000) at cut-off α ≥ 2.14.

CONCLUSION

The 4D flow-derived LA acceleration factor α allows grade II and grade III diastolic dysfunction to be distinguished from non-advanced grades as well as from each other.

CLINICAL RELEVANCE STATEMENT

As a single continuous parameter, the 4D flow-derived LA acceleration factor α shows potential to simplify the multi-parametric imaging algorithm for diagnosis of advanced LV diastolic dysfunction, thereby identifying patients at increased risk for cardiovascular events.

KEY POINTS

• Detection of advanced diastolic dysfunction is typically performed using a complex, multi-parametric approach. • The 4D flow-derived left atrial acceleration factor α alone allows accurate detection of advanced left ventricular diastolic dysfunction. • As a single continuous parameter, the left atrial acceleration factor α could simplify the diagnosis of advanced diastolic dysfunction.

Outcomes of ECLS-SHOCK Eligibility Criteria Applied to a Real-World Cohort

BACKGROUND

Cardiogenic shock (CS) exhibits high (~50%) in-hospital mortality. The recently published Extracorporeal life Support in Cardiogenic Shock (ECLS-SHOCK) trial demonstrated the neutral effects of the use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) on all-cause death, as well as on all secondary outcomes in subjects presenting with myocardial-infarction (MI)-related CS. Here, we compared ECLS-SHOCK eligibility criteria with a real-world cohort of CS patients.

METHODS AND RESULTS

ECLS-SHOCK eligibility criteria were applied to a prospective single-center CS registry (the PREPARE CS registry) consisting of 557 patients who were consecutively admitted to the catheterization laboratory (cath lab) of the Medical University of Graz, Austria, due to CS (SCAI C-E). Overall use of mechanical circulatory support (MCS) in this cohort was 19%. Sixty-nine percent of the entire cohort had MI-related CS, 38% of whom would have met ECLS-SHOCK eligibility criteria, thus representing only 27% of the PREPARE CS registry. Exclusion from the ECLS-SHOCK trial was based on patients with initial lactate values below 3 mmol/L (n = 168; 43.6%), aged over 80 years (n = 65; 16.9%), and with a duration of cardiopulmonary resuscitation (CPR) exceeding 45 min (n = 22; 5.7%). The 30-day mortality of patients of the PREPARE CS registry who met the ECLS-SHOCK eligibility criteria was 57.0%, compared to 48.4% of patients in the ECLS-SHOCK trial. The patients' baseline characteristics, however, differed considerably with respect to type of infarction, age, and gender.

CONCLUSIONS

In a real-world cohort of patients with MI-related CS, only 38% of patients met the eligibility criteria of the ECLS-SHOCK trial. Thus, the impact of the use of VA-ECMO on outcome parameters in MI-related CS, as observed in the ECLS-SHOCK trial, may differ in a more heterogeneous real-world CS population of the PREPARE CS registry.

Timing of SGLT2i initiation after acute myocardial infarction

BACKGROUND

Pharmacological post-MI treatment is routinely initiated at intensive/cardiac care units. However, solid evidence for an early start of these therapies is only available for dual platelet therapy and statins, whereas data on beta blockers and RAAS inhibitors are heterogenous and mainly limited to STEMI and heart failure patients. Recently, the EMMY trial provided the first evidence on the beneficial effects of SGLT2 inhibitors (SGLT2i) when initiated early after PCI. In patients with type 2 diabetes mellitus, SGLT2i are considered "sick days drugs" and it, therefore, remains unclear if very early SGLT2i initiation following MI is as safe and effective as delayed initiation.

METHODS AND RESULTS

The EMMY trial evaluated the effect of empagliflozin on NT-proBNP and functional and structural measurements. Within the Empagliflozin group, 22 (9.5%) received early treatment (< 24 h after PCI), 98 (42.2%) within a 24 to < 48 h window (intermediate), and 111 (48.1%) between 48 and 72 h (late). NT-proBNP levels declined by 63.5% (95%CI: - 69.1; - 48.1) in the early group compared to 61.0% (- 76.0; - 41.4) in the intermediate and 61.9% (- 70.8; - 45.7) in the late group (n.s.) within the Empagliflozin group with no significant treatment groups-initiation time interaction (pint = 0.96). Secondary endpoints of left ventricular function (LV-EF, e/e`) as well as structure (LVESD and LVEDD) were also comparable between the groups. No significant difference in severe adverse event rate between the initiation time groups was detected.

CONCLUSION

Very early administration of SGLT2i after acute myocardial infarction does not show disadvantageous signals with respect to safety and appears to be as effective in reducing NT-proBNP as well as improving structural and functional LV markers as initiation after 2-3 days.

Alterations in trimethylamine-N-oxide in response to Empagliflozin therapy: a secondary analysis of the EMMY trial

INTRODUCTION

The relationship between sodium glucose co-transporter 2 inhibitors (SGLT2i) and trimethylamine N-oxide (TMAO) following acute myocardial infarction (AMI) is not yet explored.

METHODS

In this secondary analysis of the EMMY trial (ClinicalTrials.gov registration: NCT03087773), changes in serum TMAO levels were investigated in response to 26-week Empagliflozin treatment following an AMI compared to the standard post-MI treatment. Additionally, the association of TMAO changes with clinical risk factors and cardiorenal biomarkers was assessed.

RESULTS

The mean age of patients (N = 367) was 57 ± 9 years, 82% were males, and 14% had type 2 diabetes. In the Empagliflozin group, the median TMAO value was 2.62 µmol/L (IQR: 1.81) at baseline, 3.74 µmol/L (2.81) at 6 weeks, and 4.20 µmol/L (3.14) at 26 weeks. In the placebo group, the median TMAO value was 2.90 µmol/L (2.17) at baseline, 3.23 µmol/L (1.90) at 6 weeks, and 3.35 µmol/L (2.50) at 26 weeks. The serum TMAO levels increased significantly from baseline to week 6 (coefficient: 0.233; 95% confidence interval 0.149-0.317, p < 0.001) and week 26 (0.320, 0.236-0.405, p < 0.001). The average increase in TMAO levels over time (p_interaction = 0.007) was significantly higher in the Empagliflozin compared to the Placebo group. Age was positively associated with TMAO, whereas eGFR and LVEF were negatively associated with TMAO.

CONCLUSIONS

Our results are contrary to existing experimental studies that showed the positive impact of SGLT2i on TMAO precursors and cardiovascular events. Therefore, we recommend further research investigating the impact of SGLT2i therapy on acute and long-term changes in TMAO in cardiovascular cohorts.

Impact of the SGLT2-inhibitor empagliflozin on inflammatory biomarkers after acute myocardial infarction - a post-hoc analysis of the EMMY trial

BACKGROUND

SGTL2-inhibitors are a cornerstone in the treatment of heart failure, but data on patients with acute myocardial infarction (AMI) is limited. The EMMY trial was the first to show a significant reduction in NTproBNP levels as well as improved cardiac structure and function in post-AMI patients treated with Empagliflozin compared to placebo. However, data on the potential impact of SGLT2-inhibitors on inflammatory biomarkers after AMI are scarce.

MATERIALS AND METHODS

The EMMY trial is an investigator-initiated, multicentre, double-blind, placebo-controlled trial, which enrolled patients after AMI, receiving either 10 mg Empagliflozin once daily or placebo over a period of 26 weeks on top of standard guideline-recommended therapy starting within 72 h after percutaneous coronary intervention. In this post-hoc subgroup analysis of the EMMY trial, we investigated inflammatory biomarkers of 374 patients. The endpoints investigated were the mean change in inflammatory biomarkers such as high-sensitive c-reactive protein (hsCRP), interleukin-6 (IL-6), neutrophils, leukocytes, neutrophile/lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) from baseline to 26 weeks.

