Abstracts from EuroCVP 2023
Citation: European Cardiology Review 2024;19(Suppl 1):1–33..
DOI: https://doi.org/10.15420/ecr.2024.19.s1
Copyright: © Radcliffe Group 2024. This work is open access and is licensed under CC BY-NC 4.0. Users may copy, redistribute and make derivative works for non-commercial purposes, provided the original work is cited correctly.
Advancements in the Therapy of Heart Failure
EP.01.01
Mechanisms of Atrial Fibrillation-induced Ventricular Dysfunction in the Human Myocardium
L Stengel,1 T Walter,1 D Riedl,1 T Körtl,1 P Tirilomis,4 R Schramm,2 J Gummert,2 L Maier,1 K StreckfussBömeke,3 S Pabel1 and S Sossalla1,4
1. Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany; 2. Department of Thoracic, Cardiac and Vascular Surgery (Heart and Diabetes Center), Bad Oeynhausen, Germany; 3. Institute of Pharmacology and Toxicology, University of Würzburg, Würzburg, Germany; 4. Clinic for Cardiology and Pneumology, Georg-August University Göttingen and DZHK, Göttingen, Germany
Correspondence: Laura Stengel, lauracatharinastengel@gmail.com
Background: Atrial fibrillation (AF) often coexists with heart failure (HF). Clinical studies indicate improved left ventricular (LV) function following rhythm restoration. However, the underlying myocardial processes are unclear.
Materials and Methods: Human LV tissue slices from HF patients were long-term cultivated in vitro. AF was simulated by tachyarrhythmic culture pacing at 100 BPM with 30% irregularity for seven days and contractile LV function was compared to slices undergoing sinus rhythm (SR) simulation (60 BPM/0%). After seven days, rhythm restoration was simulated by switching to SR simulation.
To elucidate cellular mechanisms involved in AF-induced LV dysfunction, human induced pluripotent stem cell-derived cardiomyocytes (iPSC-CM) were subjected to AF simulation and studied via epifluorescence microscopy (FURA-2) and confocal microscopy (Fluo-4). To investigate the pharmacological impact of reactive oxygen species (ROS) and calcium/ calmodulin-dependent protein kinase II (CaMKII), iPSC-CMs were treated with ROS-scavenger N-acetylcysteine (NAC) or CaMKII-inhibitor autocamtide-2-related inhibitory peptide (AIP).
Results: Atrial fibrillation simulation caused a progressive decline in systolic force of human LV myocardium (n=14) with significantly reduced twitch amplitudes compared to SR simulation (n=11). Within just five days of AF termination, a significant recovery in LV function was observed, indicated by improved systolic contraction amplitudes (Figure 1).
iPSC-CM measurements revealed a significant reduction in systolic Ca2+transient amplitudes after AF simulation (n=41) compared to SR simulation (n=44). However, five days after SR restoration, iPSC-CM exhibited no
A: Change of ambulatory systolic blood pressure (ASBP); (B) Change of ambulatory diastolic blood pressure (ABDP); C: Nocturnal-diurnal blood pressure drop ratio.
difference in Ca2+-transient amplitude (n=41), indicating a fast recovery of systolic Ca2+ cycling.
Further investigation of pharmacological options showed that Ca2+transient amplitude was preserved after AF-simulation in iPSC-CM when treated with AIP (n=68) as well as with N-acetylcysteine (NAC) (n=35), suggesting an interplay of ROS and CaMKII-activity with the Ca2+ homeostasis of cardiomyocytes.
Conclusion: This study demonstrates that AF impairs LV function in human HF myocardium; however, these changes are reversible following
AF termination. Moreover, it provides a first pharmacological treatment strategy that ROS scavenging and CaMKII-inhibition may be of value for the treatment of AF-induced LV dysfunction, which merits further investigation.
EP.01.02
Cardiac Contractility Modulation: A New Therapy for Heart Failure
VPettillo
A.O. dei Colli - V. Monaldi, Naples, Italy
Correspondence: Vincenzo Pettillo, vincenzo.pettillo@gmail.com
Background: Cardiac contractility modulation (CCM) is a therapy for chronic heart failure patients with ejection fraction 25–45% in sinus rhythm with QRS <130 ms clinically symptomatic (New York Heart Association [NYHA] class >II) despite optimised medical therapy. It is made possible by the implantation of the Optimizer® Smart device. CCM works by delivering a non-excitatory high-energy bipolar signal, synchronised with local electrical activity (or cooperating with another pre-existing cardiac implantable electronic device), in the absolute ventricular refractory period, by means of two actively fixating leads, positioned in the interventricular septum and spaced at least 1–2 cm apart.
Materials and Methods: A PubMed search correlated with clinical data and field experience was performed. The study included patients with severe dilated cardiomyopathy already on optimised medical therapy.
Results: The mechanism of action demonstrated a remodelling of the left ventricle with a ‘metabolic’ therapy. In CCM therapy, electrical stimulation is delivered to the heart muscle during the absolute refractory period. In this phase, electrical signals activate the mobilisation of calcium ions in cardiomyocytes. CCM signals applied during the absolute refractory period cause an increase in cytosolic calcium during systole, resulting in improved cardiac contraction without an increase in oxygen consumption.
Conclusion: Cardiac contractility modulation therapy improves contractility and cardiac performance, improving the quality of life of patients undergoing this treatment by reducing symptoms of fatigue and dyspnoea. CCM has reduced the number of hospitalisations for moderate to severe heart failure. Healthcare professionals recognise that the typical ECG of a patient implanted with a CCM device shows a ‘spike’ in the absolute refractory period of the cardiac cycle (the ‘R wave’ of the QRS complex) without being alarmed. Patients are trained to be autonomous in charging. The Optimizer Smart is recharged externally with a weekly rechargeable battery through a mini-induction charger, rechargeable by itself.
EP.01.03
Sodium-glucose Cotransporter 2 Inhibitors in Heart Failure with Reduced Ejection Fraction: Future Perspectives
MA Munteanu,1 AM Lungu,2 V Teodorescu,1,2
E Tufanoiu,1 C Nicolae1 and T Nanea1,2
1. Cardiology Department, University of Medicine and Pharmacy Carol Davila, Bucharest, Romania; 2. Cardiology Department, Clinical Hospital Dr. Th. Burghele, Bucharest, Romania
Correspondence: Madalina Andreea Munteanu, dr.amunteanu@gmail.com
Background: Heart failure (HF) with reduced ejection fraction (HFrEF) is a challenging problem due to its high mortality rate. HFrEF (<40%) is treated with diet, β-blockers, renin-angiotensin system blockers (RASB) (alone or in conjunction with sacubitril), and spironolactone. Dapagliflozin (a sodium-glucose cotransporter 2 [SGLT2] inhibitor) has demonstrated efficacy in reducing morbidity and mortality in patients with HF. However, less is known about its effects on echocardiographic parameters.
Materials and Methods: A non-randomised, single-centre, observational study of 110 patients with HFrEF <40% was conducted. To assess the ultrasound impact of dapagliflozin 10 mg once daily, this group was compared to a cohort of 89 patients with HFrEF <40% receiving conventional treatment without dapagliflozin (taken from the HF register of the centre and whose management predated the adoption of this molecule in the 2021 European Society of Cardiology [ESC] guidelines). The change in LV mass index was analysed using analysis of covariance (ANCOVA), with treatment group as fixed effect and the baseline value as covariate. All comparisons were two-sided with p<0.05 considered statistically significant.
