Effectiveness of ICD therapy in real clinical practice. The Olomouc ICD Registry

BACKGROUND

Clinical parameters linked to a low benefit of ICD implantation and increased mortality risks are needed for an individualized assessment of potential benefits and risks of ICD implantation.

METHODS

Analysis of a prospective registry of all patients hospitalized from 2009 to 2019 in a single centre for a first implantation of any type of ICD.

RESULTS

A total of 2,681 patients were included in the registry. Until the end of follow-up (38.4 ± 29.1 months), 682 (25.4%) patients died. The one-year mortality in all patients, the one-year CV mortality, the three-year mortality in all patients, and the three-year CV mortality were 7.8%, 5.7%, 20.6%, and 14.8%, respectively. There was a statistically significant difference when the subgroups were compared according to the type of cardiomyopathy. No significant difference was found between primary and secondary prevention and between the types of devices. Male gender, age ≥ 75 years, diabetes mellitus, and atrial fibrillation were associated with a significantly increased mortality risk.

CONCLUSION

In an analysis of a long-term follow-up of 2,681 ICD patients, we found no mortality difference between patients with ischemic or non-ischemic cardiomyopathy and in the device type. A higher mortality risk was found in men, patients older than 75 years, diabetics, and those with atrial fibrillation.

Nonprocedural bleeding after left atrial appendage closure versus direct oral anticoagulants: A subanalysis of the randomized PRAGUE-17 trial

INTRODUCTION

Observational studies have shown low bleeding rates in patients with atrial fibrillation (AF) treated by left atrial appendage closure (LAAC); however, data from randomized studies are lacking. This study compared bleeding events among patients with AF treated by LAAC and nonvitamin K anticoagulants (NOAC).

METHODS

The Prague-17 trial was a prospective, multicenter, randomized trial that compared LAAC to NOAC in high-risk AF patients. The primary endpoint was a composite of a cardioembolic event, cardiovascular death, and major and clinically relevant nonmajor bleeding (CRNMB) defined according to the International Society on Thrombosis and Hemostasis (ISTH).

RESULTS

The trial enrolled 402 patients (201 per arm), and the median follow-up was 3.5 (IQR 2.6-4.2) years. Bleeding occurred in 24 patients (29 events) and 32 patients (40 events) in the LAAC and NOAC groups, respectively. Six of the LAAC bleeding events were procedure/device-related. In the primary intention-to-treat analysis, LAAC was associated with similar rates of ISTH major or CRNMB (sHR 0.75, 95% CI 0.44-1.27, p = 0.28), but with a reduction in nonprocedural major or CRNMB (sHR 0.55, 95% CI 0.31-0.97, p = 0.039). This reduction for nonprocedural bleeding with LAAC was mainly driven by a reduced rate of CRNMB (sHR for major bleeding 0.69, 95% CI 0.34-1.39, p = .30; sHR for CRNMB 0.43, 95% CI 0.18-1.03, p = 0.059). History of bleeding was a predictor of bleeding during follow-up. Gastrointestinal bleeding was the most common bleeding site in both groups.

CONCLUSION

During the 4-year follow-up, LAAC was associated with less nonprocedural bleeding. The reduction is mainly driven by a decrease in CRNMB.

COVID-19 vaccine booster significantly decreases the risk of intensive care unit hospitalization in heart failure patients during the Omicron variant wave: A population-based study

Background

Heart failure (HF) patients are at higher risk of severe coronavirus disease 2019 (COVID-19). The Omicron variant has many novel mutations including those in the spike protein, leading to questions about vaccine effectiveness. The aim of this analysis was to evaluate the effectiveness of the COVID-19 vaccine with or without a booster (i.e., after the third dose) during the Omicron variant wave.

Methods

Chronic heart failure patients in the Czech Republic were included in the analysis. COVID-19 infection was monitored from January 1st 2022 to March 31st 2022. The analysis was conducted on data collected in the National Health Information System. Vaccine effectiveness of vaccinated (with or without booster) vs. unvaccinated patients was analyzed for incidence of COVID-19, COVID-19-related hospitalizations, COVID-19 related intensive care unit admissions, and COVID-19 related mechanical ventilation/extracorporeal membrane oxygenation treatment.

Findings

From a total 165,453 HF patients in the Czech Republic, 9,728 contracted COVID-19 (22.9% of them not vaccinated, 23.2% vaccinated and 53.8% vaccinated and boosted). Risk of intensive care unit (ICU) hospitalization was 7.6% in the unvaccinated group, 4.8% in the vaccinated group and 2.9% in the boosted group. The calculated effectiveness of the COVID-19 vaccine in prevention of ICU hospitalization in the vaccinated group was 41.9 and 76.6% in the boosted group.

Interpretation

The results demonstrated moderate vaccine effectiveness in the prevention of severe COVID-19 in vaccinated but not boosted HF patients. Much stronger effectiveness was found in those who were vaccinated and boosted.

[Further development of regional early care-Many roads lead to Rome : Developmental stages of four established rheumatological early care concepts in different regions of Germany]

In order to shorten the prognostically relevant waiting time until diagnosis and initiation of appropriate treatment in inflammatory rheumatic diseases, rheumatological centers in many regions across Germany have established and continuously developed specific early care concepts. Evaluated models from Altötting·Burghausen, Berlin Buch, Düsseldorf and Heidelberg and their developmental stages as a response to internal and external challenges are presented in this overview. The transparent publication of the developmental steps and the exchange of experiences aim at promoting new early care concepts in other regions and continuing the joint dialogue for improvement of the early detection and quality of care of inflammatory rheumatic diseases in Germany.

AB0752 HOW DOES TIME TO DIAGNOSIS AND GENDER AFFECT TREATMENT OUTCOMES IN PATIENTS WITH ANKYLOSING SPONDYLITIS OR PSORIATIC ARTHRITIS? – REAL WORLD DATA FROM THE GERMAN AQUILA STUDY WITH SECUKINUMAB

Background

In both, ankylosing spondylitis (AS) and psoriatic arthritis (PsA), women typically have a longer delay in diagnosis.1,2 There is scientific evidence that prognosis for AS and PsA improves when diagnosed early. The German non-interventional study AQUILA provides real-world data on the influence of time to diagnosis and gender on treatment outcomes under secukinumab, a fully human monoclonal antibody that selectively inhibits interleukin-17A.

Objectives

The aims of this interim analysis are to describe selected baseline (BL) demographics of AS and PsA patients (pts) and to evaluate the impact of time to diagnosis and gender on secukinumab treatment outcomes, such as disease activity and global functioning and health.

Methods

AQUILA is an ongoing, multi-center, non-interventional study including up to 3000 pts with AS or PsA. Pts were observed from BL up to week (w) 52 according to clinical routine. Real-world data were assessed prospectively and analyzed as observed. Validated questionnaires were used to collect data on disease activity (Bath Ankylosing Spondylitis Disease Activity Index, BASDAI), global functioning and health (Assessment of SpondyloArthritis-Health Index, ASAS-HI) in AS, and skin and joint-related disease activity (Psoriasis Area and Severity Index, PASI; tender/swollen joint counts, TJC/SJC) and impact of disease (Psoriatic Arthritis Impact of Disease - 12 items, PsAID-12 score) in PsA pts. This interim analysis focused on the subgroups of male and female AS and PsA pts stratified by time to diagnosis after disease onset (˂1 year [y] and ≥1y for early and late diagnosis, respectively).

Results

At BL, 609 AS and 1145 PsA pts were included with information on time to diagnosis (Table 1); only 18.7% of AS and 25.8% of PsA pts were diagnosed within one year. Of interest, both female AS and PsA pts as well as male PsA pts with increased BMI tended to be diagnosed later (Table 1). Regarding BASDAI scores, male AS pts diagnosed late had increased disease activity at BL and throughout the study (Figure 1A); female AS pts diagnosed late showed reduced total treatment effect with increasing time to diagnosis (Figure 1B). Similarly, both male and female AS pts diagnosed late had slightly increased ASAS-HI at BL and throughout the study (Table 1). For PsA pts, there was no difference in skin- (PASI, Figure 1C/D) and joint-related (Figure 1E/F) disease activity with respect to time to diagnosis. Furthermore, there was no difference in PsAID scores (data not shown) between early- and late-diagnosed PsA pts.

Table 1.

Overview of selected BL characteristics in AS and PsA pts stratified by time to diagnosis

AS (N=609)Time to diagnosis ˂1 year (n=114)Time to diagnosis ≥1 year (n=495)Male (n=63)Female (n=51)Male (n=301)Female (n=194)Age, years43.146.345.947.7BMI27.725.927.327.8BASDAI4.75.05.35.2ASAS-HI6.78.07.48.2PsA (N=1145)Time to diagnosis ˂1 year (n=295)Time to diagnosis ≥1 year (n=850)Male (n=126)Female (n=169)Male (n=363)Female (n=487)Age, years50.151.852.353.1BMI28.729.429.328.8PASI6.56.27.07.2PsAID4.65.24.85.3TJC/SJC5.9/3.37.3/3.27.0/3.77.3/3.8

All variables given as mean

Figure 1.