RESULTS

Baseline median (interquartile ranges) IL-6 was 17.9 pg/mL (9.0-38.7), hsCRP 18.9 mg/L (11.2-37.1), neutrophil count 7.9 x G/L (6.2-10.1), leukocyte count 10.8 x G/L (9.1-12.8) and neutrophile/lymphocyte ratio (NLR) of 0.74 (0.67-0.80). At week 26, a significant mean reduction in inflammatory biomarkers was observed, being 35.1 ± 3.2% (p < 0.001) for IL-6, 57.4 ± 0.7% (p < 0.001) for hsCRP, 26.1 ± 0.7% (p < 0.001) for neutrophils, 20.5 ± 0.6% (p < 0.001) for leukocytes, 10.22 ± 0.50% (p < 0.001) for NLR, and - 2.53 ± 0.92% for PLR (p = 0.006) with no significant difference between Empagliflozin and placebo treatment.

CONCLUSION

Trajectories of inflammatory biomarkers showed a pronounced decline after AMI, but Empagliflozin treatment did not impact this decline indicating no central role in blunted systemic inflammation mediating beneficial effects.

AMH in Males: Effects of Body Size and Composition on Serum AMH Levels

Serum concentrations of anti-Müllerian hormone (AMH) have been found to decrease with increasing body mass index (BMI) in many studies. It is not yet clear whether this stems from an adverse effect of adiposity on AMH production, or from dilution due to the greater blood volume that accompanies a larger body size. To investigate a possible hemodilution effect, we explored the relationships between serum AMH levels and different parameters of body composition using linear regression models in a cohort of adult males. Body weight, lean mass (LM), and body surface area (BSA) were found to be better predictors of AMH than measures of adiposity, such as BMI or fat mass. Since both LM and BSA correlate with plasma volume better than adipose tissue, we conclude that hemodilution of AMH does occur in adult males and should be considered for normalization in future studies.

Automated external defibrillator delivery by drone in mountainous regions to support basic life support - A simulation study

Background

Out-of-hospital cardiac arrest (OHCA) is associated with poor survival rates. Factors that may enable survival include cardiopulmonary resuscitation (CPR) initiated by bystanders and early use of an automated external defibrillator (AED). This explorative simulation study was conceptualized to test the feasibility of a semi-autonomously operating drone that delivers an AED to a remote emergency location and its bystander-use.

Methods

Ten paramedics and nineteen laypersons were confronted with a manikin simulating an OHCA as single bystanders within a field test located in a mountainous region between Austria and Slovenia. The scenario included a mock-call to the local emergency response center that dispatched a drone towards the caller's GPS coordinates and supported the ongoing CPR. The outcomes were the successful delivery of the AED, the time to the first shock, hands-off times, and the overall performance of the CPR.

Results

The AED was delivered by drone and used in all 29 scenarios without serious adverse events. The flight time of the drone was in median 5:20 (range: 1:35-8:19) minutes. The paramedics delivered the first shock after a mean of 12:15 ± 2:03 min and hands-off times were 50 ± 22 s. The laypersons delivered the first shock after 14:04 ± 2:10 min and hands-off times were 2:11 ± 0:39 min. All participants felt confident in the handling of the delivered AED.

Conclusion

The delivery and usage of an AED via a semi-autonomously flying drone in a remote region is feasible. This approach can lead to early administration of shocks.

Transesophageal echocardiography-guided versus fluoroscopy-guided patent foramen ovale closure: A single center registry

BACKGROUND

Percutaneous closure of patent foramen ovale (PFO) is conventionally performed under continuous transesophageal echocardiographic (TEE) guidance. We aimed to evaluate whether a simplified procedural approach, including pure fluoroscopy-guidance and final TEE control, as well as an aimed 'next-day-discharge' is comparable with the conventional TEE-guided procedure in terms of periprocedural and intermediate-term outcomes.

METHODS

All patients who underwent a PFO closure at our center between 2010 and 2022 were retrospectively included. Prior to June 2019 cases were performed with continuous TEE guidance (TEE-guided group). Since June 2019, only pure fluoroscopy-guided PFO closures have been performed with TEE insertion and control just prior to device release (fluoroscopy-guided group). We analyzed procedural aspects, as well as long term clinical and echocardiographic outcomes.

RESULTS

In total 291 patients were included in the analysis: 197 in the TEE-guided group and 94 in the fluoroscopy-guided group. Fluoroscopy-guided procedures were markedly shorter (48 ± 20 min vs. 25 ± 9 min; p < .01). There was no difference in procedural complications, including death, major bleeding, device dislodgement, stroke or clinically relevant peripheral embolization between the two groups (.5% vs. 0%; p = .99). Hospital stay was also shorter with the simplified approach (2.5 ± 1.6 vs. 3.5 ± 1.2 days; p < .01), allowing 85% same-day discharges during the last 12 months of observation period. At 6 ± 3 months echocardiographic follow-up a residual leakage was described in 8% of the TEE-guided cases and 2% of the fluoroscopy-guided cases (p = .08).

CONCLUSION

While a complete TEE-free PFO closure might have potential procedural risks, our approach of pure fluoroscopy-guided with a brisk final TEE check seems to be advantageous in terms of procedural aspects with no sign of any acute or intermediate-term hazard and it could offer an equitable compromise between the two worlds: a complete TEE procedure and a procedure without any TEE.

Empagliflozin in acute myocardial infarction: the EMMY trial

AIMS

Sodium-glucose co-transporter 2 inhibition reduces the risk of hospitalization for heart failure and for death in patients with symptomatic heart failure. However, trials investigating the effects of this drug class in patients following acute myocardial infarction are lacking.

METHODS AND RESULTS

In this academic, multicentre, double-blind trial, patients (n = 476) with acute myocardial infarction accompanied by a large creatine kinase elevation (>800 IU/L) were randomly assigned to empagliflozin 10 mg or matching placebo once daily within 72 h of percutaneous coronary intervention. The primary outcome was the N-terminal pro-hormone of brain natriuretic peptide (NT-proBNP) change over 26 weeks. Secondary outcomes included changes in echocardiographic parameters. Baseline median (interquartile range) NT-proBNP was 1294 (757-2246) pg/mL. NT-proBNP reduction was significantly greater in the empagliflozin group, compared with placebo, being 15% lower [95% confidence interval (CI) -4.4% to -23.6%] after adjusting for baseline NT-proBNP, sex, and diabetes status (P = 0.026). Absolute left-ventricular ejection fraction improvement was significantly greater (1.5%, 95% CI 0.2-2.9%, P = 0.029), mean E/e' reduction was 6.8% (95% CI 1.3-11.3%, P = 0.015) greater, and left-ventricular end-systolic and end-diastolic volumes were lower by 7.5 mL (95% CI 3.4-11.5 mL, P = 0.0003) and 9.7 mL (95% CI 3.7-15.7 mL, P = 0.0015), respectively, in the empagliflozin group, compared with placebo. Seven patients were hospitalized for heart failure (three in the empagliflozin group). Other predefined serious adverse events were rare and did not differ significantly between groups.

CONCLUSION

In patients with a recent myocardial infarction, empagliflozin was associated with a significantly greater NT-proBNP reduction over 26 weeks, accompanied by a significant improvement in echocardiographic functional and structural parameters.

CLINICALTRIALS.GOV REGISTRATION

NCT03087773.

