The effect of ziltivekimab on the neutrophil-lymphocyte ratio: analysis from RESCUE

Background

The neutrophil-lymphocyte ratio (NLR), derived from the complete blood count, independently predicts atherosclerotic events and is a potential biomarker for residual inflammatory risk. A previous study showed that interleukin (IL)-1β inhibition reduces the NLR, but whether inhibition with IL-6, a cytokine downstream of IL-1, also lowers the NLR is unknown.

Purpose

To evaluate whether ziltivekimab, a monoclonal antibody targeting the IL-6 ligand, dose-dependently lowers the NLR compared to placebo.

Methods

The phase II RESCUE trial randomized 264 patients with moderate to severe chronic kidney disease (CKD) and high-sensitivity CRP (hsCRP) >2mg/L in a 1:1:1:1 ratio to placebo or ziltivekimab 7.5 mg, 15 mg, and 30 mg subcutaneously once every four weeks. As previously reported, the trial met its primary endpoint as demonstrated by hsCRP reductions of 4% in the placebo group as compared to 77%, 88%, and 92% at 12 weeks in the ziltivekimab 7.5, 15, and 30 mg groups, respectively. Using RESCUE trial data, we further evaluated the percent change from baseline in the NLR at 12 weeks and sought evidence of correlation between any observed changes in the NLR with changes in other measured biomarkers.

Results

Ziltivekimab dose-dependently reduced the NLR starting at week one and sustained through week 12 (Table). The median change in the NLR at 12 weeks, the primary pre-specified endpoint, was −13.5% in the 7.5 mg group, −14.3% in the 15 mg group, and −22.4% in the 30 mg group compared to 1.56% in the placebo group. The estimated treatment difference was −14.6% (p=0.004), −15.3% (p=0.004), and −23.6% (p<0.0001) in the ziltivekimab 7.5, 15, and 30 mg groups respectively. These changes were driven largely by reductions in the absolute neutrophil count with minimal change in lymphocyte count. The change in NLR with ziltivekimab correlated modestly with the changes in hsCRP (R=0.26, p=0.0006), fibrinogen (R=0.18, p=0.02), and haptoglobin (R=0.17, p=0.03), but not serum amyloid A, ApoA1, ApoB, ApoB/ApoA ratio, or traditional risk markers.

Conclusions

IL-6 inhibition with ziltivekimab lowers the NLR. The ongoing ZEUS cardiovascular (CV) outcomes trial will assess whether ziltivekimab can reduce CV event rates among individuals with stage 3 to 4 CKD, known atherosclerotic disease, and elevated hsCRP. If ziltivekimab reduces CV risk, it would provide further evidence for critical inter-relationships between bone marrow function and atherothrombosis.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Novo Nordisk

Inflammation and risk of recurrent cardiovascular events according to prior vascular disease location

Background

In recent years, anti-inflammatory drugs have been shown to reduce the risk of recurrent cardiovascular disease (CVD) events in patients with coronary artery disease (CAD), but have not yet been tested in patients with other vascular disease locations. Whether the relation between inflammation and recurrent CVD is modified by prior vascular disease location is unknown.

Purpose

This study aimed to establish the relation between low-grade inflammation and recurrent CVD according to prior vascular disease location.

Methods

Inflammation was measured by plasma concentrations of high-sensitivity C-reactive protein (CRP). Patients from the UCC-SMART cohort with CAD (n=4,517), cerebrovascular disease (CeVD; n=2,154), peripheral artery disease (PAD, n=1,154), or abdominal aortic aneurysm (AAA, n=424), and CRP ≤10 mg/L were included in the main analysis (combined n=8,249). Patients with CRP >10 mg/L (n=756) were analysed separately. The primary outcome was a composite of myocardial infarction, ischemic stroke, or cardiovascular death. Secondary outcomes included the primary outcome components, major adverse limb events (MALE), and all-cause mortality. The relation between CRP and outcomes was assessed using Cox proportional hazard models stratified by prior vascular disease location, and adjusted for potential confounders.

