Building a post-myocardial infarction discharge intervention program for Hispanic patients

Hispanic patients disproportionally suffer from disparities in care delivery in the setting of acute myocardial infarction (AMI). More specifically, Hispanic patients have higher 30-day readmission rates post-AMI and are less likely to be referred to cardiac rehab. Because of the challenges Hispanic patients face with post-AMI care, the Hispanic Acute Myocardial Infarction Discharge Intervention Study (HAMIDI) was launched to provide a culturally sensitive discharge framework to improve readmission and mortality rates in this population. Patients enrolled in this study participate in a comprehensive post-discharge program involving follow-up with a Spanish-speaking cardiologist, a two-part educational virtual group visit program, and access to support throughout the study. During the initial year of the study, 35 patients enrolled and successfully participated in the program. This case study reviews the implementation process, initial outcomes, challenges, and future plans of the program.

Impact of immune checkpoint inhibitors on atherosclerosis progression in patients with lung cancer

BACKGROUND

Patients with lung cancer face a heightened risk of atherosclerosis-related cardiovascular events. Despite the strong scientific rationale, there is currently a lack of clinical evidence examining the impact of immune checkpoint inhibitors (ICIs) on the advancement of atherosclerosis in patients with lung cancer. The objective of our study was to investigate whether there is a correlation between ICIs and the accelerated progression of atherosclerosis among individuals with lung cancer.

METHODS

In this case-control (2:1 matched by age and gender) study, total, non-calcified, and calcified plaque volumes were measured in the thoracic aorta using sequential contrast-enhanced chest CT scans. Univariate and multivariate rank-based estimation regression models were developed to estimate the effect of ICI therapy on plaque progression in 40 cases (ICI) and 20 controls (non-ICI).

RESULTS

The patients had a median age of 66 years (IQR: 58-69), with 50% of them being women. At baseline, there were no significant differences in plaque volumes between the groups, and their cardiovascular risk profiles were similar. However, the annual progression rate for non-calcified plaque volume was 7 times higher in the ICI group compared with the controls (11.2% vs 1.6% per year, p=0.001). Conversely, the controls showed a greater progression in calcified plaque volume compared with the ICI group (25% vs 2% per year, p=0.017). In a multivariate model that considered cardiovascular risk factors, the use of an ICI was associated with a more substantial progression of non-calcified plaque volume. Additionally, individuals treated with combination ICI therapy exhibited greater plaque progression.

CONCLUSIONS

ICI therapy was associated with more non-calcified plaque progression. These findings underscore the importance of conducting studies aimed at identifying the underlying mechanisms responsible for plaque advancement in patients undergoing ICI treatment.

TRIAL REGISTRATION NUMBER

NCT04430712.

Impact of sodium-glucose cotransporter-2 inhibitors on heart failure and mortality in patients with cancer

OBJECTIVES

Sodium-glucose cotransporter-2 inhibitors (SGLT2i) reduce heart failure (HF) in at-risk patients and may possess antitumour effects. We examined the effect of SGLT2i on HF and mortality among patients with cancer and diabetes.

METHODS

This was a retrospective propensity score-matched cohort study involving adult patients with type 2 diabetes mellitus diagnosed with cancer between January 2010 and December 2021. The primary outcomes were hospitalisation for incident HF and all-cause mortality. The secondary outcomes were serious adverse events associated with SGLT2i.

RESULTS

From a total of 8640 patients, 878 SGLT2i recipients were matched to non-recipients. During a median follow-up of 18.8 months, SGLT2i recipients had a threefold lower rate of hospitalisation for incident HF compared with non-SGLT2i recipients (2.92 vs 8.95 per 1000 patient-years, p=0.018). In Cox regression and competing regression models, SGLT2i were associated with a 72% reduction in the risk of hospitalisation for HF (HR 0.28 (95% CI: 0.11 to 0.77), p=0.013; subdistribution HR 0.32 (95% CI: 0.12 to 0.84), p=0.021). The use of SGLT2i was also associated with a higher overall survival (85.3% vs 63.0% at 2 years, p<0.001). The risk of serious adverse events such as hypoglycaemia and sepsis was similar between the two groups.