Results: Patients with HFrEF were divided into three subgroups according to age and NYHA class. The most prevalent comorbidities were hypertension (43.1%), CHD (40%) and obesity (33.2%). Prescription of dapagliflozin was associated with an improvement in echocardiographic parameters (EF and LV mass index) in a population of patients with HFrEF <40% receiving conventional treatment for HF. Study drug discontinuation and serious adverse events were not frequent in the subgroups, in either men or women.
Conclusion: SGLT2 inhibitors are a novel class of antidiabetic agents that have demonstrated positive efficacy and safety outcomes in the setting of HFrEF. In the present study, dapagliflozin was safe and well-tolerated, irrespective of sex.
EP.01.04
Prognostic Performance of MECKI Score in Heart Failure Patients with Non-valvular Atrial Fibrillation Treated with Edoxaban M Mapelli,1 I Mattavelli,1 E Salvioni,1 A Bonomi,1 N Capra1 and P Agostoni1,2
1. Centro Cardiologico Monzino, IRCCS, Milan, Italy; 2. Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy
Correspondence: Massimo Mapelli, massimo.mapelli@ccfm.it
Background: Multiparametric risk stratification in heart failure (HF) is crucial. Metabolic Exercise test data combined with Cardiac and Kidney
EP01.04. Table 1: Main Population Characteristics
ACEI = angiotensin-converting enzyme inhibitor; ARNI = angiotensin receptor-neprilysin inhibitor; AT 1 = angiotensin II type 1; LVEF = left ventricular ejection fraction; MRA = mineralocorticoid receptor antagonist.
Indexes (MECKI) score is a validated prognostic model to assess the twoyear risk of cardiovascular mortality. It integrates cardiopulmonary exercise test (CPET) parameters with easy-to-obtain variables: haemoglobin, serum sodium, kidney function, left ventricle ejection fraction, peak oxygen consumption and VE/VCO2 slope. Non-valvular atrial fibrillation (NVAF) is a common feature in HF (17% of original MECKI score population were atrial fibrillation (AF) subjects treated with vitamin K antagonists (VKA). The aim of this study was to assess MECKI score reliability in HF patients treated with edoxaban.
Materials and Methods: Consecutive HF and NVAF outpatients treated with edoxaban were prospectively enroled in the study. Patients underwent a maximal ramp-protocol CPET and blood sampling for complete blood count, electrolytes and renal function. A retrospective group of NVAF HF patients treated with VKA in the MECKI score population was used to match with propensity score the edoxaban cohort for age and sex. Area under the curves (AUC) were assessed to compare the prognostic power in the two cohorts.
Results: The study included 83 HF, NVAF patients treated with edoxaban. Table 1 compares the main population characteristics. A control population was identified in the multicentric MECKI database (n=7,800) by selecting all consecutive HF, NVAF patients treated with VKA (n=844). The prognostic power of MECKI score in the edoxaban-treated population was higher, albeit not statistically significant (Figure 1). After propensity score-matching to exclude age and sex influence, MECKI score performed equally well in predicting the outcome in the two groups (AUC matched population 0.73193, AUC edoxaban group 0.6557, p=NS; Figure 1).
EP01.04. Figure 1
Conclusion: MECKI score power was confirmed in the new population treated with edoxaban with a slightly higher performance respect to patients treated with VKAs.
EP.01.05
Effects of Sacubitril/Valsartan on Exercise
Capacity: A Prognostic Improvement that Starts During Uptitration
M Mapelli,1 I Mattavelli,1 S Paolillo,3 E Salvioni,1 D Magrì,4 A Galotta,1 F De Martino,1,5 V Mantegazza,1,2 C Vignati,1,2 I Esposito,3 S Dell’Aversana,3 R Paolillo,3 T Capovilla,1,6 G Tamborini,1 A Nepitella,7 P Perrone Filardi3 and P Agostoni1,2 1. Centro Cardiologico Monzino, IRCCS, Milan, Italy; 2. Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy; 3. Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy; 4. Department of Clinical and Molecular Medicine, University La Sapienza, Rome, Italy; 5. Casa di Cura Tortorella, Salerno, Italy; 6. University of Trieste, Trieste,
Italy; 7. Policlinico Universitario D. Casula, Cardiologia AOU Cagliari, Cagliari, Italy
Correspondence: Massimo Mapelli, massimo.mapelli@ccfm.it
Background: Sacubitril/valsartan is a mainstay of the treatment of heart failure with reduced ejection fraction (HFrEF); however, its effects on exercise performance have yielded conflicting results. This study aimed to evaluate the impact of sacubitril/valsartan on exercise parameters and echocardiographic and biomarker changes at different drug doses.
Materials and Methods: Consecutive HFrEF outpatients eligible to start sacubitril/valsartan were prospectively enroled in the study. Patients underwent clinical assessment, cardiopulmonary exercise test (CPET), blood sampling, echocardiography, and completed the Kansas City Cardiomyopathy Questionnaire (KCCQ-12). Sacubitril/valsartan was introduced at 24/26 mg twice daily and progressively uptitrated in a standard monthly fashion to 97/103 mg twice daily or at maximum
NYHA = New York Heart Association; QoL = quality of life.
tolerated dose. Study procedures were repeated at each titration visit and at 6 months after reaching the maximum tolerated dose.
Results: Ninety-six patients completed the study; 73 (75%) reached maximum sacubitril/valsartan dose. There was a significant improvement in functional capacity across all study steps: oxygen intake increased at peak exercise (from 15.6 ± 4.5 to 16.5 ± 4.9 ml/min/kg; p trend =0.001), while minute ventilation/carbon dioxide production relationship reduced in patients with an abnormal value at baseline. Sacubitril/valsartan induced positive left ventricle reverse remodelling (EF from 31 ± 5 to 37 ± 8%, p trend <0.005).
Conclusion: A holistic and progressive HF improvement was observed with sacubitril/valsartan in parallel with quality of life. Likewise, a prognostic enhancement was observed.
EP.01.06
Looking into the Kinetics of NT-proBNP and sST2 Changes in Heart Failure Patients
Treated with Sacubitril/Valsartan: A Hint of Different Therapeutic Pathways
M Mapelli , 1 I Mattavelli,1 E Salvioni,1 A Bonomi,1 N Capra,1 P Palermo,1 C Banfi,1 S Paolillo,3 M. Biondi1 and P Agostoni1,2 1. Centro Cardiologico Monzino, IRCCS, Milan, Italy; 2. Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy; 3. Cardiologia SUN, Ospedale Monaldi (Azienda dei Colli), Seconda Università di Napoli, Naples, Italy
Correspondence: Massimo Mapelli, massimo.mapelli@ccfm.it
Background: N-terminal pro-B-type natriuretic peptide (NT-proBNP) and soluble interleukin 1 receptor-like 1 ST2 (sST2) are biomarkers used to grade heart failure with reduced ejection fraction (HFrEF) severity. Both are potential targets of HFrEF treatment, but the first is associated with the patient’s haemodynamic status, while the second is more indicative of
the inflammatory status and of myocardial fibrosis. The aim of this study was to assess the kinetics of these biomarkers after treatment with sacubitril/valsartan in HFrEF.