Disease activity in early- and late-diagnosed AS and PsA pts

Conclusion

In a real-world setting, secukinumab improved disease activity and global functioning in both AS and PsA pts. Both, male and female AS pts had a higher treatment response when diagnosed early. Interestingly, delay in diagnosis appeared to be BMI-dependent in female AS pts and PsA pts of both genders. However, in contrast to AS, treatment response of early- and late-diagnosed PsA pts did not differ in the further course.

References

[1]Rusman, T., van Bentum, R.E. & van der Horst-Bruinsma, I.E. Rheumatology59, iv38-iv46 (2020). 2. Passia, E., et al. OP0057. Annals of the Rheumatic Diseases79, 38-39 (2020).

Disclosure of Interests

Karolina Benesova Speakers bureau: Abbvie, BMS, Gilead/Galapagos, Janssen, Lilly, Medac, MSD, Novartis, Roche, Viatris, Consultant of: Gilead/Galapagos, Novartis, Grant/research support from: Abbvie, Novartis, Oliver Hansen Grant/research support from: Novartis, Uta Kiltz Consultant of: AbbVie, Amgen, Biogen, Chugai, Eli Lilly, Gilead, GSK, Grünenthal, Hexal, Janssen, MSD, Novartis, Pfizer, Roche, UCB, Grant/research support from: AbbVie, Amgen, Biogen, Chugai, Eli Lilly, Gilead, GSK, Grünenthal, Hexal, Janssen, MSD, Novartis, Pfizer, Roche, UCB, Jan Brandt-Juergens Consultant of: Abbvie, Affibody, BMS, Gilead, Janssen, Lilly, Medac, MSD, Novartis, Pfizer, Roche, Sanofi-Aventis, UCB, Peter Kästner Consultant of: Chugai, Novartis, Elke Riechers Consultant of: AbbVie, Chugai, Novartis, UCB, Grant/research support from: AbbVie, Chugai, Novartis, UCB, Pfizer, Daniel Peterlik Employee of: Novartis, Christina Budden Employee of: Novartis, Annika Boas Employee of: Novartis, Stefanie Welle Employee of: Novartis, Hans-Peter Tony Consultant of: AbbVie, Astra-Zeneca, BMS, Chugai, Janssen, Lilly, MSD, Novartis, Pfizer, Roche, Sanofi

Hypertension outcomes of adrenalectomy for unilateral primary aldosteronism

PURPOSE

To evaluate laboratory and clinical results after unilateral adrenalectomy in patients with primary aldosteronism (PHA).

METHODS

A cross-sectional analysis was performed using data from patients who underwent transperitoneal laparoscopic adrenalectomy for PHA, between January 2008 and December 2019. Surgical indications were based on adrenal venous sampling without ACTH stimulation. Analyses included patient demographics; preoperative clinical, pharmacological, laboratory, and radiological data; and postoperative results assessed after a median of 4 months. Antihypertensive drug use was quantified by estimating the daily defined dose (DDD) of antihypertensive medication, thus enabling standardized comparison of dosage between the drug classes. Statistical assessments included univariable and multivariable logistic regression analysis.

RESULTS

This study enrolled 87 patients. The patients were taking 5.4 DDD of antihypertensive medication before surgery, and 3.0 DDD after surgery. Complete biochemical success of surgery was reached 67 patients (77%), 19 patients (22%) had partial biochemical success. Complete clinical success with normalization of blood pressure and withdrawal of all antihypertensive drugs was achieved in 19 patients (22%). 57 patients (65%) exhibited a reduction of DDD after surgery and/or improvement of blood pressure-partial clinical success. Thus, in 76 (87%) of all enrolled patients, surgery had an overall positive effect on hypertension control. Multivariable logistic regression showed that complete clinical success was independently associated with female gender and baseline sum of antihypertensive drugs DDD < 4.

CONCLUSION

A majority of patients undergoing unilateral adrenalectomy for PHA achieved markedly improved hypertension control, despite almost halving their antihypertensive medication. Almost a quarter of patients were cured and able to cease using all antihypertensive drugs.

Kinetics of Biomarkers of Oxidative Stress in Septic Shock: A Pilot Study

Septic shock is a major cause of mortality in ICU patients, its pathophysiology is complex and not properly understood. Oxidative stress seems to be one of the most important mechanisms of shock progression to multiple organ failure. In the present pilot study, we have analysed eight oxidative-stress-related biomarkers in seven consecutive time points (i.e., the first seven days) in 21 septic shock patients admitted to the ICU. Our objective was to describe the kinetics of four biomarkers related to pro-oxidative processes (nitrite/nitrate, malondialdehyde, 8-oxo-2′-deoxyguanosine, soluble endoglin) compared to four biomarkers of antioxidant processes (the ferric reducing ability of plasma, superoxide dismutase, asymmetric dimethylarginine, mid-regional pro-adrenomedullin) and four inflammatory biomarkers (CRP, IL-6, IL-10 and neopterin). Furthermore, we analysed each biomarker’s ability to predict mortality at the time of admission and 12 h after admission. Although a small number of study subjects were recruited, we have identified four promising molecules for further investigation: soluble endoglin, superoxide dismutase, asymmetric dimethylarginine and neopterin.

Pharmacotherapy of diabetes mellitus in patients with heart failure - a nation-wide analysis of contemporary treatment

AIM

Retrospective national sub-analysis of antidiabetic pharmacotherapy in patients with diabetes mellitus (DM) and heart failure (HF) based on data reported to the National Register of Paid Health Services in the Czech Republic between 2012-2018.

METHODOLOGY AND RESULTS

In 2012, there were 75,022 patients with HF and DM (i.e. 42.5% of patients with HF), 6 years later 117,265 (i.e. 41.0% of HF patients in 2018). The most represented antidiabetic drug was metformin (45.6%). Of the insulins and analogues, glargine showed the largest positive trend (5.8% 2012; 14.8% 2018). Empagliflozin was the most prescribed SGLT-2 inhibitor (1.8% in 2018). A decrease in prescribing was observed for saxagliptin (0.5% 2012; 0.1% 2018) and for sulfonylurea derivates - gliclazide (13.0% 2012; 10.3% in 2018) and glimepiride (12.9% 2012; 9.0% 2018). Linagliptin was the most prescribed dipeptidyl peptidase inhibitor (0.7% 2012; 6.8% 2018).

CONCLUSION

In the Czech Republic, between 2012 and 2008, there was an increase in prevalence of patients with heart failure and concomitant diabetes mellitus, their proportion being similar. In correspondence with other registries, metformin was used mostly. A positive trend was observed in prescription of DDP-4 and SGLT-2 inhibitors, while there was a significant decrease in patients taking sulfonylureas.

Left Atrial Appendage Closure versus Non-Warfarin Oral Anticoagulation in Atrial Fibrillation: 4-Year Outcomes of PRAGUE-17

BACKGROUND

The PRAGUE-17 trial demonstrated that left atrial appendage closure (LAAC) was non-inferior to non-warfarin oral anticoagulants (NOAC) for preventing major neurological, cardiovascular or bleeding events in high-risk patients with atrial fibrillation (AF).

OBJECTIVE

To assess the pre-specified long-term (4-year) outcomes in PRAGUE-17.

METHODS

PRAGUE-17 was a randomized non-inferiority trial comparing percutaneous LAAC (Watchman or Amulet) with NOACs (95% apixaban) in non-valvular AF patients with a history of cardioembolism, clinically-relevant bleeding, or both CHA₂DS₂-VASc > 3 and HASBLED > 2. The primary endpoint was a composite of cardioembolic events (stroke, transient ischemic attack, or systemic embolism), cardiovascular death, clinically-relevant bleeding, or procedure/device-related complications (LAAC group only). The primary analysis was modified intention-to-treat (mITT).

RESULTS

We randomized 402 AF patients (201 per group, age 73.3±7.0 years, 65.7% male, CHA₂DS₂-VASc 4.7+1.5, HASBLED 3.1+0.9). After 3.5 years median follow-up (1,354 patients-years), LAAC was non-inferior to NOAC for the primary endpoint by mITT (subdistribution hazard ratio[sHR] 0.81, 95% CI 0.56-1.18; p=0.27; p for non-inferiority=0.006). For the components of the composite endpoint, the corresponding sHRs (and 95% CIs) were 0.68 (0.39-1.20; p=0.19) for cardiovascular death, 1.14 (0.56-2.30; p=0.72) for all-stroke/TIA, 0.75 (0.44-1.27; p=0.28) for clinically-relevant bleeding, and 0.55 (0.31-0.97; p=0.039) for non-procedural clinically-relevant bleeding. The primary endpoint outcomes were similar in the per-protocol [sHR 0.80 (95% CI 0.54-1.18), p=0.25] and on-treatment [sHR 0.82 (95% CI 0.56-1.20), p=0.30] analyses.

CONCLUSION

In long-term follow-up of PRAGUE-17, LAAC remains non-inferior to NOACs for preventing major cardiovascular, neurological or bleeding events. Furthermore, non-procedural bleeding was significantly reduced with LAAC.