May Measurement Month 2018-2019: an analysis of blood pressure screening results from Austria. Eur Heart J Suppl 2022;24:F6-F8. [PMID: 36225278 PMCID: PMC9547501 DOI: 10.1093/eurheartjsupp/suac038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Arterial hypertension is a global burden leading to over 10.8 million deaths per year worldwide. May Measurement Month (MMM) is a global project initiated by the International Society of Hypertension to raise the awareness of high blood pressure (BP) in the population. Following the MMM protocol 2508 participants ≥18 years had their BP measured in Austria in MMM18 and MMM19. Of those screened, 54.6% were found to be hypertensive, defined as a BP ≥140/90 mmHg and/or being on treatment for hypertension. Among those individuals with hypertension, 56.1% were on medication but only 42.0% of those treated had controlled BP (<140/90 mmHg). Lower BPs were found in those with previous myocardial infarction (MI), probably explained by a medical monitoring system of patients with MI in Austria. Those with hypertension were referred for further medical investigations and were provided lifestyle advice. Among a high number of individuals receiving antihypertensive treatment, BP is still not controlled. Further screening and monitoring of therapeutic effects is urgently required.

Cardiac relapse of extranodal NK/T-cell lymphoma manifesting as incessant ventricular tachycardia: a case report

Background

Cardiac tumours are rare but affected patients may present with symptoms mimicking other cardiac diseases. The most frequent symptoms include heart failure, arrhythmias, or embolic phenomena.

Case summary

A 39-year-old man with a history of extranodal NK/T-cell lymphoma of the nasal type (ENKTL-NT) in clinical remission presented at our department with incessant ventricular tachycardia. The arrhythmia could only be controlled with a combination of intravenously administered beta-blockers, ajmaline, and amiodarone. Diagnostic workup excluded ischaemia, but imaging revealed a tumour located in the apex of the left ventricle. Endomyocardial biopsy confirmed the diagnosis of cardiac relapse of ENKTL-NT. Upon chemotherapy no further arrhythmias developed.

Discussion

Many malignancies can metastasize into the heart. Multimodal imaging including echocardiography, cardiac magnetic resonance imaging, and a positron-emission tomography computed tomography paved the way to the diagnosis that was finally established by endomyocardial biopsy. In the present case, a cardiac metastasis from an ENKTL-NT presented with incessant ventricular tachycardia.

Left ventricular ejection fraction and cardiac biomarkers for dynamic prediction of cardiotoxicity in early breast cancer

Background/Purpose

This study aims to quantify the utility of monitoring LVEF, hs-cTnT, and NT-proBNP for dynamic cardiotoxicity risk assessment in women with HER2+ early breast cancer undergoing neoadjuvant/adjuvant trastuzumab-based therapy.

Materials and methods

We used joint models of longitudinal and time-to-event data to analyze 1,136 echocardiography reports and 326 hs-cTnT and NT-proBNP measurements from 185 women. Cardiotoxicity was defined as a 10% decline in LVEF below 50% and/or clinically overt heart failure.

Results

Median pre-treatment LVEF was 64%, and 19 patients (10%) experienced cardiotoxicity (asymptomatic n = 12, during treatment n = 19). The pre-treatment LVEF strongly predicted for cardiotoxicity (subdistribution hazard ratio per 5% increase in pre-treatment LVEF = 0.68, 95%CI: 0.48–0.95, p = 0.026). In contrast, pre-treatment hs-cTnT and NT-proBNP were not consistently associated with cardiotoxicity. During treatment, the longitudinal LVEF trajectory dynamically identified women at high risk of developing cardiotoxicity (hazard ratio per 5% LVEF increase at any time of follow-up = 0.36, 95% CI: 0.2–0.65, p = 0.005). Thirty-four patients (18%) developed an LVEF decline ≥ 5% from pre-treatment to first follow-up (“early LVEF decline”). One-year cardiotoxicity risk was 6.8% in those without early LVEF decline and pre-treatment LVEF ≥ 60% (n = 117), 15.9% in those with early LVEF decline or pre-treatment LVEF < 60% (n = 65), and 66.7% in those with early LVEF decline and pre-treatment LVEF < 60% (n = 3), (Gray’s test p < 0.0001).

Conclusion

Cardiotoxicity risk is low in two thirds of women with HER2+ early breast cancer who have pre-treatment LVEF ≥ 60% and no early LVEF decline > 5% during trastuzumab-based therapy. The longitudinal LVEF trajectory but not hs-cTnT or NT-proBNP allows for a dynamic assessment of cardiotoxicity risk in this setting.

PRospective REgistry of PAtients in REfractory cardiogenic shock-The PREPARE CardShock registry

Aim

Cardiogenic shock (CS) is a hemodynamically complex multisystem syndrome associated with persistently high morbidity and mortality. As CS is characterized by progressive failure to provide adequate systemic perfusion, supporting end‐organ perfusion using mechanical circulatory support (MCS) seems intriguing. Since most patients with CS present in the catheterization laboratory, percutaneously implantable systems have the widest adoption in the field. We evaluated feasibility, outcomes, and complications after the introduction of a full‐percutaneous program for both the Impella CP device and venoarterial extracorporeal membrane oxygenator (VA‐ECMO).

Methods

PREPARE CardShock (PRospective REgistry of PAtients in REfractory cardiogenic shock) is a prospective single‐center registry, including 248 consecutive patients between May 2019 and April 2021, who underwent cardiac catheterization and displayed advanced cardiogenic shock. The median age was 70 (58–77) years and 28% were female. Sixty‐five percent of the cases had cardiac arrest, of which 66% were out‐of‐hospital cardiac arrest. A local standard operating procedure (SOP) indicating indications as well as relative and absolute contraindications for different means of MCS (Impella CP or VA‐ECMO) was used to guide MCS use. The primary endpoint was in‐hospital death and secondary endpoints were spontaneous myocardial infarction and major bleedings during the hospital stay.

Results

Overall mortality was 50.4% with a median survival of 2 (0–6) days. Significant independent predictors of mortality were cardiac arrest during the index event (odds ratio [OR] with 95% confidence interval [CI]: 2.53 [1.43–4.51]; p = 0.001), age > 65 years (OR: 2.05 [1.03–4.09]; p = 0.036]), pH < 7.30 (OR: 2.69 [1.56–4.66]; p < 0.001), and lactate levels > 2 mmol/L (OR: 4.51 [2.37–8.65]; p < 0.001).

Conclusions

Conclusive SOPs assist target‐orientated MCS use in CS. This study provides guidance on the implementation, validation, and modification of newly established MCS programs to aid centers that are establishing such programs.

The Association of Cardiovascular Risk Factors and Depression of an adult Austrian Population

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): “Austrian Research Fund (COMET K-project No. 825329)”

Introduction

Depression has been recognized as a cardiovascular (CVD) risk factor. However, depression is often under-recognized and larger attention should be given to this frequent problem, also in relation to CVD sequelae. There are differences in prevalence of CVD risk factors and CVD care and prevention in Europe. Therefore, it is vital to identify the focus of CVD prevention to implement specific and country-based programs to reduce CVD burden, especially for people with depression.

Purpose

The aim of this study is to investigate the association between common CVD risk factors hypertension, body mass index (BMI), and smoking with the severity of depression in an adult Austrian population and to characterize sex-related differences.

