Bipolarity in Older individuals Living without Drugs (BOLD): Protocol and preliminary findings

INTRODUCTION

Although clinical guidelines regard prophylactic medication as the cornerstone of treatment, it is estimated almost half of patients with bipolar disorder (BD) live without medication. This group is underrepresented in research but can provide indispensable knowledge on natural course, resilience and self-management strategies. We aim to describe the clinical phenotype of patients diagnosed with BD who have discontinued maintenance treatment.

METHODS

The mixed-methods BOLD study included 58 individuals aged 50 years and over with BD that did not use maintenance medication in the past 5 years. A preliminary, quantitative comparison of clinical characteristics between BOLD and our pre-existing cohort of >220 older BD outpatients with medication (Dutch Older Bipolars, DOBi) was performed.

RESULTS

BD-I, psychiatric comorbidities, number of mood episodes and lifetime psychotic features were more prevalent in BOLD compared to DOBi. BOLD participants had a younger age at onset and reported more childhood trauma. BOLD participants reported fewer current mood symptoms and higher cognitive, social, and global functioning.

LIMITATIONS

Our findings may not be generalizable to all individuals diagnosed with BD living without maintenance medication due to selection-bias.

CONCLUSION

A group of individuals exists that meets diagnostic criteria of BD and is living without maintenance medication. They appear to be relatively successful in terms of psychosocial functioning, although they do not have a milder clinical course than those on maintenance medication. The high prevalence of childhood trauma warrants further investigation. Future analyses will examine differences between BOLD and DOBi per domain (e.g. cognition, physical health, psychosocial functioning, coping).

The usefulness of repeated CMR and FDG PET/CT in the diagnosis of patients with initial possible cardiac sarcoidosis

BACKGROUND

Cardiac sarcoidosis (CS) diagnosis is usually based on advanced imaging techniques and multidisciplinary evaluation. Diagnosis is classified as definite, probable, possible or unlikely. If diagnostic confidence remains uncertain, cardiac imaging can be repeated. The objective is to evaluate the usefulness of repeated cardiac magnetic resonance imaging (CMR) and fluorodeoxyglucose positron emission tomography (FDG PET/CT) for CS diagnosis in patients with an initial "possible" CS diagnosis.

METHODS

We performed a retrospective cohort study in 35 patients diagnosed with possible CS by our multidisciplinary team (MDT), who received repeated CMR and FDG PET/CT within 12 months after diagnosis. Imaging modalities were scored on abnormalities suggestive for CS and classified as CMR+/PET+, CMR+/PET-, CMR-/PET+ and CMR-/PET-. Primary endpoint was final MDT diagnosis of CS.

RESULTS

After re-evaluation, nine patients (25.7%) were reclassified as probable CS and 16 patients (45.7%) as unlikely CS. Two patients started immunosuppressive treatment after re-evaluation. At baseline, eleven patients (31.4%) showed late gadolinium enhancement (LGE) on CMR (CMR+) and 26 (74.3%) patients showed myocardial FDG-uptake (PET+). At re-evaluation, nine patients (25.7%) showed LGE (CMR+), while 16 patients (45.7%) showed myocardial FDG-uptake (PET+). When considering both imaging modalities together, 82.6% of patients with CMR-/PET+ at baseline were reclassified as possible or unlikely CS, while 36.4% of patients with CMR+ at baseline were reclassified as probable CS. Three patients with initial CMR-/PET+ showed LGE at re-evaluation.

CONCLUSION

Repeated CMR and FDG PET/CT may be useful in establishing or rejecting CS diagnosis, when initial diagnosis is uncertain. However, clinical relevance has to be further determined.

Value of echocardiography using knowledge-based reconstruction in determining right ventricular volumes in pulmonary sarcoidosis: comparison with cardiac magnetic resonance imaging

Background

Right ventricular (RV) dysfunction in sarcoidosis is associated with adverse outcomes. Assessment of RV function by conventional transthoracic echocardiography (TTE) is challenging due to the complex RV geometry. Knowledge-based reconstruction (KBR) combines TTE measurements with three-dimensional coordinates to determine RV volumes.

Purpose

The aim of this study was to investigate the accuracy of TTE-KBR compared to the gold standard cardiac magnetic resonance imaging (CMR) in determining RV dimensions in pulmonary sarcoidosis.

Methods

Pulmonary sarcoidosis patients prospectively received same-day TTE and TTE-KBR. If performed, CMR within three months after TTE-KBR was used as reference standard. Outcome parameters included RV end-diastolic volume (RVEDV), end-systolic volume (RVESV), stroke volume (RVSV) and ejection fraction (RVEF).