Prognostic value of oxidative stress in patients with acute myocardial infarction complicated by cardiogenic shock: A prospective cohort study

INTRODUCTION

Cardiogenic shock is a frequent complication of acute myocardial infarction. Similar to ischemia/reperfusion injury, excessive production of reactive oxygen species can be expected in those who experience cardiogenic shock. The aims of this study were to describe the extent and time course of oxidative stress and evaluate the prognostic value of oxidative stress markers in patients who experienced ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock.

METHODS

Plasma/serum levels of selected biomarkers of oxidative stress (oxidised guanine species (OGS), malondialdehyde, and glutathione peroxidase 3) and markers, which simultaneously reflect severe cellular damage (ferric ion reducing antioxidant power (FRAP), Cu/Zn-superoxide dismutase (SOD), and glutathione) were measured seven times per week in a prospective cohort of 82 patients with STEMI complicated by cardiogenic shock.

RESULTS

We found elevated OGS levels in patients who died during three months, which persisted significantly increased the next 12 h compared to surviving patients. A similar time course pattern also exhibited concentrations of FRAP and SOD. The other markers did not change significantly and did not show differences between surviving and non-surviving patients during the monitored period. In addition, a strong relationship between OGS, FRAP, and SOD levels (on admission and 12 h after admission) and 3-month mortality was found.

CONCLUSION

Levels of OGS, FRAP, and SOD within 12 h after hospital admission were revealed as early predictors of the adverse development of STEMI complicated by cardiogenic shock.

The effect of left atrial appendage closure on heart failure biomarkers: A PRAGUE-17 trial subanalysis

INTRODUCTION

The randomized PRAGUE-17 trial demonstrated noninferiority of left atrial appendage closure (LAAC) to non-vitamin K anticoagulants (NOACs) for the prevention of major cardiovascular or cerebrovascular events. However, the left atrial appendage is an important source of natriuretic peptides and plays a role in left atrial reservoir function. Changes of heart failure (HF) biomarkers after LAAC compared to NOAC has not been studied. The aim of the study was to compare the changes in concentrations of HF biomarkers between LAAC and NOAC patients.

METHODS

Of 402 patients randomized in the PRAGUE-17 trial, biomarkers were analyzed in 144 patients (73 in the NOAC and 71 in the LAAC group). Both groups had similar baseline characteristics. Serum concentration of NT-proBNP, NT-proANP, Galectin-3, and GDF-15 were measured at baseline (before the procedure in the LAAC group), at the 6-month (and at 24-month for NT-proBNP) follow-up timepoint.

RESULTS

There were no significant differences in baseline, 6 month, and delta (δ = baseline - 6 month) concentrations of NT-proANP between the groups (NOAC: baseline 2.6 [0.5; 4.9], 6-month 3.1 [1.8; 4.8], p = .068; LAAC: baseline 3.3 [1.1; 4.6], 6-month 2.6 [0.9; 5.3], p = .51; p value for δ in concentrations between groups = 0.42). Similarly, there were no significant differences in baseline, 6, 24 months, and delta concentrations of NT-proBNP between the groups (NOAC: baseline 461.0 [113.5; 1342.0], 6 month 440.0 [120.5; 1291.5], 24 month 798 [274; 2236], p = .39; LAAC: baseline 421.0 [100.0; 1320.0], 6 month 601.0 [145.0; 1230.0], 24 month 855 [410; 1367], p = .28; p value for δ in concentrations between groups = 0.73 at 6 months, and 0.58 at 24 months). Finally, no significant differences were present in baseline, 6 month, and δ concentrations of Galectin-3 and GDF-15 between the two groups.

CONCLUSION

LAAC did not significantly influence the levels of HF biomarkers 6 months after the procedure.

Prognostic value of high-sensitivity cardiac troponin I in heart failure patients with mid-range and reduced ejection fraction

Background

The identification of high-risk heart failure (HF) patients makes it possible to intensify their treatment. Our aim was to determine the prognostic value of a newly developed, high-sensitivity troponin I assay (Atellica^®, Siemens Healthcare Diagnostics) for patients with HF with reduced ejection fraction (HFrEF; LVEF < 40%) and HF with mid-range EF (HFmrEF) (LVEF 40%–49%).

Methods and results

A total of 520 patients with HFrEF and HFmrEF were enrolled in this study. Two-year all-cause mortality, heart transplantation, and/or left ventricular assist device implantation were defined as the primary endpoints (EP). A logistic regression analysis was used for the identification of predictors and development of multivariable models. The EP occurred in 14% of the patients, and these patients had higher NT-proBNP (1,950 vs. 518 ng/l; p < 0.001) and hs-cTnI (34 vs. 17 ng/l, p < 0.001) levels. C-statistics demonstrated that the optimal cut-off value for the hs-cTnI level was 17 ng/l (AUC 0.658, p < 0.001). Described by the AUC, the discriminatory power of the multivariable model (NYHA > II, NT-proBNP, hs-cTnI and urea) was 0.823 (p < 0.001). Including heart failure hospitalization as the component of the combined secondary endpoint leads to a diminished predictive power of increased hs-cTnI.

Conclusion

hs-cTnI levels ≥ 17 ng/l represent an independent increased risk of an adverse prognosis for patients with HFrEF and HFmrEF. Determining a patient’s hs-cTnI level adds prognostic value to NT-proBNP and clinical parameters.

POS0472 COMPARATIVE METABOLOMIC ANALYSIS OF SERUM SAMPLES FROM PATIENTS WITH COINCIDENTAL RHEUMATOLOGICAL AND MALIGNANT DISEASES

Background:

Rheumatic and musculoskeletal diseases (RMDs) and malignancies are both caused by a dysfunctional immune system and the probability of their coincidence in one individual is rising due to advances in cancer treatment and demographic changes. However, the lack of understanding of the complex interrelationship of both conditions often leads to undertreatment and high level of suffering in affected patients. Herein, the MalheuR project breaks new ground by systematic analysis of concomitant malignant and rheumatic diseases and closes the knowledge gaps on the clinical and molecular level.

Objectives:

To enable early diagnosis of concomitant malignancy and/or identification of patients at risk in the future, changes in serum metabolome were explored in order to create a diagnostic classification model.

Methods:

Serum samples from patients with concomitant RMD and cancer or obligate precancerous lesions (n=78, breast cancer (23), melanoma (14), MGUS (12), prostate cancer (8) and others (21)) were collected as a pilot study within the MalheuR project, a registry-based study initiated in 2018 at the university hospital Heidelberg, Germany. The following groups were defined by the underlying RMD: rheumatoid arthritis (n=42), psoriasis arthritis (n=23), spondylarthritis (n=9) and systemic lupus erythematosus (n=4). RMD patients without any malignancies were used as controls (n=280: 122 RA, 81 PsA, 46 SpA, 31 SLE).

Samples were analyzed by 1H NMR spectroscopy. For all samples, regular 1H acquisition with presaturation and Carr-Purcell-Meiboom-Gill (CPMG) spectra were acquired using a 600 MHz Bruker NMR spectrometer. Spectra were processed with TopSpin using 0.2 Hz of line broadening and manual phasing. Molar concentrations of 26 metabolites were acquired by integration of NMR spectra. With GraphPad Prism, univariate and ANOVA statistical analysis was performed to find significant differences between each malignant group and their control group as well as between all four malignant groups.

Results:

Mean disease duration was 11.8 ±10.5 years for cancer and 12.8±10.8 years for RMDs since diagnosis. 1.4% received cancer treatment (6.4% of malignancy group), 69.3% csDMARDs, 42.3% b/tsDMARDs and 46.4% glucocorticoids at the time of sample collection.

Most metabolites tested were significantly lower in the malignancy groups versus associated controls: Concentrations of amino acids V and L were significantly reduced in all malignancy samples. Additionally, T, D, N, Q, E, A, I were altered in RA, SpA and PsA, changes in G were seen in RA, PsA and SLE and P was altered in RA and PsA only. Furthermore, lower concentrations of short chain fatty acids and tricarboxylic acid cycle intermediates were present in the malignancy groups. In no case was a metabolite concentration significantly higher in the malignancy group than in the associated control. When comparing the metabolome within the four malignancy groups, only the concentrations of creatine, threonine and isoleucine were found higher in RA patients with malignancy.

Conclusion:

Significant differences between the metabolomic fingerprints of RMD patients with and without malignancies could be observed. These changes might be characteristic for cancer burden, as in most cases the underlying RMD was not relevant when comparing the concentrations between the malignancy groups. Our results may promote understanding of the interrelationships of both disease entities as well as prove useful as biomarkers for diagnostic and therapeutic purposes.

Acknowledgements:

Grant/research support from medical faculty (Olympia Morata Programme) and foundations commission (Herbert Daus estate) of University of Heidelberg

Disclosure of Interests:

None declared

POS0293 TRheuMa REGISTRY PROVIDES FIRST EVIDENCE OF DIFFERENT COURSE OF RHEUMATIC IMMUNE-RELATED ADVERSE EVENTS AND TUMOUR RESPONSE RATES DEPENDING ON THE TUMOUR ENTITY

Background:

Rheumatic immune-related adverse events (irAE) are associated with a better tumour response to immune checkpoint inhibitors (ICI). In contrast to other irAEs, their potentially chronic course may require long-term immunosuppressive treatment.