CONCLUSIONS

The use of SGLT2i was associated with a lower rate of incident HF and prolonged overall survival in patients with cancer with diabetes mellitus.

Global Circumferential and Radial Strain Among Patients With Immune Checkpoint Inhibitor Myocarditis

BACKGROUND

Global circumferential strain (GCS) and global radial strain (GRS) are reduced with cytotoxic chemotherapy. There are limited data on the effect of immune checkpoint inhibitor (ICI) myocarditis on GCS and GRS.

OBJECTIVES

This study aimed to detail the role of GCS and GRS in ICI myocarditis.

METHODS

In this retrospective study, GCS and GRS from 75 cases of patients with ICI myocarditis and 50 ICI-treated patients without myocarditis (controls) were compared. Pre-ICI GCS and GRS were available for 12 cases and 50 controls. Measurements were performed in a core laboratory blinded to group and time. Major adverse cardiovascular events (MACEs) were defined as a composite of cardiogenic shock, cardiac arrest, complete heart block, and cardiac death.

RESULTS

Cases and controls were similar in age (66 ± 15 years vs 63 ± 12 years; P = 0.20), sex (male: 73% vs 61%; P = 0.20) and cancer type (P = 0.08). Pre-ICI GCS and GRS were also similar (GCS: 22.6% ± 3.4% vs 23.5% ± 3.8%; P = 0.14; GRS: 45.5% ± 6.2% vs 43.6% ± 8.8%; P = 0.24). Overall, 56% (n = 42) of patients with myocarditis presented with preserved left ventricular ejection fraction (LVEF). GCS and GRS were lower in myocarditis compared with on-ICI controls (GCS: 17.5% ± 4.2% vs 23.6% ± 3.0%; P < 0.001; GRS: 28.6% ± 6.7% vs 47.0% ± 7.4%; P < 0.001). Over a median follow-up of 30 days, 28 cardiovascular events occurred. A GCS (HR: 4.9 [95% CI: 1.6-15.0]; P = 0.005) and GRS (HR: 3.9 [95% CI: 1.4-10.8]; P = 0.008) below the median was associated with an increased event rate. In receiver-operating characteristic (ROC) curves, GCS (AUC: 0.80 [95% CI: 0.70-0.91]) and GRS (AUC: 0.76 [95% CI: 0.64-0.88]) showed better performance than cardiac troponin T (cTnT) (AUC: 0.70 [95% CI: 0.58-0.82]), LVEF (AUC: 0.69 [95% CI: 0.56-0.81]), and age (AUC: 0.54 [95% CI: 0.40-0.68]). Net reclassification index and integrated discrimination improvement demonstrated incremental prognostic utility of GRS over LVEF (P = 0.04) and GCS over cTnT (P = 0.002).

CONCLUSIONS

GCS and GRS are lower in ICI myocarditis, and the magnitude of reduction has prognostic significance.

Trends in cardiology and oncology artificial intelligence publications

Study objective

To determine whether there has been growth in publications on the use of artificial intelligence in cardiology and oncology, we assessed historical trends in publications related to artificial intelligence applications in cardiology and oncology, which are the two fields studying the leading causes of death worldwide. Upward trends in publications may indicate increasing interest in the use of artificial intelligence in these crucial fields.

Design/setting

To evaluate evidence of increasing publications on the use of artificial intelligence in cardiology and oncology, historical trends in related publications on PubMed (the biomedical repository most frequently used by clinicians and scientists in these fields) were reviewed.

Results

Findings indicated that research output related to artificial intelligence (and its subcategories) generally increased over time, particularly in the last five years. With some initial degree of vacillation in publication trends, a slight qualitative inflection was noted in approximately 2015, in general publications and especially for oncology and cardiology, with subsequent consistent exponential growth. Publications predominantly focused on "machine learning" (n = 20,301), which contributed to the majority of the accelerated growth in the field, compared to "artificial intelligence" (n = 4535), "natural language processing" (n = 2608), and "deep learning" (n = 4459).