Method

This current thesis is a cross-sectional study examining the baseline data of the population from the BioPersMed (Biomarkers of Personalized Medicine) cohort at our Medical University. The initial non-probability recruitment started between 2011 and 2015, resulting in a study population of 1,022 adult men and women who live in the greater Graz area. Three CVD risk factors were examined for this paper and assessed by trained doctors and nurses at baseline: self-reported diagnosis of hypertension, self-reported smoking status, and BMI (kg/m2) by measuring the height and weight of each participant. The PHQ-9 (Patient Health Questionnaire) was analyzed by recording the total score value in three groups. Descriptive statistics, statistical correlation analysis, and an ordinal regression analysis was performed.

Results

977 participants were included in the data analysis, with a mean age of 57.3 years. More than half of the participants (56%) were female. Results show a significant association between hypertension and the severity of depression (p&lt;0.01) and between males and all three CVD risk factors, and between females and overweight. People with hypertension and elevated BMI, adjusted for age, sex, diagnosis of depression, and smoking were more likely to fall into a higher level of depression (BMI: increase of 0.033 in the log odds, p&lt;0.5; hypertension: increase of 0.339 in the log odds, p&lt;0.01). Moreover, men were more likely to show a lower level of depression than women (decrease of 0.435 in the log odds, p&lt;0.5).

Conclusion

This is the first cross-sectional study to examine the association between CVD risk factors and the severity of depression in an adult Austrian population. Further research for causality and longitudinal analyses in a larger sample size are recommended to thoroughly examine and confirm these findings. The results are an important indication for CVD prevention programs in Austria to incorporate specific screening (CVD and Depression) and management of cardiovascular risk factors in their protocols and readapt them according to depression severity.

miR-1183 Is a Key Marker of Remodeling upon Stretch and Tachycardia in Human Myocardium

Many cardiac insults causing atrial remodeling are linked to either stretch or tachycardia, but a comparative characterization of their effects on early remodeling events in human myocardium is lacking. Here, we applied isometric stretch or sustained tachycardia at 2.5 Hz in human atrial trabeculae for 6 h followed by microarray gene expression profiling. Among largely independent expression patterns, we found a small common fraction with the microRNA miR-1183 as the highest up-regulated transcript (up to 4-fold). Both, acute stretch and tachycardia induced down-regulation of the predicted miR-1183 target genes ADAM20 and PLA2G7. Furthermore, miR-1183 was also significantly up-regulated in chronically remodeled atrial samples from patients with persistent atrial fibrillation (3-fold up-regulation versus sinus rhythm samples), and in ventricular myocardium from dilative cardiomyopathy hearts (2-fold up-regulation) as compared to non-failing controls. In sum, although stretch and tachycardia show distinct transcriptomic signatures in human atrial myocardium, both cardiac insults consistently regulate the expression of miR-1183 and its downstream targets in acute and chronic remodeling. Thus, elevated expression of miR-1183 might serve as a tissue biomarker for atrial remodeling and might be of potential functional significance in cardiac disease.

Cohort profile: 'Biomarkers of Personalised Medicine' (BioPersMed): a single-centre prospective observational cohort study in Graz/Austria to evaluate novel biomarkers in cardiovascular and metabolic diseases

PURPOSE

Accumulating evidence points towards a close relationship between cardiovascular, endocrine and metabolic diseases. The BioPersMed Study (Biomarkers of Personalised Medicine) is a single-centre prospective observational cohort study with repetitive examination of participants in 2-year intervals. The aim is to evaluate the predictive impact of various traditional and novel biomarkers of cardiovascular, endocrine and metabolic pathways in asymptomatic individuals at risk for cardiovascular and/or metabolic disease.

PARTICIPANTS

Between 2010 and 2016, we recruited 1022 regional individuals into the study. Subjects aged 45 years or older presenting with at least one traditional cardiovascular risk factor or manifest type 2 diabetes mellitus (T2DM) were enrolled. The mean age of the participants was 57±8 years, 55% were female, 18% had T2DM, 33% suffered from arterial hypertension, 15% were smokers, 42% had hyperlipidaemia, and only 26% were at low cardiovascular risk according to the Framingham 'Systematic COronary Risk Evaluation'.

FINDINGS TO DATE

Study procedures during screening and follow-up visits included a physical examination and comprehensive cardiovascular, endocrine, metabolic, ocular and laboratory workup with biobanking of blood and urine samples. The variety of assessed biomarkers allows a full phenotyping of individuals at cardiovascular and metabolic risk. Preliminary data from the cohort and relevant biomarker analyses were already used as control population for genomic studies in local and international research cooperation.

FUTURE PLANS

Participants will undergo comprehensive cardiovascular, endocrine and metabolic examinations for the next decades and clinical outcomes will be adjudicated prospectively.

Ertugliflozin to reduce arrhythmic burden in ICD/CRT patients (ERASe-trial) - A phase III study

Sodium glucose cotransporter 2 (SGLT2) have proven profound positive effects in heart failure with reduced ejection fraction (HFrEF). These effects are independent from the presence of diabetes. Metabolic effects, antiinflammatory, and antifibrotic properties are discussed as underlying mechanisms. Despite a strong correlation of ventricular arrhythmias with HFrEF, the impact of ertugliflozin on the ventricular arrhythmic burden has not been investigated, yet. Therefore, the Ertugliflozin to Reduce Arrhythmic burden in ICD ± CRT patientS (ERASe) trial was designed to investigate the efficacy and safety of ertugliflozin in patients with reduced and midrange ejection fraction (EF) with or without diabetes. METHODS: Within a multicentre, national, randomized, double-blind, placebo-controlled, phase 3b trial we aim to enrol a total of 402 patients across Austria. Patients with reduced or midrange EF and ICD ± CRT therapy >3 months and previous ventricular tachycardia (at least 10 documented VT episodes within the last 12 months) are randomized in a 1:1 ratio to ertugliflozin (5 mg once daily orally administered) or matching placebo. The primary endpoint of the ERASe trial is to investigate the impact of ertugliflozin on total burden of ventricular arrhythmias. Further objectives will include number of therapeutic interventions of implanted devices, atrial fibrillation and heart failure biomarkers. CONCLUSION: The ERASe trial will be the first trial to test ertugliflozin in heart failure patients with nonpreserved ejection fraction and ongoing ICD ± CRT therapy regardless of their diabetic status. The ERASe trial may therefore extend the concept of SGLT2 inhibition to improve cardiac remodelling, including reduced arrhythmic burden. Trial registration Identifier EudraCT Nr. 2020-002581-14 / ClinicalTrials.gov Identifier: NCT04600921.

A biopsychosocial model of severe fear of COVID-19

Introduction

COVID-19 is a respiratory infection that causes not only somatic health issues, but also frequently psychosocial burdens. The aims of this study were to investigate biopsychosocial factors that might further aggravate fear of COVID-19, and to establish a biopsychosocial model of severe fear of COVID-19.

Methods

368 participants were included in this study. Biopsychosocial factors observed comprised biological factors (somatic risk), psychological factors (state/trait anxiety, physical symptoms of anxiety, severe health anxiety, specific phobias, depression), and psychosocial factors (social support, financial losses, social media consumption, social contacts with COVID-19 infected people). Psychometric questionnaires included State-Trait Anxiety Inventory, Beck’s Anxiety Inventory, Whiteley-Index / Illness Attitude Scales, Specific Phobia Questionnaire, WHO-5 and Social Support Survey.