Objectives:

Our registry-based study analyses real-world data on the characteristics and outcome of rheumatic irAEs and underlying malignancy. Herein, we present first evidence that these parameters and the optimal clinical management may differ depending on the tumour entity.

Methods:

The TRheuMa registry is a prospective long-term observational study of a patient cohort suffering from rheumatic side effects of cancer therapies with focus on ICI. It is part of the MalheuR project initiated in July 2018 at the University Hospital Heidelberg to explore interrelations of malignancies and RMDs.

Results:

64 patients were recruited due to a rheumatic irAE under ICI treatment (nivolumab n=30, pembrolizumab n=33, ipilimumab n=12, PD-L1i n=5, ipi/nivo n=10) with a follow-up of up to 30 months. Of these, 47% had NSCLC and 41% melanoma. In local cohorts of patients receiving ICI, 4% of NSCLC (n total=888) and 13% of melanoma (n total=195) developed a rheumatic irAE. 7% of NSCLC and 23% of melanoma patients experienced a flare of a pre-existing RMD. De novo irAE mostly resembled phenotypes of spondyloarthritis both in NSCLC (43%) as well as in melanoma patients (33%). CRP levels were increased in 83% of NSCLC and 71% of melanoma patients. Almost all irAE patients showed autoantibody negativity and signs of inflammation in ultrasound examination (96%). Comparison of best responses to treatment in patients with and without rheumatic irAE in melanoma and without any irAE in NSCLC patients were as following: Complete remission (CR) in 48% vs. 4% of melanoma patients and partial remission (PR) in 68% vs. 41% of NSCLC patients. In accordance with our severity-based treatment algorithm, 25% of the melanoma patients in CR and 16% of the NSCLC patients in PR needed add-on DMARDs for sufficient irAE-treatment. ICI-treatment was discontinued in 7 cases (17% NSCLC, 8% melanoma)

Conclusion:

Prospective real-world data from the TRheuMa-registry provide first evidence that rheumatic irAE have distinct characteristics depending on the underlying malignancy. Oncological outcome was better with rheumatic irAE than in their absence and this effect was more pronounced in melanoma patients despite a larger use of immunosuppressants for irAE-treatment.

Disclosure of Interests:

Leonore Diekmann: None declared, Lea Daniello: None declared, Julia Kunz: None declared, Jan Leipe Consultant of: Pfizer; Novartis; Honoraria (self), Abbvie; Astra Zeneca; BMS; Celgene; Hospira; Janssen-Cilag; Gilead; LEO Pharma; Lilly; MSD; Roche; Sanofi; UCB., Grant/research support from: Research grant/Funding (self): Pfizer; Novartis; Honoraria (self), Hanns-Martin Lorenz Consultant of: Abbvie; BMS; MSD; Pfizer; Celgene; Roche; Chugai; Medac; GSK; Honoraria (self), Novartis; UCB; Janssen-Cilag; Astra Zeneca; Lilly, Grant/research support from: Research grant/Funding (institution): Abbvie; BMS; MSD; Pfizer; Celgene; Roche; Chugai; Medac; GSK; Honoraria (self), Research grant/Funding (institution), Novartis; UCB; Janssen-Cilag; Astra Zeneca; Lilly; Research grant/Funding (institution): Baxter; SOBI; Biogen; Actelion; Mundipharma; Bayer Vital; Octapharm; Sanofi; Hexal; Thermo Fischer; Shire., Jessica Hassel Consultant of: MDS; Honoraria (self): Roche; Novartis; Pierre Fabre., Grant/research support from: BMS; Honoraria (self), Karin Jordan Consultant of: Advisory/Consultancy: Amgen; Merck; MSD; Riemser; Helsinn; Tesaro; Kreussler; Voluntis; Pfizer; Pomme-med; Hexal., Petros Christopoulos Consultant of: advisory board/lecture fees from AstraZeneca, Boehringer Ingelheim, Chugai, Novartis, Pfizer, Roche, Takeda., Grant/research support from: research funding from AstraZeneca, Novartis, Roche, Takeda, Karolina Benesova Grant/research support from: Foundations and Awards” commission of the University of Heidelberg: University of Heidelberg; AbbVie; Novartis; Rheumaliga Baden-Württemberg e.V

Covidogram as a simple tool for predicting severe course of COVID-19: population-based study

OBJECTIVES

COVID-19 might either be entirely asymptomatic or manifest itself with a large variability of disease severity. It is beneficial to identify early patients with a high risk of severe course. The aim of the analysis was to develop a prognostic model for the prediction of the severe course of acute respiratory infection.

DESIGN

A population-based study.

SETTING

Czech Republic.

PARTICIPANTS

The first 7455 consecutive patients with COVID-19 who were identified by reverse transcription-PCR testing from 1 March 2020 to 17 May 2020.

PRIMARY OUTCOME

Severe course of COVID-19.

RESULT

Of a total 6.2% of patients developed a severe course of COVID-19. Age, male sex, chronic kidney disease, chronic obstructive pulmonary disease, recent history of cancer, chronic heart failure, acid-related disorders treated with proton-pump inhibitors and diabetes mellitus were found to be independent negative prognostic factors (Area under the ROC Curve (AUC) was 0.893). The results were visualised by risk heat maps, and we called this diagram a 'covidogram'. Acid-related disorders treated with proton-pump inhibitors might represent a negative prognostic factor.

CONCLUSION

We developed a very simple prediction model called 'covidogram', which is based on elementary independent variables (age, male sex and the presence of several chronic diseases) and represents a tool that makes it possible to identify-with a high reliability-patients who are at risk of a severe course of COVID-19. Obtained results open clinically relevant question about the role of acid-related disorders treated by proton-pump inhibitors as predictor for severe course of COVID-19.

Prediction of serum NGAL levels using comorbidity AHEAD score and two-year prognosis in stable chronic heart failure patients (FAR NHL registry)

Background

Neutrophil gelatinase-associated lipocalin (NGAL) is marker of renal function and is strongly associated with presence of comorbidities. AHEAD comorbidity score is commonly used to predict survival in acute heart failure patients and could predict events even in chronic heart failure.

Methods

547 stable patients with chronic heart failure patients with left ventricular ejection fraction &lt;50% were included in FARmacology and NeuroHumoraL activation (FAR NHL) registry. Three cardiological centres from The Czech Republic with speciality in heart failure were participating.

Results

Median age was 66 years, 80.3% were men. The etiology of heart failure was in 54% ischemic heart disease, in 40% dilatated cardiomyopathy, in 0.5% hypertrophic cardiomyopathy. 60% of patients were in NYHA class II.

In the first two years of follow-up, 74 events (13.5%) occurred, including all-cause death, left ventricle assist device implantation or orthotopic heart transplantation.

The AHEAD comorbidity score (Atrial fibrillation, low Haemoglobin level &lt;120 g/L in female or &lt;130 g/L in male, Elderly &gt;70 years; Abnormal renal parameters with creatinine &gt;130 μmol/L, Diabetes mellitus; 1 point for each comorbidity present) was set in this registry. Patients with AHEAD 0–1 survived without event in 89.2%, AHEAD 2–3 in 82.4% and AHEAD 4–5 only in 63.5% (p&lt;0.001; pairwise comparison 0.034, &lt;0.001, 0.021).

Also levels of NGAL are higher when comorbidities from AHEAD score are present: Atrial fibrillation (62 vs. 50 ng/mL; p&lt;0.001), Haemoglobin level (Spearman's rank correlation coefficient −0.240; p&lt;0.001), Eldery (Spearman's coefficient 0.425; p&lt;0.001), Abnormal creatinine level (Spearman's coefficient 0.528; p&lt;0.001), Diabetes mellitus (57 vs. 51 ng/mL; p=0.006).

NGAL levels are singificantly higher in patients with higher AHEAD score. Mean level of NGAL in AHEAD 0–1 (N=320) is 51 ng/mL, in AHEAD 2–3 (N=190) is 78 ng/mL and in AHEAD 4–5 (N=37) is 142 ng/mL (Kruskal-Wallis test p&lt;0.001, pairwise comparision all &lt;0.001).

Conclusion

In stable chronic heart failure registry FAR NHL, comorbidity score AHEAD can predict events. Serum NGAL level is significantly higher when AHEAD score comorbidities are present: Atrial fibrillation, low Haemoglobin, Eldery, Abnormal renal function and Diabetes mellitus.