Conclusion

Trends in the general biomedical literature and particularly in cardiology and oncology indicated exponential growth over time. Further exponential growth is expected in future years, as awareness and cross-disciplinary collaboration and education increase. Publications specifically on machine learning will likely continue to lead the way.

Improving adherence to cholesterol lowering guidelines through an interactive digital tool

Background

Statins are the cornerstone of primary and secondary prevention of atheroscleoric cardiovascular disease (ASCVD). Our previous retrospective analysis of 1042 consecutive patient encounters at a large urban academic institution found that one in five patients were not prescribed an appropriate statin therapy. These patients tended to be younger, of Black race, and met statin-eligibility solely via a 10-year ASCVD risk score ≥7.5%. Only one-third of patients had follow-up cholesterol levels ordered to monitor treatment efficacy.

Purpose

To improve adherence to cholesterol guidelines at our academic institution.

Methods

We implemented multiple interventions over a four-month period to support clinical decision making of guideline directed statin therapy: a) development of an online interactive tool, b) physician education on updated cholesterol guidelines and utilization of the tool, c) display of guideline summary in the workspace, and d) a documentation reminder in the electronic health record. We randomly selected encounter dates, from which 622 consecutive patient visits were analyzed. The primary outcome measures were: prescription rates of statins, documentation of a 10-year ASCVD risk score, and follow-up cholesterol levels ordered to monitor treatment efficacy.

Results

Out of the 622 patients, 232 met statin indication. In this post-intervention group, statin prescriptions rates improved when compared to the pre-intervention group (90.5% vs 82.3%, p=0.006). Among the patients who met statin indication solely via a 10-year ASCVD risk score ≥7.5%, there was an increase in documentation of the calculated 10-year ASCVD risk score (72.3% vs 57.8%; p=0.039) and in statin prescription rate (90.8% vs 67.6%; p&lt;0.001). In addition, there was an increase in follow-up cholesterol levels ordered in all patients included in our study who met statin indication (64.1% vs 33.3%; p&lt;0.001).

Conclusion

Our study showed higher rates of statin prescription, 10-year ASCVD risk score documentation, and treatment monitoring after multiple interventions, including an easily accessible online interactive tool, at a large urban academic institution.

Funding Acknowledgement

Type of funding sources: None. Statin Prescription Rates

Assessment of the Effect of the Go Red for Women Campaign on Search Engine Queries for Cardiovascular Disease in Women

Background

The Go Red for Women (GoRedW) campaign aims to increase awareness of cardiovascular disease (CVD) and stroke in women. However, assessing the effects of social campaigns on information-seeking behaviors may be challenging. The purpose of this study was to ascertain the effect of GoRedW using a large sample of unbiased real-world data from Google Trends (GTr) and evaluate the temporal correlation of online search queries for CVD and stroke in women with GoRedW.

Methods

We conducted a retrospective study using GTr, a public tool from the Google search engine to obtain relative search volumes (RSVs) related to CVD and stroke in women in the period January 2004 to April 2019 in the USA. In addition, trends of GoRedW were compared with those of the well-established Breast Cancer Awareness Month (BCAM) campaign.

Results

RSVs increased for queries of GoRedW and all searched terms for CVD but not for stroke in women during February compared to other months of the year without active campaign. The strong pattern with peaks of temporal increase was consistent over the 15-year study period. RSV of “Go Red for Women” in February increased on average 494% (range: 211% to 789%). The highest temporal increase on search queries for CVD was for the term “heart disease (in) women” with an average of 114% (24% to 182%). We found a positive correlation between RSVs of GoRedW and the term “heart disease (in) women” (r = 0.54, P < 0.001). RSVs for “Breast Cancer Awareness Month” had a higher increase during the active campaign month compared to GoRedW and showed a stronger positive correlation (r = 0.78, P < 0.001).