Results

During a median follow-up of 9.5 years (interquartile range 5.1–13.9) 1,877 CVD events, 887 MALE events, and 2,341 deaths were observed. In the total population, CRP was related to recurrent CVD (hazard ratio [HR] per 1 mg/L 1.08; 95% confidence interval [CI] 1.05–1.10), and all secondary outcomes except for ischemic stroke (HR 1.03; 95% CI 0.99–1.08). Compared to the first quintile of CRP, HRs for recurrent CVD were 1.66 (95% CI 1.41–1.96) for the last quintile ≤10 mg/L, and 1.97 (95% CI 1.64–2.36) for the subgroup with CRP >10 mg/L. CRP was related to recurrent CVD in patients with CAD (HR per 1 mg/L 1.08; 95% CI 1.04–1.11), as well as CeVD (HR 1.05; 95% CI 1.01–1.10), PAD (HR 1.08; 95% CI 1.03–1.13), and AAA (HR 1.08; 95% CI 1.01–1.15; p for interaction 0.815). The relation between CRP and all-cause mortality was stronger for patients with CAD (HR 1.13; 95% CI 1.09–1.16) compared to other locations (HRs 1.06–1.08; p=0.002).

Conclusion

Inflammation is an independent risk factor of recurrent CVD and mortality, irrespective of prior vascular disease location. Trials of anti-inflammatory drugs in patients with CeVD, PAD, and AAA are warranted.

Funding Acknowledgement

Type of funding sources: None.

POS0219 EFFECT OF LOW-DOSE METHOTREXATE ON ESTIMATED GLOMERULAR FILTRATION RATE AND KIDNEY ADVERSE EVENTS IN THE CARDIOVASCULAR INFLAMMATION REDUCTION TRIAL

Background:

Low-dose methotrexate (LD-MTX) is a common first-line treatment for systemic rheumatic diseases, and its use is contraindicated in advanced chronic kidney disease (CKD) because it is primarily excreted by the kidneys. Among patients with preserved kidney function, the safety of LD-MTX on estimated glomerular filtration rate (eGFR) and kidney adverse events (AEs) has not been established.

Objectives:

To investigate the effect of LD-MTX on eGFR and kidney AEs using data from a randomized clinical trial.

Methods:

We performed a secondary analysis for eGFR and kidney AEs using the randomized double-blind, placebo-controlled Cardiovascular Inflammation Reduction Trial. Adults with known cardiovascular disease and diabetes and/or metabolic syndrome were randomly allocated to oral LD-MTX (target dose 15-20 mg/week) or placebo. All participants took folic acid 1 mg six days/week. Exclusion criteria included systemic inflammatory disease and creatinine clearance <40 mL/min (by Cockcroft-Gault). eGFR was calculated using the CKD-EPI formula. Clinical kidney AEs were blindly adjudicated. The least-squares mean change of eGFR from baseline was calculated at each study visit; the difference in eGFR slopes between LD-MTX and placebo was compared using a modified intention-to-treat approach. We also compared rates of kidney AEs for LD-MTX versus placebo using Cox proportional hazards models.

Results:

A total of 2,391 subjects were randomized to LD-MTX and 2,395 to placebo. At baseline, mean age was 66 years, 19% were female, mean eGFR was 80.0 mL/min/1.73m2, and 18% had stage 3 CKD or worse. Median follow-up duration was 23 months, and median LD-MTX dose was 16 mg/week. Those randomized to LD-MTX had less decline in eGFR over the entire follow-up compared to placebo (slope difference 1.12, 95%CI 0.59-1.65, p<0.001, Figure 1). Those with CKD stage 3 or worse on LD-MTX saw less eGFR decline than those with CKD stage 2 or better (slope difference among CKD stage 3 or worse: 2.46, 95%CI 1.10-3.82, p<0.001; p for interaction 0.02). The LD-MTX group had higher eGFR than placebo over the first 24 months of study follow-up (p<0.05 at each visit). On safety laboratory monitoring, there were 159 acute kidney injury AEs in the LD-MTX group and 187 in the placebo group (HR 0.83, 95%CI 0.67-1.02, Table 1). There were 37 clinical kidney AEs in the LD-MTX group and 42 in the placebo group (0.87, 95%CI 0.56-1.36). One subject began dialysis in the LD-MTX group compared to 3 in the placebo group.

Table 1.

Rates and hazard ratios for kidney adverse events per random assignment of low-dose methotrexate or placebo in the Cardiovascular Inflammation Reduction Trial (n=4,786).