Funding Acknowledgement

Type of funding source: None

AB1021 CHARACTERISTICS AND MANAGEMENT OF RHEUMATIC MANIFESTATION UNDER ESTROGEN RECEPTOR-TARGETING CANCER THERAPIES, DATA FROM A PROSPECTIVE REGISTRY

Background:

The knowledge about interdependencies between rheumatic manifestations and malignancies is limited. Further, reliable data on the occurrence of rheumatic symptoms as side effects of specific cancer therapies beyond checkpointinhibitor-induced immune-related adverse events are sparse. In this regard, although arthralgia under estrogen receptor-targeting therapies (aromatase inhibitors and the estrogen receptor modulator tamoxifen) has been frequently reported in oncological clinical trials and case reports, prospective data including an assessment of rheumatic manifestations by rheumatologists are lacking.

Objectives:

To contribute to a better understanding of interdependencies between rheumatic manifestations and cancer/ estrogen blockade and potentially improve the management of both entities, pilot data were analysed.

Methods:

Data on characteristics and treatment of rheumatic manifestations and cancer as well as their timely association were systematically, prospectively collected and analysed in the MalheuR (´malignancy and rheumatic disease´) registry, a long-term, observational study designed to study patients suffering from concomitant rheumatic disease and malignancy and/or premalignant lesions.

Results:

We identified 11 patients with rheumatic manifestations under estrogen receptor-targeting therapies (3 anastrozol, 4 letrozol, 8 tamoxifen) as part of breast cancer treatment. In addition to breast cancer one patient had a lymphoma 3 years after and another patient had a non-small cell lung cancer 2 years before breast cancer diagnosis. The patients had different cancer stages (5 IA, 3 IIA, 1 IIB, and 1 IVA). Their mean age at cancer diagnosis was 60.4 ± 11.6 years and all patients are females. The time interval between diagnosis of cancer and onset of systemic/ rheumatic symptoms was 49.5 ± 34.0 months. Of interest, the time interval between onset of rheumatic symptoms and first assessment by a rheumatologist was 16.9 ± 22.3 months. The following systemic and rheumatic symptoms were reported: arthralgia in 10, arthritis in 8 (small joints in 5, large joints in 3 affected), morning stiffness (>30 min) in 7, IBP in 1, myalgia in 7, sicca symptoms in 2, fever in 1 (new-onset FMF with heterozygous M694U mutation), class IV glomerulonephritis and polyserositis in 1 (with new-onset SLE) patient(s). Disease burden at baseline was rather high with a mean VAS pain of 65 (±12.9)/100. Laboratory analyses revealed an increased CRP in 6/11 (55%) with a mean of 10.3 ± 8.2 mg/l (<5). Autoantibody positivity was observed for ANAs in 5/10 (50%, titers ranging from 1:80 to 1:160), anti-dsDNA in 1, rheumatoid factor in only 1/10 (10%) patients, none was anti-CCP positive. Before consulting a rheumatologist, patients were treated with NSAR 3/11 (27%), 10/11 systemic glucocorticoids (91%) with an initial dose of 17.5 ± 19.5 mg and intra-articular glucocorticoids 1/11 (9%). Rheumatological assessment lead to initiation of csDMARDs (3/11 MTX, 1/11 SSZ, 1/11 HCQ, 1/11 AZA (later MMF/ rituximab in the SLE patient) 1/11 colchicine) as corticosteroid-sparing agents with good response in the majority of patients.

Conclusion:

Our data demonstrate heterogeneous rheumatic manifestations, partially with severe manifestations beyond arthralgia, so far not reported by oncological studies including follow-up, which might suggest an underreporting. Furthermore, despite close monitoring in tumor aftercare, our data show a considerable delay in referral to a rheumatologist and initiation of suitable treatment. The prospective design of the MalheuR registry enables future validation of our pilot data.

Disclosure of Interests:

Alina Dr. Patroi Consultant of: Advisory board Novartis, Leonore Diekmann: None declared, Hanns-Martin Lorenz Grant/research support from: Consultancy and/or speaker fees and/or travel reimbursements: Abbvie, MSD, BMS, Pfizer, Celgene, Medac, GSK, Roche, Chugai, Novartis, UCB, Janssen-Cilag, Astra-Zeneca, Lilly. Scientific support and/or educational seminars and/or clinical studies: Abbvie, MSD, BMS, Pfizer, Celgene, Medac, GSK, Roche, Chugai, Novartis, UCB, Janssen-Cilag, Astra-Zeneca, Lilly, Baxter, SOBI, Biogen, Actelion, Bayer Vital, Shire, Octapharm, Sanofi, Hexal, Mundipharm, Thermo Fisher., Consultant of: see above, Bernhard. Kraemer: None declared, Karolina Benesova Grant/research support from: Study grants for SCREENED study by Abbvie, Novartis and Rheumaliga Baden-Württemberg, Consultant of: One-time participation in Novartis advisory board., Jan Leipe Grant/research support from: Consultancy and speaker fees: Abbvie, AstraZeneca, BMS, Celgene, Hospira, Janssen-Cilag, LEO Pharma, Lilly, MSD, Novartis, Pfizer, Roche, Sanofi, UCB. Scientific support: Novartis, Pfizer., Consultant of: Consultancy and speaker fees: Abbvie, AstraZeneca, BMS, Celgene, Hospira, Janssen-Cilag, LEO Pharma, Lilly, MSD, Novartis, Pfizer, Roche, Sanofi, UCB. Scientific support: Novartis, Pfizer., Speakers bureau: Abbvie, AstraZeneca, BMS, Celgene, Hospira, Janssen-Cilag, LEO Pharma, Lilly, MSD, Novartis, Pfizer, Roche, Sanofi, UCB

SAT0578 RHEUMAL REGISTRY PROVIDES FIRST INSIGHTS INTO MUTUAL INTERDEPENDENCIES BETWEEN RHEUMATIC AND MUSCULOSKELETAL DISEASES AND MALIGNANCIES

Background:

Knowledge about interdependencies between rheumatic and musculoskeletal diseases (RMDs) and malignancies is limited on the clinical and molecular level. Particularly, valid prospective data on the timely association of malignancies in patients with RMDs and treatment of the latter are sparse.

Objectives:

Due to the heterogeneous patient population, a registry-based study has been conducted in order to provide insights into mutual interdependencies and novel evidence for suitable clinical management of patients with concomitant RMD and malignancies.

Methods:

The RheuMal registry is a long-term, open-end observational study designed to address the specific situation of patients suffering from concomitant RMD and concomitant malignancy and/or premalignant conditions. The RheuMal registry is one of the three subregistries of the MalheuR project, a registry-based study initiated in July 2018 at the at the university hospital Heidelberg, Germany.

Results:

Data from the RheuMal registry (n=404) show an earlier onset of gender-specific cancers and malignant melanoma in RMD patients compared to data from the German Cancer Registry Data of the Robert-Koch-Institute: compared to the reference population, in RMD patients breast cancer (n=32) occurred 5.3 years and prostate cancer (n=16) 3.3 years earlier. Onset of malignant melanoma was 2.4 years earlier in females (n=9) and 1.1 years in males (n=7) with concomitant RMD. The mean latency between the initial diagnosis of the RMD and the later occurring malignant condition was 10.2 years. The diagnosis of the malignancy frequently led to a change or interruption of disease-modifying antirheumatic therapy in RMDs.

Conclusion:

The RheuMal registry offers first insights into interdependencies between RMDs and malignancies based on demographic data, disease characteristics, clinical management and outcome as well as correlation of specific diagnoses and therapies. The earlier onset of gender-specific cancers and malignant melanoma suggests differences in the epidemiology and course of the malignant disease in RMD patients compared to a healthy reference population, suggesting interdependency between the two disease entities. Future research will focus on further understanding of this interdependency und the underlying molecular mechanisms.

Disclosure of Interests:

Karolina Benesova Grant/research support from: Study grants for SCREENED study by Abbvie, Novartis and Rheumaliga Baden-Württemberg, Consultant of: One-time participation in Novartis advisory board., Leonore Diekmann: None declared, Maria Czaja: None declared, Karin Jordan Consultant of: Consultancy and/or speaker fees: MSD, Merck, Amgen, Hexal, Riemser, Helsinn, Tesaro, Kreussler, Voluntis, Pfizer, Pomme-med., Jan Leipe Grant/research support from: Consultancy and speaker fees: Abbvie, AstraZeneca, BMS, Celgene, Hospira, Janssen-Cilag, LEO Pharma, Lilly, MSD, Novartis, Pfizer, Roche, Sanofi, UCB. Scientific support: Novartis, Pfizer., Consultant of: Consultancy and speaker fees: Abbvie, AstraZeneca, BMS, Celgene, Hospira, Janssen-Cilag, LEO Pharma, Lilly, MSD, Novartis, Pfizer, Roche, Sanofi, UCB. Scientific support: Novartis, Pfizer., Speakers bureau: Abbvie, AstraZeneca, BMS, Celgene, Hospira, Janssen-Cilag, LEO Pharma, Lilly, MSD, Novartis, Pfizer, Roche, Sanofi, UCB, Hanns-Martin Lorenz Grant/research support from: Consultancy and/or speaker fees and/or travel reimbursements: Abbvie, MSD, BMS, Pfizer, Celgene, Medac, GSK, Roche, Chugai, Novartis, UCB, Janssen-Cilag, Astra-Zeneca, Lilly. Scientific support and/or educational seminars and/or clinical studies: Abbvie, MSD, BMS, Pfizer, Celgene, Medac, GSK, Roche, Chugai, Novartis, UCB, Janssen-Cilag, Astra-Zeneca, Lilly, Baxter, SOBI, Biogen, Actelion, Bayer Vital, Shire, Octapharm, Sanofi, Hexal, Mundipharm, Thermo Fisher., Consultant of: see above

AB1147 SCREENED – HIGH REMISSION RATES UNDERLINE THE BENEFIT OF SCREENING CONSULTATION MODELS FOR EARLY RECOGNITION AND TREATMENT OF RHEUMATIC AND MUSCULOSKELETAL DISEASES

Background:

Early recognition and treatment of rheumatic and musculoskeletal diseases (RMDs) is of critical importance for the individual outcome. However, nationwide health care structures in Germany do not facilitate early access to initial rheumatologic evaluation. Furthermore, waiting times of several months due to substantial capacity constrains in regional rheumatology care services compromise the prognostically relevant “window of opportunity” for subsequent sustained remission. To promote early detection of RMDs, the Division of Rheumatology at the University hospital Heidelberg, Germany has launched a unique screening consultation model that offers early access to rheumatologic evaluation on regional level.