Materials and Methods: The blood samples of HFrEF patients were analysed at baseline (before sacubitril/valsartan treatment); after 1, 2 and 3 months (respectively, after 1 month of taking 24/26,49/51 and 97/103 mg twice daily doses), and 6 months after the maximum tolerated dose was reached (end study).
EP01.06. Table 1: General Characteristics of the Analysed Population (n=72)
Male 60 (83%)
NYHA class II 63 (88%)
NYHA class III 9 (12%)
Ischaemic aetiology 37 (51%)
CRT-D 18 (25%)
Hypertension 45 (63%)
Diabetes 15 (21%)
EP01.06. Table 1: Cont.
Moderate COPD 8 (11%)
Atrial fibrillation 18 (25%)
ACEI 52 (72%)
ARB 18 (25%)
β-blocker 71 (99%)
MRA 54 (75%)
Loop diuretic 58 (81%)
Loop diuretic dose (mg) 25 (25–50)
ACEI = angiotensin-converting enzyme inhibitors; ARB = angiotensin receptor blockers; COPD = chronic obstructive pulmonary disease; CRT-D = cardiac resynchronisation therapy defibrillator; eGFR = estimated glomerular filtration rate; LVVd = left ventricle volume (diastole); LVVs= left ventricle volume (systole); LVEF = left ventricular ejection fraction; MRA = mineralocorticoid receptor antagonist; NYHA = New York Heart Association.
EP01.06. Table 2: Confirmation of Statistical Significance of the Step-by-step Biomarker Changes in All Imputation Scenarios
NT-proBNP = N-terminal pro-B-type natriuretic peptide; ST2 = soluble interleukin 1 receptor-like 1.
EP01.06. Figure 1: NT-proBNP and sST2 Variation versus Baseline
The graph shows the percent variation of NT-proBNP and sST2 expressed as logarithms at each study step: baseline, after 1, 2 and 3 months (respectively, after a month taking the 24/26 – 49/51 –97/103 mg doses), and 6 months after the maximum-tolerated dose was reached (end study). NT-proBNP = N-terminal pro-B-type natriuretic peptide, sST2 = soluble interleukin 1 receptor-like 1
Results: Samples were obtained from 72 HFrEF patients (64.0 ± 10.5 years, 83% male). NT-proBNP and sST2 values progressively and significantly reduced up to 37% and 16%, respectively, with a greater reduction for NT-proBNP (p<0.001). Specifically, NT-proBNP reduced from 1,144 (593–2,586) to 743 (358–1,524) pg/ml and sST2 from 27.3 (20.5–35.0) to 23.1 (15.9–30.7) ng/ml; p for trend <0.001 in both cases). The reduction of the two biomarkers over time occurred with statistically significant different kinetics: deferred for sST2 and faster for NT-proBNP. No significant changes in renal function and potassium levels were recorded.
EP01.06. Figure 2: Haemodynamic and Non-haemodynamic Effects Related to Sacubitril/Valsartan Treatment Depicted with their Molecular Mechanisms
ACEI = angiotensin-converting enzyme inhibitors ARB = angiotensin receptor blockers; BNP = B-type natriuretic peptide; NEP = neprilysin; NT-proBNP = N-terminal pro-B-type natriuretic peptide;
= soluble interleukin 1 receptor-like 1.
Conclusion: These findings suggest that in HF patients, sacubitril/ valsartan effects on the cardiovascular system share a double pathway: a first, haemodynamic, faster pathway and a second, non-haemodynamic anti-inflammatory, delayed pathway. Both likely contribute to the sacubitril/ valsartan benefits in HFrEF.
EP.01.07
Effects of Dapagliflozin on Exercise Capacity, Ventricular Remodelling, Cardiac Biomarkers, Fluid Retention, and Renal and Pulmonary Function in a Cohort of Patients with Heart Failure with Reduced Ejection Fraction: A Prospective Analysis
M Mapelli,1 C Pafanin,1,2 I Mattavelli,1 A Nepitella,1,3 E Salvioni,1 V Mantegazza,1,2 A Garlasché,1 C Vignati,1,2 J Campodonico,1,2 G Tamborini1 and P Agostoni1,2 1. Centro Cardiologico Monzino, IRCCS, Milan, Italy; 2. Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy; 3. Policlinico Universitario D. Casula, Cardiologia - AOU Cagliari, Cagliari, Italy
Correspondence: Massimo Mapelli, massimo.mapelli@ccfm.it
Background: Mechanisms underlying the benefit of sodium-glucose cotransporter 2 inhibitors (SGLT2i) in heart failure with reduced ejection fraction (HFrEF) are not clear. The aim of this study was to assess dapagliflozin effects on exercise capacity, cardiac biomarkers, fluid retention, and renal and pulmonary function.
Materials and Methods: HFrEF outpatients (EF <40%, New York Heart Association [NYHA] class II/III) eligible for SGLT2i therapy (European Society of Cardiology [ESC] guidelines) were enroled in the study. Serial
cardiopulmonary exercise tests (CPET), pulmonary function tests (spirometry and diffusing carbon monoxide lung capacity [DLCO]), laboratory and echocardiographic assessments, and bioimpedance vector analysis (BIVA) at baseline, and after six months were performed.
Results: None of the patients (n=42) discontinued the treatment or experienced adverse events. There was an increase in left ventricle ejection fraction (LVEF) (32.5 ± 7.4 versus 35 ± 8.8%; p=0.002) and an LV end diastolic (EDV) and end systolic (ESV) volumes reduction (EDV 213.55 ± 87.67 versus 204.95 ± 81.7 ml, p=0.029; ESV 147.5 ± 77.13 versus 138.4 ± 71.8 ml, p=0.007). There were no significant changes in peak oxygen consumption (VO2) (p=0.663). Exercise ventilatory efficiency (VE/VCO2 slope) showed a significant improvement (34.55 (31.10–38.48) versus 33.70 (30.40–38.45); p=0.042). Haemoglobin (Hb) and haematocrit (Hct) levels improved (Hb 13.95 ± 1.43 versus 14.8 ± 1.63 g/dl; p=0.00001), while renal function decreased (eGFR 64.07 [54.27–88.82] versus 63.66 (51.21–82.63); p=0.008). Sodium and potassium levels remained stable, while N-terminal pro-BNP (NT-proBNP), glycated haemoglobin (HbA1c), suppression of tumorigenicity 2 (ST2), and high-sensitivity troponin I (hsTNI) did not reach statistical significance. NYHA functional class improved (p=0.045), together with a significant decrease of Metabolic Exercise test data combined with Cardiac and Kidney Indexes (MECKI) score, from 3.8% to 2.57%, with a positive impact on the two-year prognosis (p=0.002). Hydration index, total water, DLCO and spirometry values did not change.
Conclusion: Dapagliflozin demonstrated beneficial effects on LV remodelling, ventilatory efficiency during exercise, and functional status. This study did not detect medium-term effects on spirometry values, DLCO, fluid retention, and NT-proBNP. As in the DAPA-HF trial, a mild worsening of eGFR was observed. An extended follow-up is needed to confirm these preliminary data.