Low-dose methotrexate (n=2,391)Placebo (n=2,395) (reference)HR (95%CI)EventsRate per 100 person-years (95%CI)EventsRate per 100 person-years (95%CI)SCr collected at safety visitsAny event*1593.42 (2.93, 3.98)1874.06 (3.53, 4.67)0.83 (0.67, 1.02)Mild (SCr 1.5-1.9x baseline)1543.47 (2.97, 4.06)1774.06 (3.51, 4.69)0.85 (0.68, 1.06)Moderate (SCr 2-2.9x baseline)190.41 (0.26, 0.64)240.52 (0.35, 0.78)0.78 (0.43, 1.43)Severe (SCr ≥3x baseline)20.04 (0.01, 0.17)50.11 (0.05, 0.26)0.40 (0.08, 2.04)Adjudicated clinical kidney adverse eventsAny event*370.80 (0.58, 1.11)420.92 (0.68, 1.24)0.87 (0.56, 1.36)Mild240.52 (0.35, 0.77)250.55 (0.37, 0.81)0.95 (0.55, 1.67)Moderate110.24 (0.13, 0.43)110.24 (0.13, 0.43)1.00 (0.43, 2.29)Severe40.09 (0.03, 0.23)80.17 (0.09, 0.35)0.50 (0.15, 1.64)New dialysis10.02 (0.00, 0.15)30.17 (0.09, 0.35)0.34 (0.04, 3.17)

*Acute kidney injury presence and severity was defined by KDIGO (Kidney Disease: Improving Global Outcomes) classification.

CI, confidence interval; HR, hazard ratio; SCr, serum creatinine.

Conclusion:

These results demonstrate the kidney safety of LD-MTX among patients without advanced CKD at baseline. We observed a possible beneficial effect of LD-MTX on preserving kidney function, suggesting that inflammation may be involved in the pathogenesis of CKD in this population.

Disclosure of Interests:

Jeffrey Sparks Consultant of: Dr. J Sparks has performed consultancy for Bristol-Myers Squibb, Gilead, Inova Diagnostics, Optum, and Pfizer unrelated to this work., Grant/research support from: Dr. J Sparks has received research support from Bristol-Myers Squibb., Kathleen Vanni: None declared, Matthew Sparks: None declared, Chang Xu: None declared, Leah Santacroce: None declared, Robert Glynn Grant/research support from: Dr. Glynn has received grant support unrelated to the present research from AstraZeneca, Kowa, Pfizer, and Novartis., Paul Ridker Consultant of: Dr. Ridker has served as a consultant to Corvidia, Inflazome, and CiviBioPharm., Grant/research support from: Dr. Ridker receives research support unrelated to the present study from Kowa, Novartis, and Amarin., Daniel Solomon Grant/research support from: Dr. Solomon receives research support unrelated to the present study from Abbvie, Amgen, Corrona, Genentech, Janssen, and Pfizer.

Collaborative meta-analysis of individual participant data from observational studies of Lp-PLA2 and cardiovascular diseases

BACKGROUND

A large number of observational epidemiological studies have reported generally positive associations between circulating mass and activity levels of lipoprotein-associated phospholipase A2 (Lp-PLA2) and the risk of cardiovascular diseases. Few studies have been large enough to provide reliable estimates in different circumstances, such as in different subgroups (e.g., by age group, sex, or smoking status) or at different Lp-PLA2 levels. Moreover, most published studies have related disease risk only to baseline values of Lp-PLA2 markers (which can lead to substantial underestimation of any risk relationships because of within-person variability over time) and have used different approaches to adjustment for possible confounding factors.

OBJECTIVES

By combination of data from individual participants from all relevant observational studies in a systematic 'meta-analysis', with correction for regression dilution (using available data on serial measurements of Lp-PLA2), the Lp-PLA2 Studies Collaboration will aim to characterize more precisely than has previously been possible the strength and shape of the age and sex-specific associations of plasma Lp-PLA2 with coronary heart disease (and, where data are sufficient, with other vascular diseases, such as ischaemic stroke). It will also help to determine to what extent such associations are independent of possible confounding factors and to explore potential sources of heterogeneity among studies, such as those related to assay methods and study design. It is anticipated that the present collaboration will serve as a framework to investigate related questions on Lp-PLA2 and cardiovascular outcomes.