Objectives:

The registry-based study SCREENED (“Screen for early diagnosis”) has been initiated to monitor the outcome of patients that were diagnosed with an RMD at the screening clinic and to assess the costs and benefits of this consultation model for the regional quality of care.

Methods:

The screening consultation model has been launched in two phases: in the first phase (02/2016 - 01/2018), a screening clinic open to all patients without previous rheumatologic evaluation with appointments according to the registration order has been established through rearrangement of available capacities. In contrast to regular appointments, the screening clinic took place in shorter consultation time frames and without additional diagnostic procedures. In the second phase (02/2018 - 01/2020), in order to manage and prioritize access to rheumatologic care at our division more efficiently, prior to appointment allocation (not only) to the screening clinic all new patient registrations became subject to a preselection procedure based on the evaluation of an anamnesis questionnaire, medical reports and laboratory findings by an experienced rheumatologist. Furthermore, SCREENED project has been launched for scientific evaluation of both phases of the consultation model.

Results:

The screening consultation model achieved a significant reduction in waiting times to few weeks compared to six months for a regular appointment. In the first phase, the screening clinic had a high sensitivity of 94.3% and an improvable specificity of 31.1%. In the retrospective cohort, high remission rates have been observed over all RMD entities (120/206 = 58.3% patients based on physicians’ assessment in the follow-up after screening clinic) and in rheumatoid arthritis (RA) in particular (38/61 = 62.3% and 33/55 = 60% patients with DAS28 score < 2,6 after 12 and 24 months respectively). Remission was usually reached within a year after the first appointment (9.5 ± 6.7 months), however, a trend to higher remission rates in patients with shorter illness duration was obvious. In RA patients, csDMARDs have been initiated in a third of patients immediately at diagnosis in the screening clinic and in another third within six months after the first appointment. After 12 months, > 80% have received csDMARDs, while only 14.2% needed b/tsDMARDs in the follow-up over 24 months.

Conclusion:

High sensitivity and significant reduction in waiting times for initial rheumatologic evaluation in the screening clinic pave the way for early recognition and treatment of RMDs. Subsequently, high remission rates in the follow-up were reached. In RA, a high proportion of patients only required csDMARDs to achieve sustained remission. A correspondingly small proportion of patients necessitating b/tsDMARD in the follow-up points towards a significant health economic benefit of the early rheumatologic intervention in the screening consultation model.

Disclosure of Interests:

Karolina Benesova Grant/research support from: Study grants for SCREENED study by Abbvie, Novartis and Rheumaliga Baden-Württemberg, Consultant of: One-time participation in Novartis advisory board., Vivienne Lion Grant/research support from: Grant/research support from: Study grants for SCREENED study by Abbvie, Novartis and Rheumaliga Baden-Württemberg, Oliver Hansen Grant/research support from: Grant/research support from: Study grants for SCREENED study by Abbvie, Novartis and Rheumaliga Baden-Württemberg, Hanns-Martin Lorenz Grant/research support from: Consultancy and/or speaker fees and/or travel reimbursements: Abbvie, MSD, BMS, Pfizer, Celgene, Medac, GSK, Roche, Chugai, Novartis, UCB, Janssen-Cilag, Astra-Zeneca, Lilly. Scientific support and/or educational seminars and/or clinical studies: Abbvie, MSD, BMS, Pfizer, Celgene, Medac, GSK, Roche, Chugai, Novartis, UCB, Janssen-Cilag, Astra-Zeneca, Lilly, Baxter, SOBI, Biogen, Actelion, Bayer Vital, Shire, Octapharm, Sanofi, Hexal, Mundipharm, Thermo Fisher., Consultant of: see above

OP0270 TRHEUMA REGISTRY EXPLORES CHARACTERISTICS AND SUITABLE DIAGNOSTIC AND THERAPEUTIC MANAGEMENT OF RHEUMATIC IMMUNE-RELATED ADVERSE EVENTS (IRAES)

Background:

Reports of rheumatic immune-related adverse events (irAEs) in patients receiving immune checkpoint inhibitors (ICPi) have recently attracted new attention to the complex interrelations of malignancies andrheumatic and musculoskeletal diseases (RMDs). Since those two entities represent two sides of a dysregulated immune response, further research on rheumatic irAEs and mechanisms underlying the better tumor response rates in irAE-affected patients may contribute to a better understanding of the different pathophysiology characterizing tumor and rheumatic disease.

Objectives:

Given the heterogeneity of the patient population with rheumatic irAEs, a registry-based study has been conducted to provide first evidence regarding characteristics of rheumatic irAEs and further insights into the optimal diagnostic and therapeutic management of rheumatic irAEs.

Methods:

The TRheuMa registry is a long-term, open-end observational study of a patient cohort suffering from rheumatic symptoms as a result of ICPi or other cancer therapies. The TRheuMa registry is one of the three subregistries of the MalheuR project, a registry-based study initiated in July 2018 at the at the university hospital Heidelberg to explore interrelations of malignancies and RMDs.

Results:

Over 18 months, 52 of 63 patients in the TRheuMa registry were recruited with a rheumatic irAE under ICPi treatment (pembrolizumab n=21, nivolumab n=28, ipilimumab n=11, durvalumab n=1, atezolizumab n=2, avelumab n=1, history of >1 ICPi n=11). Of the 52 patients, 22 (42.3%) had non-small cell lung cancer and 23 (44.2%) had a melanoma. Eight (15.3%) patients experienced a flare of a preexisting RMD under ICPi treatment. The remaining 44 patients withde novoirAEs were characterized by rheumatoid arthritis-like (20.5%) or polymyalgia rheumatica-like (18.1%) and psoriatic or other spondyloarthritis-like phenotypes (50.0%). However, laboratory findings differed from classical RMDs with elevated CRP-levels in 73.1% particularly in psoriatic arthritis-like, but not necessarily in polymyalgia rheumatica-like irAEs. On the contrary, autoantibody positivity was very rare. The majority of patients (78.8%) showed signs of inflammation upon ultrasound examination.

Based on the severity of signs and symptoms as well as treatment response, we developed a therapeutic algorithm for rheumatic irAEs: non-steroidal anti-inflammatory drugs and/or low dosed glucocorticoids (≤10mg prednisone equivalent) as first treatment step were sufficient for 75% patients, whereas 17.3% required higher dosed glucocorticoids and 11.5% patients required further treatment with a cs- or bDMARD. In two cases ICPi-treatment was discontinued on patients’ request due to the pain and functional impairment caused by the rheumatic irAE, although a satisfactory symptom control was reached in the further course.

Complete remission of cancer was observed in 43.5% of melanoma patients, 66.7% experienced additional severe irAEs in other organ systems.

Conclusion:

Overall, data from the TRheuMa-registry show that rheumatic irAEs mostly resemble classical RMDs, however show distinct characteristics. Our diagnostic and therapeutic management of rheumatic irAEs demonstrated efficacy in the majority of patients. These findings contribute to the further understanding of rheumatic irAEs and malignancies. Future research agenda includes a correlation of irAE severity with tumor response.