EP01.07. Figure 1: Effects of Dapagliflozin Therapy on Renal Function, NYHA Functional Class, Blood Pressure, LVEF, ESV/EDV, VE/VCO2 Slope, peak VO2, Haemoglobin and Haematocrit
EP.01.08
Effects of Chronic Kidney Disease on Electrophysiological Function and Incidence of Arrhythmias in Human Myocardium
T Körtl,1 N Hankowitz,1 O Pfeuffer,1 D Riedl,1 L Stengel,1 S Pabel,1 B Flörchinger,2 S Schopka,2 F Schweda,3 L Maier,1 N Hamdani,4 K Streckfuß-Bömeke5 and S Sossalla1
1. University Medical Center Regensburg, Department of Internal Medicine II, Regensburg, Germany; 2. University Medical Center Regensburg, Department of Cardiothoracic Surgery, Regensburg, Germany; 3. University of Regensburg, Institute of Physiology, Regensburg, Germany; 4. Ruhr University Bochum, Department of Molecular and Experimental Cardiology, Bochum, Germany; 5. University of Würzburg, Institute of Pharmacology and Toxicology, Würzburg, Germany
Correspondence: Thomas Körtl, thomas.koertl@ukr.de
Background: Chronic kidney disease (CKD) affects more than 10% of the population worldwide and is associated with increased mortality and arrhythmogenicity. The underlying myocardial mechanisms are poorly understood. New pharmacotherapy is needed to improve outcome of patients with concomitant CKD and cardiovascular disease.
Materials and Methods: Experiments were conducted using human left ventricular myocardium. Based on the glomerular filtration rate (GFR),
patients were divided into a control group (GFR >60 ml/min/1.73 m2) or CKD group (GFR <60 ml/min/1.73 m2). Electrolyte imbalances seen in dialysis patients were simulated using a human iPSC-cardiomyocyte (iPSC-CM) model to study the arrhythmic potential. Medium exchanges represented patient’s dialysis sessions with fast changes from high to low potassium and phosphate concentration (Figure 1). Epifluorescence microscopy and patch-clamp technique was performed.
Results: Ca2+-transient amplitude reduction was observed in the CKD group, pointing to negative inotropic effects and contractile dysfunction. Action potential measurements revealed an action potential duration (APD) prolongation in the CKD group, which represents a potential arrhythmic trigger. Both reduced Ca2+-transient amplitudes as well as prolonged action potentials are also known as hallmarks of heart failure. Dialysis simulation revealed that significantly more arrhythmias occurred in the dialysis group after a final medium exchange. Before the final dialysis simulation (medium exchange), a preliminary strong trend towards more arrhythmias in the dialysis group was observed. This indicates that electrolyte changes occurring during dialysis have proarrhythmogenic effects and may be responsible for the impaired prognosis of patients requiring dialysis.
Conclusion: This study demonstrated for the first time that cardiomyocytes isolated from patients with CKD show impaired cellular electrophysiological function and that an iPSC model identifies dialysis
as an arrhythmogenic trigger. The next step is to identify mechanisms underlying the described changes and to find potential links for pharmacotherapeutic approaches.
EP.01.10
Predictors of Worsening Kidney Function and their Relation to Sodium-glucose Cotransporter 2
Inhibitor Dapagliflozin Administration in Type 2 Diabetes Patients with Chronic Heart Failure
TA Berezina,1 IM Fushtey,2 AA Berezin,2,3 Z Obradovic,3 M Lichtenauer4 and AE Berezin4,5
1. VitaCenter, Department of Internal Medicine and Nephrology, Zaporozhye, Ukraine; 2. Medical Academy of Postgraduate Education, Department of Internal Medicine, Zaporozhye, Ukraine; 3. Klinik Barmelweid, Department of Psychosomatic Medicine and Psychotherapy, Barmelweid, Switzerland; 4. Paracelsus Medical University, Department of Internal Medicine II, Division of Cardiology, Salzburg, Austria; 5. State Medical University, Department of Internal Medicine, Zaporozhye, Ukraine
Correspondence: Alexander Berezin, talexberezina@gmail.com
Background: Sodium-glucose cotransporter 2 inhibitors (SGLT2i) have a favourable impact on kidney function in heart failure (HF) patients. The aim of this study was to identify plausible predictors for kidney function outcome among HF patients and investigate their association with SGLT2i.
Materials and Methods: This study prospectively enrolled 480 patients with established type 2 diabetes (T2D) and concomitant chronic HF and followed them for 52 weeks. Kidney outcome was determined as a composite of a sustained decline in estimated glomerular filtration rate (eGFR) by 40% from baseline, newly end-stage of kidney disease, or kidney replacement therapy. All patients received guideline-recommended optimal therapy, which was adjusted to phenotype/severity of HF,
cardiovascular risk and comorbidity profiles and fasting glycaemia.
Results: Composite kidney outcome was detected in 88 (18.3%) patients. Multivariate logistic regression revealed that use of SGLT2i (OR 0.92; p=0.048), baseline serum levels of irisin <4.50 ng/ml (OR 1.51; p=0.001), adropin <2.10 ng/ml (OR 1.15; p=0.001) along with increase in levels of these biomarkers <15% (OR 1.60; p=0.001) and <6% (OR 1.21; p=0.001), respectively, retained an independent predictor for composite kidney endpoint. Irisin serum levels <4.50 ng/ml at baseline and increase in irisin <15% added more valuable predictive information than the reference variable. However, the combination of irisin <4.50 ng/ml at baseline and increase in irisin serum levels <15% (AUC 0.91; 95% CI [0.87–0.95]) improved discriminative value of each biomarker alone.
Conclusion: Low levels of irisin and its inadequate increase during administration of SGLT2i are promising predictors for unfavourable kidney outcome among T2D patients with concomitant HF.
EP.01.11
In-hospital Maximum Furosemide Dose and 12-month Mortality in a Cohort of 212 Patients Hospitalised for Acute Heart Failure
F Piani, G Armenise and C Borghi
Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
Correspondence: Federica Piani, federica.piani@unibo.it
Background: Acute heart failure (AHF) affects millions of people worldwide, with incidence rates rising as the population ages. AHF is the leading cause of hospital admissions among adults >65 years of age. Efforts in early detection, prevention and improved management strategies are essential to address AHF epidemiological challenges. Furosemide, a loop diuretic, is the cornerstone of AHF management. Its
EP01.11. Table 1: Comparisons between Patients who Died within 1 Year after Discharge and Patients who Survived
EP01.11. Table 1: Cont.