METHODS

A central database is being established containing data on circulating Lp-PLA2 values, sex and other potential confounding factors, age at baseline Lp-PLA2 measurement, age at event or at last follow-up, major vascular morbidity and cause-specific mortality. Information about any repeat measurements of Lp-PLA2 and potential confounding factors has been sought to allow adjustment for possible confounding and correction for regression dilution. The analyses will involve age-specific regression models. Synthesis of the available observational studies of Lp-PLA2 will yield information on a total of about 15 000 cardiovascular disease endpoints.

GWAS for executive function and processing speed suggests involvement of the CADM2 gene

To identify common variants contributing to normal variation in two specific domains of cognitive functioning, we conducted a genome-wide association study (GWAS) of executive functioning and information processing speed in non-demented older adults from the CHARGE (Cohorts for Heart and Aging Research in Genomic Epidemiology) consortium. Neuropsychological testing was available for 5429-32,070 subjects of European ancestry aged 45 years or older, free of dementia and clinical stroke at the time of cognitive testing from 20 cohorts in the discovery phase. We analyzed performance on the Trail Making Test parts A and B, the Letter Digit Substitution Test (LDST), the Digit Symbol Substitution Task (DSST), semantic and phonemic fluency tests, and the Stroop Color and Word Test. Replication was sought in 1311-21860 subjects from 20 independent cohorts. A significant association was observed in the discovery cohorts for the single-nucleotide polymorphism (SNP) rs17518584 (discovery P-value=3.12 × 10(-8)) and in the joint discovery and replication meta-analysis (P-value=3.28 × 10(-9) after adjustment for age, gender and education) in an intron of the gene cell adhesion molecule 2 (CADM2) for performance on the LDST/DSST. Rs17518584 is located about 170 kb upstream of the transcription start site of the major transcript for the CADM2 gene, but is within an intron of a variant transcript that includes an alternative first exon. The variant is associated with expression of CADM2 in the cingulate cortex (P-value=4 × 10(-4)). The protein encoded by CADM2 is involved in glutamate signaling (P-value=7.22 × 10(-15)), gamma-aminobutyric acid (GABA) transport (P-value=1.36 × 10(-11)) and neuron cell-cell adhesion (P-value=1.48 × 10(-13)). Our findings suggest that genetic variation in the CADM2 gene is associated with individual differences in information processing speed.

The benefits of statins in people without established cardiovascular disease but with cardiovascular risk factors: meta-analysis of randomised controlled trials

OBJECTIVES

To investigate whether statins reduce all cause mortality and major coronary and cerebrovascular events in people without established cardiovascular disease but with cardiovascular risk factors, and whether these effects are similar in men and women, in young and older (>65 years) people, and in people with diabetes mellitus.

DESIGN

Meta-analysis of randomised trials.

DATA SOURCES

Cochrane controlled trials register, Embase, and Medline. Data abstraction Two independent investigators identified studies on the clinical effects of statins compared with a placebo or control group and with follow-up of at least one year, at least 80% or more participants without established cardiovascular disease, and outcome data on mortality and major cardiovascular disease events. Heterogeneity was assessed using the Q and I(2) statistics. Publication bias was assessed by visual examination of funnel plots and the Egger regression test.

RESULTS

10 trials enrolled a total of 70 388 people, of whom 23 681 (34%) were women and 16 078 (23%) had diabetes mellitus. Mean follow-up was 4.1 years. Treatment with statins significantly reduced the risk of all cause mortality (odds ratio 0.88, 95% confidence interval 0.81 to 0.96), major coronary events (0.70, 0.61 to 0.81), and major cerebrovascular events (0.81, 0.71 to 0.93). No evidence of an increased risk of cancer was observed. There was no significant heterogeneity of the treatment effect in clinical subgroups.

CONCLUSION

In patients without established cardiovascular disease but with cardiovascular risk factors, statin use was associated with significantly improved survival and large reductions in the risk of major cardiovascular events.