Results

282 patients underwent same day TTE and TTE-KBR. In total, 122 patients received a CMR within 90 days of TTE and were included. TTE-KBR measured RVEDV and RVESV showed strong correlation with CMR measurements (R=0.73, R=0.76), while RVSV and RVEF correlated weakly (R=0.46, R=0.46). Bland-Altman analyses (mean bias ±95% limits of agreement), showed good agreement for RVEDV (ΔRVEDVKBR-CMR, 5.67±55.4mL), while RVESV, RVSV and RVEF showed poor agreement (ΔRVESVKBR-CMR, 21.6±34.1mL; ΔRVSVKBR-CMR, −16.1±42.9mL; ΔRVEFKBR-CMR, −12.9±16.4%). Image quality, time to CMR and learning curve showed no impact.

Conclusions

TTE-KBR is convenient and shows good agreement with CMR for RVEDV. However, there is poor agreement for RVESV, RVSV and RVEF. The use of TTE-KBR does not seem to provide additional value in the determination of RV dimensions in pulmonary sarcoidosis patients.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): ZonMW (The Netherlands Organisation for Health Research and Development) Figure 1. Correlation plotsFigure 2. Bland-Altman plots

Effectiveness and safety of infliximab in cardiac Sarcoidosis

BACKGROUND

Immunosuppressive therapy in active cardiac sarcoidosis (CS) might prevent potential life-threatening complications. Infliximab (IFX) is a tumor necrosis factor alpha monoclonal antibody proven to be effective in refractory extracardiac sarcoidosis. It is sparsely used in CS, because of its association with worsening heart failure in prior studies. The goal of this study is to assess the effectiveness and safety of IFX in CS.

METHODS AND RESULTS

A retrospective, single center cohort study was performed in sarcoidosis patients treated with IFX based on a cardiac indication between January 2016 and March 2019. Patients received IFX intravenously at a dose of 5 mg/kg at week 0, 2, and subsequently every 4 weeks. After every six months, treatment response was evaluated within the multidisciplinary team using FDG-PET/CT, transthoracic echocardiography, biomarkers and device interrogation reports. Responder analysis definitions were based on; dosage of immunosuppressive drugs, improvement in functional class, left ventricular ejection fraction (LVEF) and SUVmax. Twenty-two patients were included (mean age 51.0 SD10.0 years, male 68.2%) with a mean follow-up of 18.9 months (6 to 44 months) of whom 18 (82%) were classified as responders. Median SUVmax on FDG-PET/CT decreased from SUVmax 5.2 [3.7-8.4] to 2.3 [1.4-2.3], p = 0.015. The target-to-background ratio decreased from 3.2 [2.1-5.1] to 1.0 [0.7-2.4], p = 0.002. The median left ventricular (LV) ejection fraction increased from 45.0% [34.0-60.0] to 55.0% [41.0-60.0], p = 0.02. The majority of patients (73%) experienced no side effects and no patients had worsening of heart failure.

CONCLUSION

In this pilot study, patients with refractory CS treated with infliximab, on top of standard of care, had a reduction in inflammation on FDG-PET/CT and an improvement in LV function, without serious adverse events.

Long-term monitoring of arrhythmias in cardiac sarcoidosis

Introduction

Screening for cardiac sarcoidosis (CS) is recommended since it can manifest with ventricular arrhythmias (VA), atrioventricular conduction block (AVB) and sudden cardiac death (SCD). However, risk stratification for SCD is challenging, in particular in patients without overt cardiac symptoms.

Purpose

This study reports the practice-based risk stratification for SCD and the incidence of arrhythmias and mortality in CS patients by long-term monitoring of arrhythmias.

Methods

A retrospective, single center cohort study was performed in 537 patients with sarcoidosis screened for cardiac involvement with cardiac MRI and fluorodeoxyglucose PET in an hospital, a Dutch tertiary referral center. CS was diagnosed in 115 of 537 patients (21%), complete follow up was available in 108 patients (94%). After risk assessment for SCD (figure 1) an ICD was implanted in 16 high-risk patients. Within the92 low-risk patients, 80 had an internal loop recorder (ILR) implanted and 12 patients received no device. Chart review was performed to assess the occurrence of VA, AVB, death, ICD therapy and device related complications.

Results

During a mean follow-up of 31±15 months, 9 out of 80 ILR patients (11.3%) received an ICD of whom 7 (8.8%) based on recorded arrhythmias (VA in 5 and AVB in 2 patients).

Five out of the total 25 ICD patients (20%) experienced sustained VA successfully treated with anti-tachycardia pacing in 2 (8%) and terminated spontaneously in all other patients. Two ICD patients experienced a mild pocket infection, treated with antibiotics. Two deaths occurred in the low-risk patients: 1 non-cardiac death and 1 SCD due to asystole.