Disclosure of Interests:

Karolina Benesova Grant/research support from: Study grants for SCREENED study by Abbvie, Novartis and Rheumaliga Baden-Württemberg, Consultant of: One-time participation in Novartis advisory board., Leonore Diekmann: None declared, Hanns-Martin Lorenz Grant/research support from: Consultancy and/or speaker fees and/or travel reimbursements: Abbvie, MSD, BMS, Pfizer, Celgene, Medac, GSK, Roche, Chugai, Novartis, UCB, Janssen-Cilag, Astra-Zeneca, Lilly. Scientific support and/or educational seminars and/or clinical studies: Abbvie, MSD, BMS, Pfizer, Celgene, Medac, GSK, Roche, Chugai, Novartis, UCB, Janssen-Cilag, Astra-Zeneca, Lilly, Baxter, SOBI, Biogen, Actelion, Bayer Vital, Shire, Octapharm, Sanofi, Hexal, Mundipharm, Thermo Fisher., Consultant of: see above, Karin Jordan Consultant of: Consultancy and/or speaker fees: MSD, Merck, Amgen, Hexal, Riemser, Helsinn, Tesaro, Kreussler, Voluntis, Pfizer, Pomme-med., Jan Leipe Grant/research support from: Consultancy and speaker fees: Abbvie, AstraZeneca, BMS, Celgene, Hospira, Janssen-Cilag, LEO Pharma, Lilly, MSD, Novartis, Pfizer, Roche, Sanofi, UCB. Scientific support: Novartis, Pfizer., Consultant of: Consultancy and speaker fees: Abbvie, AstraZeneca, BMS, Celgene, Hospira, Janssen-Cilag, LEO Pharma, Lilly, MSD, Novartis, Pfizer, Roche, Sanofi, UCB. Scientific support: Novartis, Pfizer., Speakers bureau: Abbvie, AstraZeneca, BMS, Celgene, Hospira, Janssen-Cilag, LEO Pharma, Lilly, MSD, Novartis, Pfizer, Roche, Sanofi, UCB

[Side effects of novel cancer immunotherapies]

Systemic treatment with immune checkpoint inhibitors (ICI) has revolutionized the treatment of hematological and oncological diseases in recent years. The mechanism of action hinges on enhancing the natural ability of the immune system to eliminate malignant cells. The most important substances in this arena include inhibitors of PD‑1, PD-L1 and CTLA‑4. As a consequence, the spectrum of treatment-associated adverse reactions is shifting away from classical cytotoxic effects (e.g. pancytopenia and polyneuropathy) towards novel entities of immune-mediated complex diseases. These so-called immune-related adverse events (irAEs) can involve any organ system and mimic known classical autoimmune conditions. Timely recognition of irAEs is the key for rapid initiation of a suitable treatment and is especially challenging in the clinical routine as it requires an intensive interdisciplinary management. Nephrologists are particularly confronted with this kind of problem due to the highly interdisciplinary nature of their work. This article summarizes the broad spectrum of currently known renal and more frequently occuring non-renal forms of irAEs and aims to prime the reader on diagnostic and therapeutic options.

Activation of the Nitric Oxide Pathway and Acute Myocardial Infarction Complicated by Acute Kidney Injury

BACKGROUND/AIMS

The pathophysiology of acute kidney injury (AKI) in ST-elevation myocardial infarction (STEMI) patients remains poorly explored. The involvement of the nitric oxide (NO) pathway has been demonstrated in experimental ischemic AKI. The aim of this study was to assess the predictive value of circulating biomarkers of the NO pathway for AKI in STEMI patients.

METHODS

Four hundred and twenty-seven STEMI patients treated with primary percutaneous coronary intervention were included. The primary end point was AKI. Biomarkers of the NO pathway (plasma superoxide dismutase [SOD], uric acid, nitrite/nitrate [NOx], neopterin) as well as cardiac biomarkers (B-type natriuretic peptide [BNP] and troponin) were sampled 12 h after admission. The predictive value of circulating biomarkers was evaluated in addition to the multivariate clinical model.

RESULTS

AKI developed in 8.9% of patients. The 3-month mortality was significantly higher in patients with AKI (34.2 vs. 4.1%; p < 0.001). SOD, uric acid, NOx, neopterin, BNP and troponin were significantly associated with the development of AKI (area under curve [AUC]-receiver operating curve [ROC] ranging between 0.70 and 0.81). In multivariate analysis cardiogenic shock, neopterin, NOx and troponin were independent predictors of AKI. AUC-ROC of the association of multibiomarkers and clinical model was 0.90 and outperformed the predictive value of the clinical model alone. OR of NOx ≥45 µmol/L was 8.0 (95% CI 3.1-20.6) for AKI.

CONCLUSION

Biomarkers of the NO pathway are associated with the development of AKI in STEMI patients. These results provide insights into the pathophysiology of AKI and may serve at developing preventing strategies for AKI targeting this pathway.

[Early recognition and screening consultation: a necessary way to improve early detection and treatment in rheumatology? : Overview of the early recognition and screening consultation models for rheumatic and musculoskeletal diseases in Germany]

In order to reduce the prognostically relevant time interval between the initial manifestation of a rheumatic and musculoskeletal disease and diagnosis as well as the consecutive initiation of an appropriate treatment, several rheumatological centers in Germany have improved the access to initial rheumatologic evaluation by establishing early recognition/screening clinics at their respective sites. Corresponding models located at Altoetting·Burghausen, Bad Pyrmont, Berlin Buch, Duesseldorf, Heidelberg, Herne, Mannheim as well as supraregional/multicenter initiatives Rheuma Rapid, RhePort and Rheuma-VOR are presented in this overview along with the respective characteristics, potential advantages and disadvantages, but also first evaluation results of several models. The aim of this publication is to promote early detection of rheumatic and musculoskeletal diseases as one of the most important challenges in current rheumatology by encouraging further rheumatologic centers and practices to launch their own early recognition/screening consultation model on the basis of aspects presented herein.

1418Adverse effects of spironolactone in long-term treatment of resistant arterial hypertension

Background

Spironolactone is recommended as a fourth line antihypertensive drug by current hypertension guidelines. This drug had relatively few adverse effects in short term clinical trials, but data about their occurrence during long-term treatment of resistant hypertension are scarce.

Purpose

To evaluate the occurrence and type of adverse effects of spironolactone during long-term treatment and their possible clinical and laboratory predictors.

Methods

We prospectively followed 274 patients with resistant arterial hypertension who started treatment with spironolactone between September 2007 and December 2016. The duration of spironolactone use, its dose, the incidence of adverse events, blood pressure, and laboratory findings were recorded at baseline and during the last clinical examination.

Results

Patients were followed for an average of 35 (± 29) months, the mean dose of spironolactone was 27.5 mg/day. Adverse effects occurred in 72 patients (26.3%) and in 61 (84.7%) lead to discontinuation of spironolactone. The most common adverse reactions were gynaecomastia (30.6%), hyperkalaemia (30.6%) and symptomatic hypotension (26.4%). The mean duration of spironolactone treatment before their occurrence was 25 (± 27) months. According to the Kaplan-Meier curve, the median for the incidence of adverse events would be 97 months (91.5–102.5 months), i.e. 50% of patients could be treated with no adverse events for more than 8 years. Adverse events were more common in the elderly (hazard ratio – HR 1.38, P=0.007), patients with higher baseline serum creatinine (HR 1.12, P=0.035) and patients taking angiotensin receptor blockers (HR 1.65, P=0.040).

Kaplan-Meier estimate – adverse events

Conclusion

During long-term treatment of resistant hypertension with spironolactone, more than a quarter of patients experience adverse reactions that usually require discontinuation of spironolactone.

Acknowledgement/Funding

Supported by the grants of Palacký University in Olomouc Nr. IGA_LF_2016_038 and IGA_LF_2017_029.

P1657Hyperuricaemia treatment in acute heart failure patients does not improve their long-term prognosis: a propensity score matched analysis from the AHEAD registry

Background

Hyperuricaemia is associated with a poorer prognosis in heart failure (HF) patients. Benefits of hyperuricaemia treatment with allopurinol have not yet been confirmed in clinical practice. The aim of our work was to assess the benefit of allopurinol treatment in a large cohort of HF patients.

Methods and results

The prospective acute heart failure registry (AHEAD) was used to select 3,160 hospitalized patients with a known level of uric acid (UA) who were discharged in a stable condition. Hyperuricaemia was defined as UA ≥500μmol/l and/or allopurinol treatment at admission. The patients were classified into three groups: without hyperuricaemia, with treated hyperuricaemia and with untreated hyperuricaemia at discharge. Two- and five-year all-cause mortality were defined as endpoints. Patients without hyperuricaemia, unlike those with hyperuricaemia, had a higher left ventricular ejection fraction, a better renal function and higher haemoglobin levels, had less frequently diabetes mellitus and atrial fibrillation, and showed better tolerance to treatment with ACEIs/ARBs and/or beta-blockers. In a primary analysis, the patients without hyperuricaemia had the highest survival rate. After using the propensity score to set up comparable groups, the patients without hyperuricaemia had a similar five-year survival rate as those with untreated hyperuricaemia (42.0% vs 39.7%, p=0.362) whereas those with treated hyperuricaemia had a poorer prognosis (32.4% survival rate; p=0.006 vs non-hyperuricaemia group and p=0.073 vs untreated group).

Conclusion

Hyperuricaemia was associated with an unfavourable cardiovascular risk profile in HF patients. Treatment of hyperuricaemia with low doses of allopurinol did not improve the longterm prognosis of HF patients.

Acknowledgement/Funding

Ministry of Health CZ 65269705 and MUNI/A/1250/2017

Hyperuricemia treatment in acute heart failure patients does not improve their long-term prognosis: A propensity score matched analysis from the AHEAD registry

BACKGROUND

Hyperuricemia is associated with a poorer prognosis in heart failure (HF) patients. Benefits of hyperuricemia treatment with allopurinol have not yet been confirmed in clinical practice. The aim of our work was to assess the benefit of allopurinol treatment in a large cohort of HF patients.