Conclusions

Search engines are a valuable resource to provide insights on information demand and to assess the effectiveness of social campaigns and interventions. Our study showed an increase in the RSVs for queries of GoRedW and all CVD terms which correlated with the active campaign months over a 15-year period.

Spontaneous tumor lysis syndrome in T-cell malignancy: two case reports

Tumor lysis syndrome (TLS) refers to a constellation of metabolic abnormalities that result from release of intracellular solutes (potassium, phosphate, and nucleic acid metabolites) from rapidly dying tumor cells. While TLS most commonly occurs following chemotherapy, spontaneous TLS can rarely occur in rapidly dividing liquid or solid malignancies. Here, we report the cases of two patients who presented with non-specific symptoms and were found to have spontaneous TLS. Work-up in both cases led to a diagnosis of T-cell malignancy (i.e., acute lymphoblastic leukemia and angioimmunoblastic lymphoma). Given that spontaneous TLS can be the first manifestation of an underlying malignancy, all physicians should be familiar with this oncologic emergency. Early recognition and prompt management can be lifesaving for patients with an otherwise curable malignancy.

Role of Phosphodiesterase-5 Inhibitors in Acute Right Ventricular Failure Due to Pulmonary Embolism

Patient: Male, 56

Final Diagnosis: Right heart failure due to pulmonary embolism

Symptoms: Syncope

Medication: —

Clinical Procedure: —

Specialty: Cardiology

A Case of Acute Heart Failure due to Immune Checkpoint Blocker Nivolumab

Immune checkpoint inhibitors can be potentially cardiotoxic. It has not been frequently reported in the literature. Cardiomyopathy with these agents can have early onset and may start with non-specific symptoms like fatigue, weakness before presenting with obvious features of acute heart failure. Rapid progression and fulminant course of this disease necessitate high index of clinical suspicion and early diagnosis. High-dose steroids should be instituted early to blunt the immune response against myocardium. Further bigger studies are needed to fully understand the pathogenesis of this condition.

Multimodal Genetic Approach for Molecular Imaging of Vasculature in a Mouse Model of Melanoma

PURPOSE

In this study, we evaluated a genetic approach for in vivo multimodal molecular imaging of vasculature in a mouse model of melanoma.

PROCEDURES

We used a novel transgenic mouse, Ts-Biotag, that genetically biotinylates vascular endothelial cells. After inoculating these mice with B16 melanoma cells, we selectively targeted endothelial cells with (strept)avidinated contrast agents to achieve multimodal contrast enhancement of Tie2-expressing blood vessels during tumor progression.

RESULTS

This genetic targeting system provided selective labeling of tumor vasculature and showed in vivo binding of avidinated probes with high specificity and sensitivity using microscopy, near infrared, ultrasound, and magnetic resonance imaging. We further demonstrated the feasibility of conducting longitudinal three-dimensional (3D) targeted imaging studies to dynamically assess changes in vascular Tie2 from early to advanced tumor stages.

CONCLUSIONS

Our results validated the Ts-Biotag mouse as a multimodal targeted imaging system with the potential to provide spatio-temporal information about dynamic changes in vasculature during tumor progression.

In vivo Mn-enhanced MRI for early tumor detection and growth rate analysis in a mouse medulloblastoma model