Conclusion

The practice-based risk stratification supported an ICD implantation in up to 5% of sarcoidosis patients screened for CS. Sustained VA occurred in 20% of ICD patients.Early detection of important arrhythmias with an ILR can optimize risk assessment for SCD in CS.

Practise-based risk stratification

Funding Acknowledgement

Type of funding source: None

Mortality in a well-defined group of predominantly Caucasian pulmonary sarcoidosis patients

Background

Sarcoidosis is an inflammatory systemic disease. Mortality has often been described in patients with more advanced disease, especially in those awaiting lung transplant. The PULSAR study is a cross sectional study prospectively investigating at least two year follow up on mortality in a large prospective, well-defined cohort of Dutch sarcoidosis patients, newly referred to a tertiary centre for sarcoidosis, including data on echocardiography.

Methods

All patients underwent prospective screening. Patients with intermediate or high probability for PH where referred for right heart catheterisation (RHC). In accordance to the guideline PH was defined as a mean PAP ≥25mmHg by RHC. Elevated pulmonary artery pressure was defined as >20 and <25mmHg. The absence of PH was defined as a mean PAP <25mmHg or a low PH probability on echocardiography. Survival was defined as absence of mortality or transplantation at the time of evaluation.

Results

399 patients were included in the analysis. All patients had follow up of at least 2 years. Five patients had died during fallow up, and none were transplanted. The PH prevalence was 3%. PH and elevated pulmonary artery pressure was associated with worse survival. On echocardiography, high PH probability was associated with worse survival compared to low PH probability (HR 1.78, p=0.01). If measurable, RVSP differed significantly between groups.

Conclusion

Only high PH probability and RVSP measurement on echocardiography were associated with mortality

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): ZonMW

Aetiology of sarcoidosis-associated pulmonary hypertension

Background

Pulmonary hypertension (PH) is a known complication of pulmonary sarcoidosis and its aetiology is unclear. The severity of PH may not correlate well with the degree of parenchymal disease; therefore other pathophysiological mechanisms have been hypothesized.

Purpose

The purpose of this study is to provide an insight in the different mechanisms of sarcoidosis-associated pulmonary hypertension (SAPH) and their characteristics.

Methods

We conducted a cohort study on all SAPH patients in our center. All patients were extensively analysed and discussed in a multidisciplinary expert team to determine the pathophysiology of PH case by case. Finally, patients were classified into different groups or a combination of groups based on the most likely mechanism of PH.

Results

Between 2010 and 2019, 41 patients with SAPH were identified. One patient was classified as isolated post-capillary PH, two patients as combined pre- and post-capillary PH and 38 patients as pre-capillary PH based on right heart catheterisation. In total, 17 patients were classified as PH solely due to chronic lung disease, one patient as suspected vasculopathy and one patient as compression of pulmonary vasculature. A combination of chronic lung disease with suspected vasculopathy (n=16), left heart disease (n=2), chronic pulmonary embolisms (n=1) or compression of pulmonary vasculature (n=5) was also found.

Conclusion

In sarcoidosis, different pathophysiological mechanisms contributing to the presence of PH can be identified. Extended analysis is helpful in order to differentiate between different mechanisms and could contribute to personalised therapeutic decision-making.

Venn diagram: classification of SAPH

Funding Acknowledgement

Type of funding source: None

Safety of macitentan in sarcoidosis-associated pulmonary hypertension: a case-series

Background:

Pulmonary hypertension (PH) is a known complication of pulmonary sarcoidosis and is associated with higher morbidity and mortality. Currently, there are no approved PH-targeted therapies for sarcoidosis-associated pulmonary hypertension (SAPH). Macitentan is frequently used as treatment for pulmonary arterial hypertension, but no results are known in the SAPH population.

Objective:

We investigated the safety and effect of macitentan as treatment for SAPH.

Methods:

We retrospectively reviewed our patient database for all SAPH patients receiving macitentan as treatment, with a minimum follow-up of twelve months for monitoring safety. Safety outcomes included reported side-effects, hospitalisations and mortality. Furthermore, six-minutes walking distance, New York Heart Association functional class and NT-proBNP levels were collected.

Results:

Six cases (three men) with a median age of 64 years (range 52-74 years) were identified. During macitentan treatment, one patient experienced side effects and aborted therapy after five days of treatment and died 16 months later. Three patients were hospitalised during treatment for congestive heart failure. Four patients showed improvement of their functional class and three patients in exercise capacity after 12 months of therapy.

Conclusion:

Macitentan was well tolerated in five out of six cases with severe pulmonary sarcoidosis and PH. Functional capacity improved in four cases. Prospective controlled trials are warranted before therapeutic recommendations can be made. (Sarcoidosis Vasc Diffuse Lung Dis 2020; 37 (1): 74-78)