Systematically missing confounders in individual participant data meta-analysis of observational cohort studies

One difficulty in performing meta-analyses of observational cohort studies is that the availability of confounders may vary between cohorts, so that some cohorts provide fully adjusted analyses while others only provide partially adjusted analyses. Commonly, analyses of the association between an exposure and disease either are restricted to cohorts with full confounder information, or use all cohorts but do not fully adjust for confounding. We propose using a bivariate random-effects meta-analysis model to use information from all available cohorts while still adjusting for all the potential confounders. Our method uses both the fully adjusted and the partially adjusted estimated effects in the cohorts with full confounder information, together with an estimate of their within-cohort correlation. The method is applied to estimate the association between fibrinogen level and coronary heart disease incidence using data from 154 012 participants in 31 cohorts.† Copyright © 2009 John Wiley & Sons, Ltd.

The Emerging Risk Factors Collaboration: analysis of individual data on lipid, inflammatory and other markers in over 1.1 million participants in 104 prospective studies of cardiovascular diseases

Many long-term prospective studies have reported on associations of cardiovascular diseases with circulating lipid markers and/or inflammatory markers. Studies have not, however, generally been designed to provide reliable estimates under different circumstances and to correct for within-person variability. The Emerging Risk Factors Collaboration has established a central database on over 1.1 million participants from 104 prospective population-based studies, in which subsets have information on lipid and inflammatory markers, other characteristics, as well as major cardiovascular morbidity and cause-specific mortality. Information on repeat measurements on relevant characteristics has been collected in approximately 340,000 participants to enable estimation of and correction for within-person variability. Re-analysis of individual data will yield up to approximately 69,000 incident fatal or nonfatal first ever major cardiovascular outcomes recorded during about 11.7 million person years at risk. The primary analyses will involve age-specific regression models in people without known baseline cardiovascular disease in relation to fatal or nonfatal first ever coronary heart disease outcomes. This initiative will characterize more precisely and in greater detail than has previously been possible the shape and strength of the age- and sex-specific associations of several lipid and inflammatory markers with incident coronary heart disease outcomes (and, secondarily, with other incident cardiovascular outcomes) under a wide range of circumstances. It will, therefore, help to determine to what extent such associations are independent from possible confounding factors and to what extent such markers (separately and in combination) provide incremental predictive value.

Plasma fibrinogen level and the risk of major cardiovascular diseases and nonvascular mortality: an individual participant meta-analysis

CONTEXT

Plasma fibrinogen levels may be associated with the risk of coronary heart disease (CHD) and stroke.

OBJECTIVE

To assess the relationships of fibrinogen levels with risk of major vascular and with risk of nonvascular outcomes based on individual participant data.

DATA SOURCES

Relevant studies were identified by computer-assisted searches, hand searches of reference lists, and personal communication with relevant investigators.

STUDY SELECTION

All identified prospective studies were included with information available on baseline fibrinogen levels and details of subsequent major vascular morbidity and/or cause-specific mortality during at least 1 year of follow-up. Studies were excluded if they recruited participants on the basis of having had a previous history of cardiovascular disease; participants with known preexisting CHD or stroke were excluded.

DATA EXTRACTION

Individual records were provided on each of 154,211 participants in 31 prospective studies. During 1.38 million person-years of follow-up, there were 6944 first nonfatal myocardial infarctions or stroke events and 13,210 deaths. Cause-specific mortality was generally available. Analyses involved proportional hazards modeling with adjustment for confounding by known cardiovascular risk factors and for regression dilution bias.

DATA SYNTHESIS

Within each age group considered (40-59, 60-69, and > or =70 years), there was an approximately log-linear association with usual fibrinogen level for the risk of any CHD, any stroke, other vascular (eg, non-CHD, nonstroke) mortality, and nonvascular mortality. There was no evidence of a threshold within the range of usual fibrinogen level studied at any age. The age- and sex- adjusted hazard ratio per 1-g/L increase in usual fibrinogen level for CHD was 2.42 (95% confidence interval [CI], 2.24-2.60); stroke, 2.06 (95% CI, 1.83-2.33); other vascular mortality, 2.76 (95% CI, 2.28-3.35); and nonvascular mortality, 2.03 (95% CI, 1.90-2.18). The hazard ratios for CHD and stroke were reduced to about 1.8 after further adjustment for measured values of several established vascular risk factors. In a subset of 7011 participants with available C-reactive protein values, the findings for CHD were essentially unchanged following additional adjustment for C-reactive protein. The associations of fibrinogen level with CHD or stroke did not differ substantially according to sex, smoking, blood pressure, blood lipid levels, or several features of study design.