Results

162/368 (44.0%) participants had almost no fear, 170/368 (46.2%) participants had moderate fear, and 45/368 (12.2%) participants had severe fear of COVID-19. Female participants showed higher levels of fear of COVID-19 than male participants (gender: χ2 = 18.47, p<0.001). However, the level of fear of COVID-19 increased in male participants when they had contact with people who were infected with COVID-19, while in contrast the level of fear of COVID-19 decreased in female participants when they had such contacts [ANCOVA: fear of COVID-19 (contact x gender): F(1,363) = 5.596, p = .019]. Moreover, participants without relationships showed higher levels of fear of COVID-19 (marital status: χ2 = 14.582, p = 0.024). Furthermore, financial losses due to the COVID-19 were associated with higher levels of fear of COVID-19 [ANCOVA: fear of COVID-19(financial loss x gender): F(1, 363) = 22.853, p< .001]. Multiple regression analysis revealed female gender, severe health anxiety (WI-IAS) and state /trait anxiety (STAI) as significant predictors of severe fear of COVID-19.

Conclusion

In this study significant predictors of severe fear of COVID-19 were female gender, pre-existing state and trait anxiety, as well as severe health anxiety. The finding of significant predictors of fear of COVID-19 might contribute to detect people who might suffer most from severe, overwhelming fear of COVID-19 at an early stage.

Lipoprotein(a) and Pulmonary Embolism Severity-A Retrospective Data Analysis

Aim

We aimed to investigate a correlation between PE severity and Lp(a) levels.

Methods

We performed a retrospective data analysis from our medical records of PE patients admitted to the University Hospital Graz, Austria. Patients with an Lp(a) reading within a 1-year interval before and after PE diagnosis were included. In accordance with the 2019 ESC guidelines for the diagnosis and management of acute PE, severity assessment was carried out classifying patients into four groups: low risk (LR), intermediate low risk (IML), intermediate high risk (IMH) and high risk (HR). The study period of interest was between January 1, 2002 and August 1, 2020.

Results

We analyzed 811 patients with PE, of whom 323 (40%) had low-risk PE, 343 (42%) had intermediate-low-risk PE, 64 (8%) had intermediate-high-risk PE, and 81 (10%) had high-risk PE, respectively. We did not observe an association between PE severity and Lp(a) concentrations. In detail, median Lp(a) concentrations were 17 mg/dL [25–75th percentile: 10-37] in low-risk PE patients, 16 mg/dL [10–37] in intermediate-low-risk PE patients, 15mg/dL [10–48] in intermediate-high-risk PE patients, and 13mg/dL [10–27] in high-risk PE patients, respectively (Kruskal-Wallis p = 0.658, p for linear trend = 0.358).

Conclusion

The current findings suggest no correlation between PE severity and Lp(a) levels.

SGLT2 Inhibitors and Their Antiarrhythmic Properties

Sodium-glucose cotransporter 2 (SGLT2) inhibitors are gaining ground as standard therapy for heart failure with a class-I recommendation in the recently updated heart failure guidelines from the European Society of Cardiology. Different gliflozins have shown impressive beneficial effects in patients with and without diabetes mellitus type 2, especially in reducing the rates for hospitalization for heart failure, yet little is known on their antiarrhythmic properties. Atrial and ventricular arrhythmias were reported by clinical outcome trials with SGLT2 inhibitors as adverse events, and SGLT2 inhibitors seemed to reduce the rate of arrhythmias compared to placebo treatment in those trials. Mechanistical links are mainly unrevealed, since hardly any experiments investigated their impact on arrhythmias. Prospective trials are currently ongoing, but no results have been published so far. Arrhythmias are common in the heart failure population, therefore the understanding of possible interactions with SGLT2 inhibitors is crucial. This review summarizes evidence from clinical data as well as the sparse experimental data of SGLT2 inhibitors and their effects on arrhythmias.

DXA-Derived Indices in the Characterisation of Sarcopenia

Sarcopenia is linked with increased risk of falls, osteoporosis and mortality. No consensus exists about a gold standard "dual-energy X-ray absorptiometry (DXA) index for muscle mass determination" in sarcopenia diagnosis. Thus, many indices exist, but data on sarcopenia diagnosis agreement are scarce. Regarding sarcopenia diagnosis reliability, the impact of influencing factors on sarcopenia prevalence, diagnosis agreement and reliability are almost completely missing. For nine DXA-derived muscle mass indices, we aimed to evaluate sarcopenia prevalence, diagnosis agreement and diagnosis reliability, and investigate the effects of underlying parameters, presence or type of adjustment and cut-off values on all three outcomes. The indices were analysed in the BioPersMed cohort (58 ± 9 years), including 1022 asymptomatic subjects at moderate cardiovascular risk. DXA data from 792 baselines and 684 follow-up measurements (for diagnosis agreement and reliability determination) were available. Depending on the index and cut-off values, sarcopenia prevalence varied from 0.6 to 36.3%. Height-adjusted parameters, independent of underlying parameters, showed a relatively high level of diagnosis agreement, whereas unadjusted and adjusted indices showed low diagnosis agreement. The adjustment type defines which individuals are recognised as sarcopenic in terms of BMI and sex. The investigated indices showed comparable diagnosis reliability in follow-up examinations.

Hypochlorite-Modified LDL Induces Arrhythmia and Contractile Dysfunction in Cardiomyocytes

Neutrophil-derived myeloperoxidase (MPO) and its potent oxidant, hypochlorous acid (HOCl), gained attention as important oxidative mediators in cardiac damage and dysfunction. As cardiomyocytes generate low-density lipoprotein (LDL)-like particles, we aimed to identify the footprints of proatherogenic HOCl-LDL, which adversely affects cellular signalling cascades in various cell types, in the human infarcted myocardium. We performed immunohistochemistry for MPO and HOCl-LDL in human myocardial tissue, investigated the impact of HOCl-LDL on electrophysiology and contractility in primary cardiomyocytes, and explored underlying mechanisms in HL-1 cardiomyocytes and human atrial appendages using immunoblot analysis, qPCR, and silencing experiments. HOCl-LDL reduced ICa,L and IK1, and increased INaL, leading to altered action potential characteristics and arrhythmic events including early- and delayed-afterdepolarizations. HOCl-LDL altered the expression and function of CaV1.2, RyR2, NCX1, and SERCA2a, resulting in impaired contractility and Ca2+ homeostasis. Elevated superoxide anion levels and oxidation of CaMKII were mediated via LOX-1 signaling in HL-1 cardiomyocytes. Furthermore, HOCl-LDL-mediated alterations of cardiac contractility and electrophysiology, including arrhythmic events, were ameliorated by the CaMKII inhibitor KN93 and the INaL blocker, ranolazine. This study provides an explanatory framework for the detrimental effects of HOCl-LDL compared to native LDL and cardiac remodeling in patients with high MPO levels during the progression of cardiovascular disease.

Post-processing measurement of left ventricular ejection fraction compared to direct measurement in patients with heart failure with reduced ejection fraction

Introduction

Left ventricular ejection fraction (LVEF) derived from transthoracic echocardiography (TTE) is routinely used to guide therapeutic decisions in patients with heart failure with reduced ejection fraction (HFrEF). However, TTE-based quantification of LVEF is limited by low diagnostic accuracy and poor agreement with gold-standard methods which may be improved by application of post-processing (pp) analysis tools. In our study, we aimed to compare different methods of LVEF quantification, using direct and pp techniques, and their correlations to NT-proBNP plasma concentrations in patients with a previous diagnosis of HFrEF.

Methods

A total of 205 clinically stable patients with HFrEF were enrolled in a prospective cohort study. They underwent a standardized TTE examination performed by two experienced investigators. Biplane LVEF according to Simpson's method was evaluated directly during the examination. Pp evaluation of biplane and triplane LVEF (pp LVEF) using a vendor-independent software on digitally saved echo loops was performed by a blinded investigator who underwent comprehensive training in pp analysis but was otherwise unexperienced in TTE. For correlation analyses patients were subdivided according to the underlying etiology into ischemic and non-ischemic HF.