Aetiology of cardiopathy (n, %)
Unknown 37 (30.8%)
Hypertensive 19 (15.8%)
Ischaemic 41 (34.2%)
Valvular 8 (6.7%)
Arrhythmic 3 (2.5%)
Hypertensive 12 (13.0%)
Cardiomyopathy 12 (10%) Unknown 28 (30.4%)
Ischaemic 38 (41.3%)
Valvular 8 (8.7%) Arrhythmic 4 (4.3%) Cardiomyopathy 2 (2.2%)
Hypertension (n, %) 93 (77.5%) 76 (82.6%) 0.224
Dyslipidaemia (n, %) 58 (48.3%) 39 (42.4%) 0.488
Active smoke habit (n, %) 7 (5.8%) 4 (4.3%) 0.567
Atrial fibrillation (n, %) 65 (54.2%) 51 (55.4%) 0.780
Chronic obstructive bronchopneumopathy (n, %) 40 (33.3%) 20 (21.7%) 0.089
Type 1 diabetes (n, %) 1 (0.8%) 1 (1.1%) 0.838
Type 2 diabetes (n, %) 34 (28.3%) 31 (33.7%) 0.332
Chronic kidney disease (n, %) 43 (35.8%) 38 (41.3%) 0.320
Obesity (n, %) 23 (19.2%) 11 (11.9%) 0.191
Pacemaker carriers (n, %) 13 (10.8%) 15 (16.3%) 0.721
More than one cardiovascular risk factor (n, %) 97 (80.8%) 74 (80.4%) 0.697
β-blocker (n, %) 75 (62,5%) 55 (59.8%) 0.886
RAASI (n, %) 59 (49.2%) 40 (43.5%) 0.487
Non-dihydropyridine calcium channel blocker (n, %) 7 (5.8%) 7 (7.6%) 0.590
Dihydropyridine calcium channel blocker (n, %) 32 (26.7%) 20 (21.7%) 0.519
Nitrates (n, %) 7 (5.8%) 6 (6.5%) 0.817
Febuxostat (n, %) 4 (3.3%) 7 (7.6%) 0.213
Warfarin (n, %) 24 (20%) 23 (25%) 0.404
Direct oral anticoagulants (n, %) 36 (30%) 22 (23.9%) 0.436
Acetylsalicylic acid (n, %) 34 (28.3%) 24 (26%) 0.876
Clopidogrel (n, %) 13 (10.8%) 8 (8.7%) 0.817
Metformin (n, %) 9 (7.5%) 6 (6.5%) 0.803
SGLT2i (n, %) 3 (2.5%) 0 (0%) NA
Insulin (n, %) 12 (10%) 12 (13%) 0.515
GLP1 RA (n, %) 0 (0%) 2 (2.2%) NA
DPP4I (n, %) 3 (2.5%) 3 (3.3%) 0.729
Thiazide diuretics (n, %) 7 (5.8%) 2 (2.2%) 0.305
DPP4I = dipeptidyl peptidase IV Inhibitors; GLP-1 RA = receptor agonists; RAASI= reninangiotensin-aldosterone system inhibitors; SGLT2I = sodium-glucose cotransporter 2 inhibitors.
EP01.11.
Table
2: Logistic Regression Analysis for 12-month Mortality
Diuresis of the first 24 h
effectiveness in reducing congestion is undeniable, yet previous studies on its long-term impact including mortality are inconsistent.
Materials and Methods: Patients hospitalised for AHF at the Cardiovascular Unit from 2019 to 2021 who gave their consent to participate were enrolled for the study. Exclusion criteria included respiratory failure of non-cardiac origin, advanced neoplastic disease. Baseline characteristics and in-hospital outcomes were collected. One year after discharge data on mortality and hospitalisations for AHF were collected from hospital medical records and telephone interview to patients or their relatives. Characteristics of patients who died within a year from discharge were compared to characteristics of patients who survived. Adjusted regression models were used to assess the associations between furosemide prescription during hospitalisation and 12-month mortality.
Results: Two hundred and twelve patients were enrolled in the study. Patients who died within 12 months from discharge (n=92) were older, had higher B-type natriuretic peptide (BNP) levels at admission and were prescribed with a higher maximum daily dose of IV furosemide (Table 1). In the adjusted logistic regression model, maximum furosemide dosage prescribed during hospitalisation was significantly associated with increased risk of 12-month mortality (OR 1.013, 95% CI [1.005–1.022]; p=0.001; Table 2).
Conclusion: Optimal furosemide dosing in AHF is a subject of on-going research and clinical debate. In this study maximum daily dosage of furosemide during hospitalisation was associated with 12-month mortality. The need for higher doses of furosemide during hospitalisation for AHF may hold prognostic value for long-term mortality and guide follow-up strategies.
EP.01.12
Polypharmacy in Patients with Heart Failure with Preserved Ejection Fraction
R-E Martin-Graur,1 C Delcea,1,2 A-M Muste,1,2 D-A Ionescu,1 A-E Vijan,1,2 C-A Buzea,1,2 E Badila1,2 and GA Dan1,21. Colentina Clinical Hospital, Bucharest, Romania; 2. Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
Correspondence: Ruxandra-Elena Martin-Graur, ruxandra.1995@yahoo.com
Background: Polypharmacy (PPh), defined as the use of 10 or more medications, is frequently seen in elderly patients and is associated with poor prognosis. Data about PPh in heart failure with preserved ejection fraction (HFpEF) have been evaluated. The aim of this study was to assess the clinical and biological profiles associated with PPh in middle-aged and elderly patients with HFpEF.
Materials and Methods: Middle-aged and elderly HFpEF patients admitted consecutively to the clinic from December 2017 to February 2020 were retrospectively analysed. Readmissions and in-hospital mortality were excluded.
Results: The study sample consisted of 394 patients. The mean age of patients was 72.69 ± 9.34 years and 64.12% were female. The median number of medications was 6 [IQR 5–8], and cardiovascular medications 5 [IQR 4–6]. 12.21% patients had PPh. They were taking more cardiovascular (median 7 [IQR 5–8] versus 5 [IGR 3–6], p<0.001) as well as noncardiovascular medications (median 4 [IQR 3–6] versus 1 [IQR 0–2], p<0.001) compared to the rest of the cohort. In multivariable analysis, the factors independently correlated with PPh were New York Heart Association (NYHA) class III–IV (HR 4.08, 95% CI [1.86–8.93]; p<0.001), diabetes (HR 4.82, 95% CI [2.29–10.15], p<0.001), chronic kidney disease stage IV KDOQI (HR 9.37, 95% CI [1.95–45.06], p=0.005), malignancy (HR 3.20, 95% CI [1.25–8.19], p=0.015) and autoimmune or connective tissue disorders (HR 5.04, 95% CI [1.02 –25.02], p=0.047). Conditions such as ischaemic heart disease (p=0.059), history of stroke (p=0.10) or myocardial infarction (p=0.18), atrial fibrillation (p=0.53), anaemia (p=0.25), sleep apnoea (p=0.38), chronic obstructive pulmonary disease (p=0.88), cirrhosis (p=0.45), dementia (p=0.12) and thyroid disorders (p=0.11) were not correlated with PPh in multivariable analysis.
Conclusion: In middle-aged and elderly HFpEF patients, PPh was independently correlated with non-cardiac conditions as well as with NYHA class. De-escalation of therapy should be assessed in all HFpEF patients.
EP.01.14
Cardiac-specific Overexpression of GTP Cyclohydrolase 1 Protects against Heart Failure with Preserved Ejection Fraction
M Zhang,1 C Liu,2 Z Xia3 and Y Cai1
1. The Hong Kong Polytechnic University, Hong Kong, Hong Kong; 2. The First Hospital of Jilin University, Jilin, China; 3. Affiliated Hospital of Guangdong Medical University, Guangdong, China
Correspondence: Miao Zhang, miureal.zhang@polyu.edu.hk
Background: Heart failure with preserved ejection fraction (HFpEF) is a clinical syndrome of HF with no effective treatment. Notably, nitric oxide (NO) signalling is disrupted, and recognised as a driving factor for the development of HFpEF. The activity of NO is controlled by
EP01.14. Figure 1: Impaired GCH1/BH4
Signalling May Contribute to HFpEF
tetrahydrobiopterin (BH4), of which, the biosynthesis is catalysed by GTP cyclohydrolase 1 (GCH1). The impaired GCH1/BH4 signalling potentially contributes to metabolic and dyslipidaemia abnormalities, but its involvement in the pathogenesis of HFpEF is largely uncharted. This study investigates whether cardiac-specific GCH1 overexpression safeguards against HFpEF and its underlying mechanisms.