CONCLUSIONS

In this large individual participant meta-analysis, moderately strong associations were found between usual plasma fibrinogen level and the risks of CHD, stroke, other vascular mortality, and nonvascular mortality in a wide range of circumstances in healthy middle-aged adults. Assessment of any causal relevance of elevated fibrinogen levels to disease requires additional research.

Docosahexaenoic acid restores endothelial function in children with hyperlipidemia: results from the EARLY study

OBJECTIVE

The primary objective of this study was to determine whether the National Cholesterol Education Program Step II (NCEP-II) diet or supplementation with docosahexaenoic acid (DHA) with the diet, affects endothelial function in children with familial hypercholesterolemia (FH) or the phenotype of familial combined hyperlipidemia (FCH). As secondary endpoints, the influence of diet and DHA supplementation on lipid profiles as well as biomarkers for oxidative stress and inflammation, and asymmetric dimethylarginine (ADMA), an endogenous inhibitor of nitric oxide synthase, were all evaluated.

METHODS

In a double-blind, placebo-controlled, randomized, crossover study design, 20 children (ages 9-19 years) with FH (n = 12) and FCH (n = 8) received nutritional counseling based on the National Cholesterol Education Program Step II (NCEP-II) and food guide pyramid dietary guidelines for 6 weeks. They were then randomly assigned to supplementation with docosahexaenoic acid (DHA 1.2 g/d) or placebo for 6 weeks, followed by a washout phase of 6 weeks and crossover phase of 6 weeks while continuing the NCEP-II diet. Endothelium-dependent flow-mediated dilation (FMD) of the brachial artery was determined by high-resolution ultrasound. Plasma levels of total cholesterol, triglycerides and lipoprotein classes (LDL, HDL, VLDL) were measured by ultracentrifugation and enzymatic methods, plasma F2 isoprostanes by gas chromatography/mass spectrometry, urinary 8-OH-2' deoxyguanosine by liquid chromatography, high sensitivity C-reactive protein by immunonephelometry and ADMA by liquid chromatography.

RESULTS

FMD increased significantly after DHA supplementation compared to baseline (p < 0.001), diet alone (p < 0.002), placebo (p < 0.012) and washout (p < 0.001) phases of the study without affecting biomarkers for oxidative stress, inflammation or ADMA. DHA supplementation was associated with increased levels of total cholesterol (p < 0.01), LDL- and HDL cholesterol concentrations (p < 0.001) compared to the NCEP-II diet.

CONCLUSION

This study demonstrates that DHA supplementation restores endothelial-dependent FMD in hyperlipidemic children. The endothelium may thus be a therapeutic target for DHA. This is consistent with a hypothesis of increasing NO bioavailability, with the potential for preventing the progression of early coronary heart disease in high-risk children.

The gene encoding atrial natriuretic peptide and the risk of human stroke

BACKGROUND

Recent evidence from an animal model of stroke, the stroke-prone spontaneously hypertensive rat, implicated the gene encoding atrial natriuretic peptide (ANP) as a possible candidate contributing to the likelihood of experiencing a stroke. The purpose of the present study was to investigate the role of ANP in the pathogenesis of cerebrovascular accidents in humans.

METHODS AND RESULTS

We investigated 2 previously known markers at ANP, G1837A and T2238C, for their possible association with the occurrence of stroke. This was the largest matched case-controlled sample studied thus far; the sample was drawn from a large prospective study (the Physician's Health Study). When assuming a dominant mode of inheritance, a statistically significant positive association was observed for the 1837A allele, indicating an odds ratio of 1.64 (95% confidence interval, 1.01 to 2.65) for stroke. This observation led to the discovery of a new molecular variant in exon 1, G664A, which was responsible for a valine-to-methionine substitution in the proANP peptide. This mutation, which was in linkage disequilibrium with the G1837A marker, was associated with the occurrence of stroke (odds ratio, 2.0; 95% confidence interval, 1.17 to 3.19; P=0.01).

CONCLUSIONS

Our findings suggest that molecular variants of the ANP gene may represent an independent risk factor for cerebrovascular accidents in humans. The strong parallelism to the experimental data obtained in the stroke-prone animal model provides assurance for the relevance of our observation.