Mouse models have increased our understanding of the pathogenesis of medulloblastoma (MB), the most common malignant pediatric brain tumor that often forms in the cerebellum. A major goal of ongoing research is to better understand the early stages of tumorigenesis and to establish the genetic and environmental changes that underlie MB initiation and growth. However, studies of MB progression in mouse models are difficult due to the heterogeneity of tumor onset times and growth patterns and the lack of clinical symptoms at early stages. Magnetic resonance imaging (MRI) is critical for noninvasive, longitudinal, three-dimensional (3D) brain tumor imaging in the clinic but is limited in resolution and sensitivity for imaging early MBs in mice. In this study, high-resolution (100 μm in 2 hours) and high-throughput (150 μm in 15 minutes) manganese-enhanced MRI (MEMRI) protocols were optimized for early detection and monitoring of MBs in a Patched-1 (Ptch1) conditional knockout (CKO) model. The high tissue contrast obtained with MEMRI revealed detailed cerebellar morphology and enabled detection of MBs over a wide range of stages including pretumoral lesions as early as 2 to 3 weeks postnatal with volumes close to 0.1 mm³. Furthermore, longitudinal MEMRI allowed noninvasive monitoring of tumors and demonstrated that lesions within and between individuals have different tumorigenic potentials. 3D volumetric studies allowed quantitative analysis of MB tumor morphology and growth rates in individual Ptch1-CKO mice. These results show that MEMRI provides a powerful method for early in vivo detection and longitudinal imaging of MB progression in the mouse brain.

4D MEMRI atlas of neonatal FVB/N mouse brain development

The widespread use of the mouse as a model system to study brain development has created the need for noninvasive neuroimaging methods that can be applied to early postnatal mice. The goal of this study was to optimize in vivo three- (3D) and four-dimensional (4D) manganese (Mn)-enhanced MRI (MEMRI) approaches for acquiring and analyzing data from the developing mouse brain. The combination of custom, stage-dependent holders and self-gated (motion-correcting) 3D MRI sequences enabled the acquisition of high-resolution (100-μm isotropic), motion artifact-free brain images with a high level of contrast due to Mn-enhancement of numerous brain regions and nuclei. We acquired high-quality longitudinal brain images from two groups of FVB/N strain mice, six mice per group, each mouse imaged on alternate odd or even days (6 3D MEMRI images at each day) covering the developmental stages between postnatal days 1 to 11. The effects of Mn-exposure, anesthesia and MRI were assessed, showing small but significant transient effects on body weight and brain volume, which recovered with time and did not result in significant morphological differences when compared to controls. Metrics derived from deformation-based morphometry (DBM) were used for quantitative analysis of changes in volume and position of a number of brain regions. The cerebellum, a brain region undergoing significant changes in size and patterning at early postnatal stages, was analyzed in detail to demonstrate the spatiotemporal characterization made possible by this new atlas of mouse brain development. These results show that MEMRI is a powerful tool for quantitative analysis of mouse brain development, with great potential for in vivo phenotype analysis in mouse models of neurodevelopmental diseases.

Engineering an effective Mn-binding MRI reporter protein by subcellular targeting

PURPOSE

Manganese (Mn) is an effective contrast agent and biologically active metal, which has been widely used for Mn-enhanced MRI (MEMRI). The purpose of this study was to develop and test a Mn binding protein for use as a genetic reporter for MEMRI.

METHODS

The bacterial Mn-binding protein, MntR was identified as a candidate reporter protein. MntR was engineered for expression in mammalian cells, and targeted to different subcellular organelles, including the Golgi Apparatus where cellular Mn is enriched. Transfected HEK293 cells and B16 melanoma cells were tested in vitro and in vivo, using immunocytochemistry, MR imaging and relaxometry.

RESULTS

Subcellular targeting of MntR to the cytosol, endoplasmic reticulum and Golgi apparatus was verified with immunocytochemistry. After targeting to the Golgi, MntR expression produced robust R1 changes and T1 contrast in cells, in vitro and in vivo. Co-expression with the divalent metal transporter DMT1, a previously described Mn-based reporter, further enhanced contrast in B16 cells in culture, but in the in vivo B16 tumor model tested was not significantly better than MntR alone.

CONCLUSION

This second-generation reporter system both expands the capabilities of genetically encoded reporters for imaging with MEMRI and provides important insights into the mechanisms of Mn biology which create endogenous MEMRI contrast.