Results

Pp analysis was feasible in 164 patients. Mean direct biplane LVEF was 36.0±9.1%, mean pp biplane LVEF was 35.8±8.2%, mean pp triplane LVEF was 34.2±8.8%, and median NT-proBNP was 978 [IQR 332–2279] pg/mL. All LVEF parameters had strong and comparable correlations to NT-proBNP (direct biplane r=−0.352; pp biplane r=−0.412; pp triplane r=−0.426; p&lt;0.01 for each). Bland Altman Plot revealed a high variability between direct and pp biplane LVEF, with a mean difference of 0.15±6.2%. Linear regression analysis indicated proportional bias across all LVEF ranges (β=0.154, p=0.049). Among 83 patients with direct biplane LVEF &gt;35%, 16 had a pp biplane LVEF ≤35% (mean pp biplane 43.3±4.5 vs 32.0±2.3%, p&lt;0.001; median NT-proBNP 511 [179–1421] vs 1205 [457–3706] pg/mL, p=0.055). On the other hand, out of 81 patients with direct biplane LVEF ≤35%, 16 patients had pp biplane LVEF &gt;35% (mean pp biplane 28.2±4.8 vs 39.2±3.4%, p&lt;0.001; median NT-proBNP 1644 [711–3113] vs 543 [297–3015] pg/mL, p=0.1). Furthermore, the correlation between biplane LVEF and NT-proBNP was more pronounced in patients with ischemic HF (n=65) using pp than direct measurement (pp r=−0.443, p&lt;0.001; direct r=−0.314, p=0.01). We did not observe such a signal in patients with non-ischemic HF (n=99).

Conclusion

Direct biplane LVEF shows low agreement with pp biplane LVEF in patients with HFrEF. Moreover, application of pp analyses leads to a reclassification from LVEF &gt;35 to ≤35% in one out of five patients. In conclusion, pp biplane LVEF analysis appears to provide more accurate values and should be preferred in examinations with therapeutic implication, particularly in patients with HFrEF of ischemic origin.

Funding Acknowledgement

Type of funding sources: None.

Rituximab as a Treatment Option after Autologous Hematopoietic Stem Cell Transplantation in a Patient with Systemic Sclerosis

Systemic sclerosis (SSc) is an intractable autoimmune disease characterized by vasculopathy and organ fibrosis. Autologous hematopoietic stem cell transplantation (AHSCT) should be considered for the treatment of selected patients with rapid progressive SSc at high risk of organ failure. It, however, remains elusive whether immunosuppressive therapies such as rituximab (RTX) are still necessary for such patients after AHSCT, especially in those with bad outcomes. In the present report, a 43-year-old man with diffuse cutaneous SSc received AHSCT. Despite AHSCT, SSc further progressed with progressive symptomatic heart failure with newly developed concomitant mitral and tricuspid valve insufficiency, thus the patient started on RTX 8 months after AHSCT. Shortly after initiation of RTX, clinical symptoms and organ functions ameliorated subsequently. Heart valve regurgitations were reversible after initiation of RTX treatment. Currently, the patient remains in a stable condition with significant improvement of clinical symptoms and organ functions. Reporting about therapies after AHSCT in SSc is a very important issue, as randomized controlled trials are lacking, and therefore this report adds to evidence that RTX can be considered as a treatment option in patients with SSc that do not respond to AHSCT.

Advanced isolated light chain amyloid cardiomyopathy with negative immunofixation and normal free light chain ratio

Amyloid light chain (AL) cardiomyopathy is the most malignant specific cardiomyopathy. According to international recommendations, it should be ruled out non‐invasively using the serum free light chain (FLC) ratio and immunofixation electrophoresis in both serum and urine. Here, we report on a 69‐year‐old female patient with new‐onset heart failure with mid‐range ejection fraction. Cardiac imaging was highly suggestive of cardiac amyloidosis. Amyloid scintigraphy showed faint myocardial tracer uptake according to Perugini Score 1, but immunofixation was negative and the FLC ratio was normal, despite a slight increase in lambda FLCs. Endomyocardial biopsy revealed advanced myocardial lambda immunoglobulin light chain deposition. Clinically relevant extracardiac amyloid organ infiltration could not be detected. Conclusively, non‐invasive testing can in rare cases fail to exclude isolated AL amyloid cardiomyopathy. We suggest that even slight increases in serum lambda or kappa FLCs should be considered abnormal in suspected cardiac amyloidosis if non‐invasive testing delivers discrepant results.

Can sodium-glucose cotransporter 2 inhibitors be beneficial in patients with acute myocardial infarction?

The sodium-glucose cotransporter 2 inhibitors (SGLT2i), empagliflozin, dapagliflozin, and canagliflozin, have shown impressive beneficial effects in patients with type 2 diabetes mellitus in mandatory cardiovascular outcome trials. Retrospective data analysis revealed signals that pointed towards positive effects independent of the antidiabetic effects. This could be confirmed for empagliflozin and dapagliflozin in chronic heart failure with reduced ejection fraction alone, where rates of hospitalization for heart failure and cumulative major adverse cardiovascular events were reduced to a similar extent in patients with and without diabetes mellitus as in corresponding outcome trials. Cardiac remodeling following myocardial infarction leads to heart failure with reduced ejection fraction in many patients and aggravates morbidity and mortality. Clinical data of SGLT2i treatment after acute myocardial infarction is sparse. This review focuses on available experimental data on the effects of SGLT2i used before, during, and after myocardial infarction as well as already published and currently ongoing clinical trials.

MIR1183 as a new tissue biomarker with triggered acute response and upregulation in chronic atrial and ventricular remodeling

Background and purpose

Cardiac remodeling can be caused by a variety of insults linked to either stretch or tachycardia as a triggering mechanism. We aimed to investigate similarities and differences of the transcriptomic profiles in response to either acute stretch or tachycardia in isolated human atrial myocardium. In addition, we tested the highest acutely regulated target for its chronic regulation in human tissue with atrial or ventricular cardiac remodeling.

Methods

For acute trigger testing we applied either stretch (high pre- and afterload) or sustained tachycardia (2.5 Hz) for 6 hours in isolated atrial human trabeculae from cardiac surgery patients (all in sinus rhythm, SR). We performed gene expression profiling by RNA microarrays (n=5 per group) as a remodeling readout. For chronic regulation we performed qPCR of selected genes of interest in right atrial appendage tissue obtained from cardiac surgery patients with persistent atrial fibrillation compared to control patients with SR (n=6 per group), and also in ventricular tissue samples from failing hearts (from transplanted dilative cardiomyopathy patients) or non-failing control hearts (from multi-organ donors denied for transplantation), n=6 per group.

Results

The expression patterns of stretch and tachycardia were largely independent with 1305 transcripts regulated solely by stretch and 1837 transcripts by tachycardia with p&lt;0.05. In contrast, the fraction of commonly regulated genes was small (65 transcripts with p&lt;0.05). However, this fraction contained the strongest upregulated transcript, the microRNA precursor gene MIR1183, which was similarly upregulated by both triggers (4.1fold in stretch and 2.7fold in tachycardia, both p&lt;0.05). MIR1183 also showed upregulation in two important chronic remodeling settings: In atrial samples with persistent atrial fibrillation in comparison to sinus rhythm, it was 2.8fold upregulated, and in ventricular samples from dilative cardiomyopathy hearts it was 1.6fold upregulated (p&lt;0.05 for both). A functional role of MIR1183 in remodeling was also suggested by significant downregulation of its predicted downstream target genes ADAM20 and PLA2G7. Our ongoing research aims to confirm upregulation also in the circulating expression levels of the mature form of MIR1183 in human plasma samples in a cohort of atrial fibrillation patients with diseased atria, these findings will also be presented at scientific sessions.