Materials and Methods: Male mice with cardiac-specific overexpression of human GCH1 (8 weeks old) and age-matched wild-type counterparts were subjected to either a high-fat diet (HFD) or a chow diet for 16 weeks. During this time, mice received angiotensin II (AngII, 1.25 mg/kg/day) via osmotic mini pumps for 4 weeks to induce HFpEF. Glucose/insulin tolerance tests were assessed for insulin sensitivity and glucose utilisation. Cardiac structure and function were evaluated by echocardiography. Plasma biomarkers, including N-terminal pro-B-type natriuretic peptide (NT-proBNP), triglyceride (TG) and free fatty acid (FFA), were quantified using assay kits, while the expression of proteins related to cardiac glucose and FA metabolism were measured via western blots.
Results: Mice subjected to HFD+AngII exhibited severe diastolic dysfunction, evidenced by elevated E/A ratios, myocardial performance index and global longitudinal strain but preserved EF. This occurred along with increased weight, heart mass, plasma NT-proBNP levels. GCH1 overexpression augmented cardiac BH4 levels and alleviated HFpEF phenotypes, along with an improved diastolic function and glucose utilisation, but reduced weight and plasma parameters. Mechanistically, GCH1 overexpression significantly reduced cardiac protein levels of CD36 and PDK4, while increasing abundance of ACC and GLUT1, implicating a rebalanced FA-glucose metabolism in the mouse heart with HFpEF.
Conclusion: Overexpression of cardiac GCH1 in mice with HFpEF may enhance glucose utilisation and reduce fatty acid metabolism, leading to improved cardiac performance.
Advancements in the Therapy of Hypertension
EP.02.01
Different Efficacy of Angiotensin Receptor Blockers for Nocturnal Blood Pressure Reduction in Patients with Mild to Moderate Hypertension: A Systematic Review and Meta-analysis
and their Functional Recovery after Termination of AF Simulation
A: Original traces of examined AF- and rhythmic-paced tissue slices on days 0 and 7 of AF simulation and at day 12 (last day of simulated rhythm restoration); B: Mean amplitude heights ± SE mean of measured tissue slices up to 7 days simulation of AF followed by regular pacing (rhythm control treatment). All measured values were normalised to their respective basal values measured prior the arrhythmic stimulation protocol and to the control-treated slices. AF-simulated slices are presented in orange while control slices are displayed in green. Recovery-treated slices are depicted in grey. The number of examined slices and utilised hearts (n) is depicted in the figure legend. Not all time points could be acquired from each preparation.
J Liu, W Chen, S Shao, Y Chen, H Wang, Y Xi and L Wang
Peking University Peoples Hospital, Beijing, China
Correspondence: Jing Liu, heartcenter@163.com
Background: High nocturnal blood pressure (BP) is an important predictor of the risk of cardiovascular events in hypertensive patients. As the most commonly prescribed BP-lowering agents, angiotensin II receptor blockers (ARBs) maybe have different efficacy for nocturnal BP reduction in patients with mild to moderate hypertension (MMH).
Materials and Methods: A systematic search was conducted in PubMed, Embase and Cochrane Library from inception to 8 August 2022. Ambulatory BP study data of different ARBs (allisartan, candesartan, irbesartan, losartan, olmesartan, telmisartan and valsartan) in patients with MMH following PICO principle were collected. Data were extracted and the risk of bias of the included studies was evaluated accordingly. R software (version 4.0.0) was used for statistical analysis.
Results: Seventy-eight studies comprising 13,108 patients were included. The results of meta-analysis showed that allisartan, olmesartan and telmisartan were associated with greater reduction in nocturnal systolic BP. In the aspect of the nocturnal-diurnal BP drop ratio, only allisartan was greater than 1 (Figure 1). Additionally, allisartan showed more advantages in the last 4–6-hour ambulatory BP drop, proportion of patients with dipping BP pattern, and 24-hour ambulatory BP drop compared to other ARBs.
Conclusion: For patients with MMH, allisartan, olmesartan and telmisartan have more advantages in nocturnal BP reduction among the ARBs, while allisartan can reduce nocturnal BP more than daytime BP and improve the dipping pattern and contribute to the restoration of normal BP rhythm.
EP.02.02
Little Strokes Fell Great Oaks
A Ivanescu, A Marincas and G-A Dan Carol Davila University of Medicine , Colentina Clinical Hospital, Bucharest, Romania
Correspondence: Andreea-Cristina Ivanescu, andreea.cardio@gmail.com
Background: In resistant hypertension (HT), searching for possible correctable factors is a cornerstone of management. In elderly patients with multiple comorbidities, drug interactions and over-the-counter (OTC) therapy should be thoroughly evaluated as possible causes of resistance and electrolyte imbalance.
Materials and Methods: A 76-year-old patient was hospitalised for high blood pressure (BP) over the prior two weeks (maximum systolic BP 220 mmHg), mostly during the night. The current episode began with increased BP, nausea and vomiting. She had a history of HT and heart failure with preserved ejection fraction. For the past year, she was prescribed various schemes of antihypertensive medication, with insufficient BP control. At admission the patient had BP 180/90 mmHg, without congestion, and normal ECG. Estimated glomerular filtration rate was 36 ml/min/1.73 m2 and blood electrolytes were normal. Ultrasonography showed left ventricular hypertrophy, left ventricular ejection fraction 55%, significant stenosis of the right renal artery, and decreased blood flow on the left kidney.
Results: In-hospital therapy with ramipril, indapamide, amlodipine and bisoprolol was initiated. The patient rapidly developed nausea and hyponatraemia (hNa; 123 mEq/l). Indapamide and ramipril were stopped; clonidine was initiated and hNa (presumed due to drugs) was corrected. Unfortunately, the patient developed visual hallucinosis, regarded as an adverse reaction to clonidine, which was stopped. Spironolactone, doxazosin, and isosorbide mononitrate were started. BP remained moderately elevated; however, Na concentration was normal and stable. Several days after discharge the patient complained of weakness and hyponatraemia was identified. On repeated anamnesis, it was found that she was habitually drinking herbal diuretic teas Equisetum arvense, Achillea
EP02.02. Figure 1: Timeline of Therapeutic Approach and Evolution of Patient
EP02.02. Figure 2: Timeline of Management during Rehospitalisation
millefolium and Vaccinium Vitis-idea. After stopping these, the patient’s Na value remained normal, and for the next weeks her BP was controlled.
Conclusion: Secondary hypertension should be considered in patients resistant to therapy. However, evaluation should not stop at this stage, as other factors could contribute to resistance. Obscure causes such as OTC habitual medication should be considered, as they could complicate the clinical scenario and management.