Abstract 1560: Early tumor detection and characterization of a novel mouse model of Shh-driven medulloblastoma using contrast-enhanced micro-MRI

Introduction: An important translational application of preclinical models is the ability to draw insights into the etiology and molecular pathways altered in cancers. This is especially true for brain tumors since the early stages of disease are rarely detectable in patients and advanced-stage tumors may not accurately reflect the mutations responsible for tumor initiation. Therefore, there is a critical need for sensitive imaging protocols that allow the study of the early stages of tumor formation. In this study we optimized an in vivo high-resolution contrast-enhanced MRI protocol for the early detection and characterization of a novel mouse model of medulloblastoma (MB), the most common pediatric brain tumor which originates in the cerebellum (Cb).

Method: The Patched (Ptc1) mutant mouse is one of the most studied models of MB. In our study we generated a new variant of this model (referred as Ptc1-CKO) by breeding Ptf1acre/+ mice with mice homozygous for a floxed allele of the Ptc1 gene (Ptc1fl/fl). Using this approach, Ptc1 was deleted in less than 1,000 embryonic Ptf1a-expressing granule cell progenitors (GCPs) compared to the extensive mutation of many GCPs seen in many models. Based on our results, tumors in Ptc1-CKO mice likely initiate from a single mutated GCP, and thus better models the clonal origin of sporadic human MBs. Thus, the Ptc1-CKO mouse is an ideal platform to study the early stages of MB tumorigenesis. For in vivo imaging, we used manganese-enhanced MRI (MEMRI) to obtain images 24h after intraperitoneal (IP) injection of a manganese chloride (MnCl2) solution using a 7T micro-MRI system. We acquired three-dimensional (3D) images with a 15-minute and 2-hour protocol for screening and high-resolution images, respectively. Image analysis was performed using AMIRA software. After imaging, tumors were extracted for histological and molecular analysis.

Results: The contrast obtained with our MEMRI protocol showed detailed cerebellar morphology and allowed detection of MBs in Ptc1-CKO mice at different stages. Our in vivo MRI protocol was sensitive enough to detect pre-neoplastic lesions as early as 2 weeks postnatal age (N=22) and was validated with histology (N=12). Furthermore, in vivo longitudinal micro-MRI allowed the noninvasive monitoring of individual pre-neoplastic lesions and showed that individual lesions have different tumorigenic potential. Volumetric studies were performed to analyze tumor morphology and growth rates (N=25), and the advanced phenotypes were correlated with immunohistochemistry. In addition, 3D MRI images were used to guide the dissection of tumor tissue for microarray expression analysis (N=6). Our results show that Shh-driven MBs in Ptc1-CKO mice display at least two distinct imaging and molecular phenotypes, contrary to previous reports that all Shh-driven tumors converge to a common molecular endpoint.

Citation Format: Giselle A. Suero-Abreu, Praveen B. Raju, Diane Pham, Edward J. Houston, Alexandra L. Joyner, Daniel H. Turnbull. Early tumor detection and characterization of a novel mouse model of Shh-driven medulloblastoma using contrast-enhanced micro-MRI. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 1560. doi:10.1158/1538-7445.AM2013-1560

Divalent metal transporter, DMT1: a novel MRI reporter protein

Manganese (Mn)-enhanced MRI (MEMRI) has found a growing number of applications in anatomical and functional imaging in small animals, based on the cellular uptake of Mn ions in the brain, heart, and other organs. Previous studies have relied on endogenous mechanisms of paramagnetic Mn ion uptake and enhancement. To genetically control MEMRI signals, we reverse engineered a major component of the molecular machinery involved in Mn uptake, the divalent metal transporter, DMT1. DMT1 provides positive cellular enhancement in a manner that is highly sensitive and dynamic, allowing greater spatial and temporal resolution for MRI compared to previously proposed MRI reporters such as ferritin. We characterized the MEMRI signal enhancement properties of DMT1-expressing cells, both in vitro and in vivo in mouse models of cancer and brain development. Our results show that DMT1 provides an effective genetic MRI reporter for a wide range of biological and preclinical imaging applications.