Conclusion

Stretch and tachycardia show distinct transcriptomic signatures in human atrial trabeculae but share the strongest upregulated gene MIR1183 and consistent regulation of its downstream targets. This is present in an acute as well as chronic remodeling setting. Expression levels of MIR1183 might serve as a biomarker for atrial remodeling and to some extend ventricular remodeling and have potential functional significance in cardiac disease.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Medical University of Graz

Ticagrelor and prasugrel are independent predictors of improved long-term survival in ACS patients

AIM

To investigate the long-term clinical benefit of dual antiplatelet therapy with potent P2Y12 inhibitors compared to clopidogrel in patients with acute coronary syndrome (ACS).

METHODS

In this prospective multicenter observational study, we enrolled 708 patients with ACS treated with clopidogrel (n = 137), ticagrelor (n = 260) or prasugrel (n = 311). Major adverse cardiac events (MACE; over 1 year) and long-term mortality (median: 5.6 years; interquartile range [IQR] 4.9-6.5 years) were assessed. Multiple electrode aggregometry (MEA) was used to measure adenosine diphosphate (ADP)- and arachidonic acid (AA)-induced platelet aggregation.

RESULTS

Type of P2Y12 inhibitor emerged as an independent predictor of long-term mortality and MACE: patients treated with potent platelet inhibitors prasugrel or ticagrelor were at lower risk for long-term mortality (adjusted hazard ratio [HR] = 0.44; 95% CI: 0.22-0.92; P = .028) or MACE (adjusted HR = 0.38; 95% CI: 0.20-0.73; P = .004) than those treated with clopidogrel independent from clinical risk factors. In contrast, the efficacy of clopidogrel decreased with increasing severity of ACS: platelet aggregation was 37% higher in patients with ST segment elevation myocardial infarction (STEMI) and 25% higher in patients with non-ST elevation myocardial infarction (non-STEMI) compared to patients with unstable angina (P = .039). Patients with diabetes achieved less potent ADP- and AA-induced platelet inhibition under clopidogrel, compared to patients without diabetes (P = .045; P = .030, respectively).

CONCLUSION

In the setting of ACS, treatment with ticagrelor or prasugrel reduced long-term mortality and 1-year MACE as compared to clopidogrel.

The role of stretch, tachycardia and sodium-calcium exchanger in induction of early cardiac remodelling

Stretch and tachycardia are common triggers for cardiac remodelling in various conditions, but a comparative characterization of their role in the excitation‐transcription coupling (ETC) and early regulation of gene expression and structural changes is lacking. Here, we show that stretch and tachycardia directly induced hypertrophy of neonatal rat cardiac myocytes and also of non‐myocytes. Both triggers induced similar patterns of hypertrophy but had largely distinct gene expression profiles. ACTA1 served as good hypertrophy marker upon stretch, while RCAN1 was found increased in response to tachycardia in a rate‐dependent fashion. Mechanistically, several calcium‐handling proteins, including the sodium‐calcium exchanger (NCX), contributed to ETC. Phosphorylation of the calcium/calmodulin‐dependent protein kinase II (CaMKII) was elevated and occurred downstream of NCX activation upon tachycardia, but not stretch. Microarray profiling revealed that stretch and tachycardia regulated around 33% and 20% genes in a NCX‐dependent manner, respectively. In conclusion, our data show that hypertrophy induction by stretch and tachycardia is associated with different gene expression profiles with a significant contribution of the NCX.

Impact of EMpagliflozin on cardiac function and biomarkers of heart failure in patients with acute MYocardial infarction-The EMMY trial

BACKGROUND

Sodium glucose cotransporter 2 (SGLT2) inhibitors are established antidiabetic drugs with proven cardiovascular benefit. Although growing evidence suggests beneficial effects on myocardial remodeling, fluid balance and cardiac function, the impact of empagliflozin initiated early after acute myocardial infarction (AMI) has not been investigated yet. Therefore, the impact of EMpagliflozin on cardiac function and biomarkers of heart failure in patients with acute MYocardial infarction (EMMY) trial was designed to investigate the efficacy and safety of empagliflozin in diabetic and non-diabetic patients after severe AMI.

METHODS

Within a multicenter, randomized, double-blind, placebo-controlled, phase 3b trial we will enroll patients with AMI and characteristics suggestive of severe myocardial necrosis are randomized in a 1:1 ratio to empagliflozin (10 mg once daily) or matching placebo. The primary endpoint is the impact of empagliflozin on changes in NT-proBNP within 6 months after AMI. Secondary endpoints include changes in echocardiographic parameters, levels of ketone body concentrations, HbA1c levels and body weight, respectively. Hospitalization rate due to heart failure or other causes, the duration of hospital stay and all-cause mortality will be assessed as exploratory secondary endpoints.

DISCUSSION

The EMMY trial will test empagliflozin in patients with AMI regardless of their diabetic status. The EMMY trial may therefore underpin the concept of SGLT2 inhibition to improve cardiac remodeling, pre-and afterload reduction and cardiac metabolism regardless of its antidiabetic effects. Results will provide the rationale for the conduct of a cardiovascular outcome trial to test the effect of empagliflozin in patients with AMI.

P2614Comparison of global longitudinal strain and ejection fraction in correlation to NT-proBNP in ischemic and non-ischemic heart failure

Background

In chronic heart failure (CHF) NT-proBNP and left ventricular ejection fraction (LVEF) by echocardiography are standard diagnostic as well as follow-up markers and are known to correlate with prognosis. Speckle-tracking echocardiography is a more recent technique to quantify myocardial deformation as a measurement of left ventricular function with potential benefits over LVEF.

Purpose

The purpose of this investigation was to analyse the cross-sectional relationship between 2D speckle tracking-derived global longitudinal strain (GLS) and NT-proBNP plasma levels in a prospective cohort of ischemic and non-ischemic CHF patients.

Methods

We enrolled 205 patients with chronic heart failure. Major inclusion criteria were age over 18 years, stable disease with absence of unplanned hospitalization or change in medication or device therapy in the previous month or major surgery in the previous 3 months. CHF treatment had to be according to the recommendations of the ESC CHF guidelines 2016 and LVEF had to be below 50%.

Patient history, physical examination and an extensive echocardiography exam were performed. Lab results included NT-proBNP. Manual longitudinal strain was calculated using EchoPAC (General Electric Medical Systems, Horten, Norway) by a single and blinded examiner. LVEF was measured using Simpson's biplane method.

Results

205 patients included in the study. The baseline characteristics included mean age 65.0 years and 75% male. Mean GLS was −9.6% (SD ±4.5%) and median NT-proBNP 1269.5 (IQR 379.5–2759.5) ng/ml. The CHF aetiology was 70.0% ischemic vs 30.0% non-ischemic.

There was a significant negative correlation between GLS and NT-proBNP (Pearson r=0.239, p=0.029), this was not significant for LVEF and NT-proBNP (Pearson r=0.149, p=0.228).In a multivariate regression analysis adjusted for age, sex, NYHA classification and HF aetiology, GLS remained significantly correlated with NT-proBNP (adjusted beta-coefficient= 0.289, p=0.011). Furthermore, in contrast to LVEF, GLS showed a significant correlation to NT-proBNP in patients with ischemic (Pearson r=0.266, p=0.049) as well as non-ischemic aetiology of heart failure (Pearson r=0.434, p=0.034).