EP.02.03
Guideline Adherence, Medication Adherence and Goal Attainment in the Treatment of Hypertension and Dyslipidaemia in Irish Populations: A Systematic Review
R Elhiny,1,2 LM O’Keeffe,3,4,5 S Byrne1 and M Bermingham1
1. Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Ireland; 2. Clinical Pharmacy Department, Faculty of Pharmacy, Minia University, Minia, Egypt; 3. School of Public Health, University College Cork, Cork, Ireland; 4. MRC Integrative Epidemiology Unit at the University of Bristol, University of Bristol, Bristol, UK; 5. Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
Correspondence: Rehab Elhiny, 122109898@umail.ucc.ie
Background: Achieving guideline goals of blood pressure and lowdensity lipoprotein cholesterol (LDL-C) is a healthcare challenge. Studies report inadequate medication adherence among people with primary or secondary prevention of cardiovascular diseases and suboptimal guidelines adherence among prescribers. This systematic review aims to
EP02.04. Figure 1: Risk Curves for Cardiovascular Mortality with Blood Pressure Categories Measured at Baseline of the Cardiovascular Observation Study or 15 Years Earlier at the Health Survey
Curves reflect the risk of cardiovascular mortality during follow-up of the observation study (OS) associated with blood pressure (BP) measured either at the OS baseline (blue) or in the identical patients 15 years earlier, at the health survey (beige). BP categories were built with systolic (sys) and diastolic (dias) BP measurements (A) according to US (ACC/AHA) or (B) according to European (ESC/ESH) guidelines adopted by the ADA and the EASD, respectively.
estimate the level of medication adherence and achievement of guideline goals among people with hypertension, dyslipidaemia, or secondary prevention and levels of guideline adherence relating to these conditions among prescribers.
Materials and Methods: The systematic review protocol is published in PROSPERO (CRD42023422050). Four databases were searched for relevant articles in January 2023. Quantitative articles reporting medication adherence, guideline adherence, and blood pressure and LDL-C goal achievement among an Irish population aged 18 years and older, diagnosed with hypertension or dyslipidaemia and treated for these conditions, or treated for secondary prevention of cardiovascular disease with blood pressure or lipid-lowering medications were included.
Results: The database search identified 4,065 records. Following full-text screening, 23 studies met inclusion criteria. Thirteen studies reported blood pressure and LDL-C goal attainment, nine studies reported levels of medication adherence, and five studies reported levels of guideline adherence. The proportion of participants who attained LDL <1.8 mmol/l ranged between 27.7% and 73%, and achievement of blood pressure goal <130/80 mmHg ranged between 16.7% and 52.3%. The highest rate of guideline achievement was among participants in hospital settings rather than community based. Medication adherence was evaluated by either indirect methods: Morisky Medication Adherence Scale (three studies), proportion of days covered (three studies), medication possession ratio (one study), group-based trajectory modelling (one study) and selfreported medication adherence (three studies) or direct methods: mass spectrometry urine analysis (two studies). Reported medication adherence ranged from 27.4% and 92% for antihypertensives and 51.3% and 90% for lipid-lowering therapy.
Conclusion: Findings of this work document the level of guideline adherence, medication adherence, and goal attainments for blood pressure and dyslipidaemia in Ireland.
EP.02.04
Cardiovascular Mortality Prediction Depends on the Time Point of Blood Pressure Measurement Rather than on the use of European Versus US Blood Pressure Categorisations
A Leiherer,1,3,4 W Brozek,7 A Muendlein,1 H Ulmer,7 CH Saely,1,2,3 T Plattner,1,2,3 A Vonbank,1,2,3 A Mader,1,2,3 L Sprenger,1,2 M Maechler,1,2 B Larcher,1,2,3 P Fraunberger,3,4 G Nagel,7 E Zitt,2,7 H Drexel1,3,5,6 and H Concin7
1. Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Feldkirch, Austria; 2. Medicine, Academic Teaching Hospital Feldkirch, Feldkirch, Austria; 3. Private University in the Principality of Liechtenstein, Triesen, Liechtenstein; 4. Medical Central Laboratories, Feldkirch, Austria; 5. Vorarlberger Landeskrankenhaus Betriebsgesellschaft, Feldkirch, Austria; 6. Drexel University College of Medicine, Philadelphia, US; 7. Agency for Preventive and Social Medicine, Bregenz, Austria
Correspondence: Andreas Leiherer, vivit@lkhf.at
Background: Blood pressure (BP) is a predictor of cardiovascular risk, but it changes over a lifetime. This observation study (OS) compares the value of systolic and diastolic BP at different stages of life for predicting cardiovascular mortality risk.
Materials and Methods: At the baseline of the OS, BP was measured in 1,497 cardiovascular disease patients at a median age of 65 years and their outcome was recorded over 21 years. Fifteen years prior to the OS, the identical patients had participated in a health survey (HS) comprising BP measurement. The value of earlier HS versus recent OS BP measurements for risk prediction was addressed using both guidelinedefined BP categorisations from Europe (ESC/ESH) and the US (ACC/AHA).
Results: BP at HS was a significantly better predictor of cardiovascular mortality than BP at OS (NRIESC/ESH 0.29, p<0.001; NRIACC/AHA 0.30,
p<0.001). Each 10 mmHg increase was significantly positively associated with cardiovascular mortality for both systolic and diastolic BP (HR 1.17 [1.11–1.23] and 1.20 [1.09–1.32], respectively) when measured at HS. In contrast, for systolic BP recorded at OS, the significant association with cardiovascular mortality (HR 1.04 [0.98–1.10]) was abrogated, and with diastolic BP the association reversed (HR 0.82 [0.74–0.92]. In contrast, ESC/ESH and ACC/AHA BP categorisations were comparably valuable predicting cardiovascular mortality (NRIHS 0.04, p=0.563; NRIOS 0.02, p=0.817).
Conclusion: Irrespective of categorisation differences between European and US BP guidelines, earlier-in-life BP readings are valuable risk predictors for cardiovascular mortality and outperform BP readings taken at a more advanced age.
Anticoagulation Therapy: New Targets. Focus on Factors XI and XII
EP.03.01
Safety of Direct Oral Anticoagulants Reversal Agents: An Analysis of VigiBase, the WHO Spontaneous Reporting Database
G Crescioli,1 E Arzenton,2 N Luxi,2 S Fumagalli,3 G Mannaioni,4 G Trifirò,2 A Vannacci1 and N Lombardi1
1. Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy; 2. Department of Diagnostics and Public Health, University of Verona, Verona, Italy; 3. Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; 4. Toxicology Unit, Poison Control Center, Careggi University Hospital, Florence, Italy
Correspondence: Giada Crescioli, giada.crescioli@unifi.it
Background: Specific reversal agents for direct oral anticoagulants include idarucizumab for dabigatran and andexanet alfa for apixaban and rivaroxaban. These agents carry a high thrombotic risk. The association between these agents and serious adverse reactions (ADRs), particularly thrombotic events, are uncertain. To investigate the characteristics of ADRs related to idarucizumab and andexanet alfa recorded in the WHO global individual case safety report (ICSR) database (VigiBase) an observational retrospective cohort study was performed.
Materials and Methods: For each ICSR, anonymous administrative data and patient and drug information were evaluated. If a medication was considered probably responsible for the ADR, it was defined as ‘suspect/ interacting’. If not, it was defined as ‘concomitant’. Multivariate logistic regression models were fitted to estimate the ORs with 95% CIs of serious ADRs and death.