METHODS

The prospective acute heart failure registry (AHEAD) was used to select 3160 hospitalized patients with a known level of uric acid (UA) who were discharged in a stable condition. Hyperuricemia was defined as UA ≥500 μmoL/L and/or allopurinol treatment at admission. The patients were classified into three groups: without hyperuricemia, with treated hyperuricemia, and with untreated hyperuricemia at discharge. Two- and five-year all-cause mortality were defined as endpoints. Patients without hyperuricemia, unlike those with hyperuricemia, had a higher left ventricular ejection fraction, a better renal function, and higher hemoglobin levels, had less frequently diabetes mellitus and atrial fibrillation, and showed better tolerance to treatment with angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and/or beta-blockers.

RESULTS

In a primary analysis, the patients without hyperuricemia had the highest survival rate. After using the propensity score to set up comparable groups, the patients without hyperuricemia had a similar 5-year survival rate as those with untreated hyperuricemia (42.0% vs 39.7%, P = 0.362) whereas those with treated hyperuricemia had a poorer prognosis (32.4% survival rate, P = 0.006 vs non-hyperuricemia group and P = 0.073 vs untreated group).

CONCLUSION

Hyperuricemia was associated with an unfavorable cardiovascular risk profile in HF patients. Treatment with low doses of allopurinol did not improve the prognosis of HF patients.

Prognostic value of NT-proBNP added to clinical parameters to predict two-year prognosis of chronic heart failure patients with mid-range and reduced ejection fraction - A report from FAR NHL prospective registry

Background

According to guidelines, the prognosis of patients with chronic heart failure can be predicted by determining the levels of natriuretic peptides, the NYHA classification and comorbidities. The aim our work was to develop a prognostic score in chronic heart failure patients that would take account of patients’ comorbidities, NYHA and NT-proBNP levels.

Methods and results

A total of 1,088 patients with chronic heart failure with reduced ejection fraction (HFrEF) (LVEF<40%) and mid-range EF (HFmrEF) (LVEF 40–49%) were enrolled consecutively. Two-year all-cause mortality, heart transplantation and/or LVAD implantation were defined as the primary endpoint (EP). The occurrence of EP was 14.9% and grew with higher NYHA, namely 4.9% (NYHA I), 11.4% (NYHA II) and 27.8% (NYHA III–IV) (p<0.001). The occurrence of EP was 3%, 10% and 15–37% in patients with NT-proBNP levels ≤125 ng/L, 126–1000 ng/L and >1000 ng/L respectively. Discrimination abilities of NYHA and NT-proBNP were AUC 0.670 (p<0.001) and AUC 0.722 (p<0.001) respectively. The predictive value of the developed clinical model, which took account of older age, advanced heart failure (NYHA III+IV), anaemia, hyponatraemia, hyperuricaemia and being on a higher dose of furosemide (>40 mg daily) (AUC 0.773; p<0.001) was increased by adding the NT-proBNP level (AUC 0.790).

Conclusion

The use of prediction models in patients with chronic heart failure, namely those taking account of natriuretic peptides, should become a standard in routine clinical practice. It might contribute to a better identification of a high-risk group of patients in which more intense treatment needs to be considered, such as heart transplantation or LVAD implantation.

The quality of life following allogeneic hematopoietic stem cell transplantation - a multicenter retrospective study

Although allogeneic haematopoietic stem cell transplantation (allo-HSCT) offers a unique curative potential, it may be connected with high treatment-related morbidity and mortality. Besides many organ complications, allo-HSCT may significantly affect quality of life (QOL).

PATIENTS AND METHODS

Between January 2011 and December 2012, five hundred and ninety patients (pts) from 6 transplant centers in the Czech Republic filled in the questionnaire for the quantitative measurement of QOL using Functional Assessment of Cancer Therapy-General (FACT-G) version 4. Study cohort characteristics were as follows: 325 males, 340 pts received myeloablative conditioning, 383 pts received PBPC, representation of diagnoses; acute leukemia (n=270), bone marrow failure (n=36), chronic myeloid leukemia (n=74), myelodysplastic/myeloproliferative syndrom (n=110), lymphoproliferative disease (n=93). The median age at allo-HSCT was 43 years (range: 1.7 - 71.0), the median time from allo-HSCT to questionnaire completing was 3.8 years (range: - 0.2 - 21.6). The earliest allo-HSCT was performed in November 1989, the last in September 2012. In this retrospective study, we investigated the impact of various factors on the QOL after allo-HSCT: age, gender, diagnosis, type of conditioning, time from diagnosis to allo-HSCT, disease stage, graft type, donor type, time from allo-HSCT to questionnaire completing, GVHD, relapse. Only data from patients who were more than 3 months after allo-HSCT were used for the multivariate analysis. The overall results of the total FACT-G score (median=85.0; range: 29-108) as well as the results of each specific dimension - PWB (median=23.0; range: 5-28), SWB (median=24.0; range: 7-28), EWB (median= 19.0; range: 4-24), FWB (mean=21.0; range: 2-28) showed a value in the highest quartile of the possible evaluation. In multivariate analysis, an inferior QOL score was reported for patients with aGVHD (p=0.002), cGVHD (p<0.001), QOL decreased with increasing age (p=0.048) and increased with time elapsed since allo-HSCT (p<0.001).Allogeneic HSCT represents an important intervention into the overall integrity of the organism. In particular, the development of GVHD can cause very serious organ, but also mental problems which can significantly reduce the QOL. The QOL is steadily increasing with increasing interval from allo-HSCT but improvement and disappearance of these complications may take many years, and sometimes these effects may probably persist permanently.

Impact of surgery on quality of life in Crohn´s disease patients: final results of Czech cohort

INTRODUCTION

Crohns disease (CD) belongs to chronic diseases that highly affect the patient´s quality of life (QoL). The effect of the disease and impairment of QoL in CD patients is already known. The aim was to assess how surgical treatment influences the patients QoL and determine factors that can affect postoperative QoL.

METHODS AND PATIENTS

We compared the QoL before and after surgery in patients who had undergone a bowel resection at our department due to CD between 2010-2016. The patients filled in a standardized QLQ-CR29 questionnaire to assess QoL in the preoperative period and the postoperative period after a 2-month interval. The control groups were CD patients who had not undergone surgical treatment (bowel resection) and a healthy cohort. In the QoL evaluation, 132 patients with CD who had undergone surgery (bowel resection), 83 patients with CD without an operation and 104 healthy subjects were enrolled.

RESULTS

104 of the operated patients experienced a postoperative improvement of the overall QoL (78.8 %), 2 patients did not register any changes in QoL (1.5 %) and 26 patients (19.7 %) experienced a worsening of their postoperative QoL. The results were statistically significant (p < 0.001).

CONCLUSION

We detected a significant improvement of the overall QoL after surgical resection in CD patients (measured 2 months after surgery). Gender was identified as the only statistically relevant factor with influence on postoperative QoL.Key words: bowel resection - Crohn´s disease - Czech cohort - inflammatory bowel disease - quality of life - surgical treatment.

Higher incidence of hypotension episodes in women during the sub-acute phase of ST elevation myocardial infarction and relationship to covariates

OBJECTIVE

The introduction of primary percutaneous coronary intervention (PPCI) has modified the profile of ST elevation myocardial infarction (STEMI) patients. Occurrence and prognostic significance of hypotension episodes are not known in PPCI treated STEMI patients. It is also not known whether and/or how the hypotension episodes correlate with the degree of myocardial damage and whether there are any sex differences.

METHODS

Data of 293 consecutive STEMI patients (189 males) treated by PPCI and without cardiogenic shock were analyzed. Blood pressure was measured noninvasively. A hypotensive episode was defined as a systolic blood pressure below 90 mmHg over a period of at least 30 minutes.

RESULTS

A hypotensive episode was observed in 92 patients (31.4%). Female sex was the strongest independent predictor of hypotension episodes (p < 0.0001), while there was no relationship to electrocardiographic STEMI localization. Hypotensive patients had significantly higher levels of troponin T and brain natriuretic peptide; hypotensive episodes were particularly frequent in women with increased troponin T. Treatment with angiotensin-converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB) and betablockers was less frequent in hypotensive patients. After a mean 20-month follow-up, all-cause mortality did not differ between hypotensive patients and others. However, mortality in hypotensive patients who did not tolerate ACEI/ARB therapy was significantly higher compared to other hypotensive patients (p = 0.016).

CONCLUSION

Hypotension episodes are not uncommon in the sub-acute phase of contemporarily treated STEMI patients with a striking difference between sexes-female sex was the strongest independent predictor of hypotension episodes. Hypotensive episodes may lead to a delay in pharmacotherapy which influences prognosis. Higher incidence of hypotension in women could at least partially explain the sex-related differences in the use of cardiovascular pharmacotherapy which was repeatedly observed in various studies.