Conclusion

Global longitudinal strain, not LVEF, was significantly correlated with NT-proBNP in patients with CHF, independently of age, sex, symptoms or heart failure aetiology. This shows that speckle-tracking might be superior to LVEF for the assessment of left ventricular function in CHF.

Alternate Day Fasting Improves Physiological and Molecular Markers of Aging in Healthy, Non-obese Humans

Caloric restriction and intermittent fasting are known to prolong life- and healthspan in model organisms, while their effects on humans are less well studied. In a randomized controlled trial study (ClinicalTrials.gov identifier: NCT02673515), we show that 4 weeks of strict alternate day fasting (ADF) improved markers of general health in healthy, middle-aged humans while causing a 37% calorie reduction on average. No adverse effects occurred even after >6 months. ADF improved cardiovascular markers, reduced fat mass (particularly the trunk fat), improving the fat-to-lean ratio, and increased β-hydroxybutyrate, even on non-fasting days. On fasting days, the pro-aging amino-acid methionine, among others, was periodically depleted, while polyunsaturated fatty acids were elevated. We found reduced levels sICAM-1 (an age-associated inflammatory marker), low-density lipoprotein, and the metabolic regulator triiodothyronine after long-term ADF. These results shed light on the physiological impact of ADF and supports its safety. ADF could eventually become a clinically relevant intervention.

Incidence, predictors, and prognosis of premature discontinuation or switch of prasugrel or ticagrelor: the ATLANTIS - SWITCH study

Aim of the present study was to investigate the frequency and predictors of premature discontinuation or switch of ADP receptor blockers and its association with serious adverse events. For this purpose 571 consecutive ACS patients receiving ticagrelor (n = 258, 45%) or prasugrel (n = 313, 55%) undergoing PCI were enrolled in this prospective, observational, multicenter ATLANTIS-SWITCH substudy. Predictors of premature discontinuation or switch of antiplatelet therapy and their association with major adverse cardiovascular events and TIMI bleeding events were evaluated. Premature stop/switch was found in 72 (12.6%) patients: 34 (5.9%) stopped and 38 (6.7%) switched the ADP blocker. Ticagrelor treated patients were significantly more likely to stop/switch therapy as compared to prasugrel (15.9% vs. 9.2%, p = 0.016). We identified 4 independent predictors for stop/switch of ADP blocker: major surgery, need for oral anticoagulation (OAC), TIMI major bleeding and drug intolerance. TIMI major bleeding was a driver of stop/switch actions and occurred in 4.3% vs 0.2% in patients with vs without stop/switch (p = 0.001). The majority of stop/switch actions (75%) were physicians driven decisions. Importantly, stop/switch of therapy was not associated with increased risk of MACE (p = 0.936). In conclusion premature switch/stop of ADP blockers appears to be safe when mainly driven by physician’s decision and clinical indication.

Platelet reactivity patterns in patients treated with dual antiplatelet therapy

AIM

The aim of the present study was to investigate the patterns of platelet reactivity and discriminators of therapeutic response to dual antiplatelet therapy (DAPT) with aspirin and ticagrelor or prasugrel in patients with acute coronary syndrome (ACS).

DESIGN

In this multicentre prospective observational study, 492 patients with ACS were enrolled. Platelet aggregation was determined by multiple electrode aggregometry after stimulation with adenosine diphosphate (ADP) or arachidonic acid (AA) as agonists in the maintenance phase of treatment with prasugrel or ticagrelor.

RESULTS

Age emerged as the strongest variable influencing aspirin response status: The mean AA-induced platelet aggregation in patients <49 years of age was 49% higher than in those >49 years (13.1 U vs 8.8 U; P = 0.011). The second strongest discriminator of aspirin response was sex: Male patients had a 40% higher AA-induced platelet aggregation values than female patients (9.5 U vs 6.8 U; P = 0.026). Platelet count emerged as the only variable influencing ADP antagonists response status showing that patients with platelet count >320 g/L displayed higher ADP-induced platelet aggregation. About 12% of patients had high on-treatment platelet reactivity (HTPR) to aspirin, 3% and 4% a HTPR to prasugrel and ticagrelor, respectively, and only 2% displayed HTPR to dual antiplatelet therapy.

CONCLUSION

When potent platelet inhibitors as prasugrel and ticagrelor are administered with aspirin, HTPR to DAPT plays only a marginal role.

May Measurement Month 2017: an analysis of blood pressure screening results in Austria-Europe

Elevated blood pressure (BP) is a growing burden worldwide, leading to over 10 million deaths each year. May Measurement Month (MMM) is a global initiative aimed at raising awareness of high BP and to act as a temporary solution to the lack of screening programs worldwide. An opportunistic cross-sectional survey of volunteers aged ≥18 was carried out in May 2017. Blood pressure measurement, the definition of hypertension (HTN), and statistical analysis followed the standard MMM protocol. In total, 2711 individuals (58.6% female) were screened during MMM17 in 56 centres. After multiple imputation, 1704 (62.9%) had HTN (≥140/90 mmHg). Of individuals not receiving antihypertensive medication, 764 (43.2%) were hypertensive. Of individuals receiving antihypertensive medication, 597 (63.5%) had uncontrolled BP. MMM17 was one of the largest BP screening campaigns undertaken in Austria. A large number of undiagnosed hypertensives was found and connected to a therapeutic strategy. An alarming number of uncontrolled but treated hypertensives should attract the attention of doctors and health care system in Austria.

Intermittent Fasting (Alternate Day Fasting) in Healthy, Non-obese Adults: Protocol for a Cohort Trial with an Embedded Randomized Controlled Pilot Trial

BACKGROUND/OBJECTIVES

Alternate day fasting (ADF) is a subtype of intermittent fasting and is defined as a continuous sequence of a fast day (100% energy restriction, zero calories) and a feed day (ad libitum food consumption), resulting in roughly 36-h fasting periods. Previous studies demonstrated weight reductions and improvements of cardiovascular risk factors with ADF in obese subjects. However, rigorous data on potential endocrine, metabolic and cardiovascular effects, besides weight loss, are lacking. Therefore we aim to investigate the short- and mid- to long-term clinical and molecular effects of ADF in healthy non-obese subjects.

METHODS

We will perform a prospective cohort study with an embedded randomized controlled trial (RCT) including 90 healthy subjects. Thirty of them will have performed ADF for at least 6 months (mid-term group). Sixty healthy subjects without a particular diet before enrolment will serve as the control group. These subjects will be 1:1 randomized to either continuing their current diet or performing ADF for 4 weeks. All subjects will undergo study procedures that will be repeated in RCT participants after 4 weeks. These procedures will include assessment of outcome parameters, dual-energy X-ray absorptiometry, measurement of endothelial function, an oral glucose tolerance test, 24-h blood pressure measurement, retinal vessel analysis, echocardiography and physical activity measurement by an accelerometer. Blood, sputum, buccal mucosa and faeces will be collected for laboratory analyses. Participants in the RCT will wear a continuous glucose monitor to verify adherence to the study intervention.

PLANNED OUTCOMES

The aim of this project is to investigate the effects of ADF on human physiology and molecular cellular processes. This investigation should gain in-depth mechanistic insights into the concept of ADF and form the basis for larger subsequent cohort recruitment and consecutive intervention studies.

TRIAL REGISTRATION

NCT02673515; registered 24 November 2015. Current protocol date/version: 7 February 2017/version 1.8.