Results: A total of 1,095 ICSRs were analysed. The mean age was 75 years, and the majority of subjects were male (44.5%), exposed to a single suspect/interacting drug (73.6%), with only 18% exposed to polypharmacy. Idarucizumab represented 72% of the cases. Most cases were classified as serious ADRs (88.6%), of which 61.6% resulted in death. Multivariate logistic analysis showed an increased risk of serious ADRs both for the group exposed to 1–4 concomitant drugs (OR 2.51; CI [1.38–4.57]), and for those exposed to more than five concomitant drugs (OR 6.35, CI: 2.28–17.68). The risk of death was also increased in these subjects. Of the total preferred terms reported (n=2,180), thromboembolic events accounted for 6.5%.
EP04.02. Figure 1
Means and interquartile range (box-plots) of sTXB2 expressed as percentage of the reference, in samples stored for different time intervals at 4°C before centrifugation. Continuous line: identity line; Dashed lines: assay variability.
Conclusion: Real-world data showed a significant rate of serious ADRs and notable mortality in individuals requiring idarucizumab and andexanet alfa. Healthcare providers must closely monitor and provide comprehensive care, addressing bleeding and clotting concerns.
Antiplatelet Therapy in Acute and Chronic Conditions and in Special Populations: Extremes of Weight, Age (Paediatric versus Elderly Subjects) and Chronic Kidney Disease
EP.04.02
Serum Thromboxane B2 Measurements in Patients on Acetylsalicylic Acid: Investigation of Different Pre-analytical Conditions to Improve Feasibility in Clinical Studies
G Petrucci,1 E Zagarrì,2 F Dentali,3 M Slingardi,4 G Frisullo,5 I Scala,5 S Bellavia,5 PA Rizzo5 and B Rocca1 1. Department of Safety and Bioethics, Section of Pharmacology, Catholic University School of Medicine, Rome, Italy; 2. Research Department, FADOI Foundation, Milan, Italy; 3. Research Department, FADOI Foundation, Milan and Department of Medicine and Surgery, Insubria University, Varese, Varese, Italy; 4. Internal Medicine Unit, Ospedale Maggiore, Bologna, Bologna, Italy; 5. Department of Neurology, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy
Correspondence: Giovanna Petrucci, petrucciscatolini@gmail.com
Background: Serum thromboxane B2 (sTXB2) concentration in blood clotted ex vivo is the regulatory endorsed biomarker of low-dose aspirin pharmacodynamics, reflecting maximal platelet cyclooxygenase activity. For reliable results, whole blood samples must start 37°C incubation within 5 minutes from withdrawal for 1 hour, then be centrifuged, and supernatant serum can be frozen for later measurement. Thus, the feasibility of this assay in large studies can be limited, since blood withdrawal, incubation and centrifugation sites can be distant, samples handled by different personnel (physicians, nurses, technicians) and the assay unfeasible 24/7 (i.e. during weekend or night). We have shown that delayed incubation generates artifacts on sTXB2 values. In this study we investigated how to handle possible delays in centrifugation and storage of clotted samples and their impact on sTXB2. A preliminary survey at the
hospital’s blood withdrawal sites showed that a fridge is usually available nearby. Thus, we tested whether blood samples after a correct 37°C incubation step can be stored at 4°C for 12–72 hours before centrifugation and storage.
Materials and Methods: Blood samples from 72 patients on aspirin were incubated at 37°C. One sample was immediately processed (reference sample), while another clotted sample was stored at 4°C for 12, 24, 48 and/or 72 hours before centrifugation.
Results: sTXB2 levels expressed as percentage of reference were stable in samples kept up to 48 hours at 4°C with values comprised within the variation of the method (±11% in relative terms; Figure 1). Samples stored for 72 hours at 4°C showed a wider variability (Figure 1). Values at each time point were highly correlated with the reference sample.
Conclusion: Clotted blood sample can be stored for up to 48 hours at 4°C after 37°C incubation without impacting sTXB2 stability. These data could increase feasibility of multicentre studies if immediate processing after 37°C incubation is not always possible.
EP.04.03
Effect of Long-term Storage and Freezethawing Cycles on Arachidonic Acid Metabolites
in Human Urine Samples
G Petrucci,1 D Hatem,1 D Pitocco,2 A Rizzi,2 A Habib3 and B Rocca1
1. Department of Safety and Bioethics, Section of Pharmacology, Catholic University School of Medicine, Rome, Italy; 2. Diabetes Care Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; 3. Department of Basic Medical Sciences, College of Medicine, QU Health, Qatar University, Doha, Qatar
Correspondence: Giovanna Petrucci, petrucciscatolini@gmail.com
Background: Biological samples are often stored for several years in biobanks, thus assessing the reproducibility of biomarker measurements over long-term storage and/or repeated cycles of freezing and thawing is crucial for data reliability and study interpretation. This study investigated the long-term stability of two major urinary metabolites of arachidonic acid 11-dehydrothromboxane (TX) B2, 8-iso-prostaglandin F2alpha (PGF2α) and creatinine as control molecule, in human urine samples stored at -40°C over 10 years and the effect of freezing and thawing cycles.
Materials and Methods: A total of 703 urine samples, already assayed for 11-dehydro-TXB2, 8-iso-PGF2α and creatinine, stored at -40°C, were thawed for repeated measure after an interval of between 2 and 10 years. To evaluate the effect of freezing and thawing, urine samples underwent 10 sequential freeze-thaw cycles in the presence or absence of the antioxidant (4-hydroxy-TEMPO).
Results: Urinary levels of 11-dehydro-TXB2, 8-iso-PGF2α and creatinine, expressed as percentage of the first measurement were reproducible in samples stored up to 10 years and the first and second measurements were highly correlated (all rho 0.99, p<0.0001). 11-dehydro-TXB2 and creatinine were stable for up to 10 cycles of freezing and thawing (11-dehydro-TXB2 95.8 ± 14%; creatinine 100.7 ± 5.7% of baseline on the last thawing cycle, n=10). 8-iso-PGF2α concentrations showed a significant increase from the fifth thawing (138 ± 1.5% of baseline at cycle 5, n=10,
p<0.001), which was not observed when 4-hydroxy-TEMPO was added (103.1 ± 3.3% of baseline at cycle 10, n=5, p=NS). Oxidation species significantly increased after four cycles of freezing and thawing (24.4 ± 15-fold increase versus baseline; n=3, p=0.04)
Conclusion: Urinary arachidonic acid metabolites and creatinine appear stable in samples stored at -40°C for up to 10 years. Multiple freeze-thaw cycles paradoxically increased 8-iso-PGF2α levels in association with increased oxidative species generation. These data are relevant when measuring biomarkers in samples stored over a long time, or when samples undergo multiple cycles of freezing and thawing.
EP.04.05
Increased Thromboxane Biosynthesis in Patients with Melanoma
G Petrucci,1 A Di Stefani,2 L Di Nardo,3
B Rocca,1 C Patrono1 and K Peris3
1. Dipartimento di Sicurezza e Bioetica, Sezione di Farmacologia, Università Cattolica del Sacro Cuore, Rome, Italy; 2. UOC Dermatologia, Dip di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; 3. Dermatologia, Dip Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
Correspondence: Giovanna Petrucci, petrucciscatolini@gmail.com
Background: Melanoma is a complex skin cancer, resulting from genetic, host and environmental risk factors. The 10-year survival rate is 75–85% for early diagnosis and only 20–40% for patients with metastases. Melanoma has limited therapeutic options. Platelet activation and inflammation support tumour initiation and progression. The chemopreventive effect of aspirin, most convincingly against colorectal cancer, further supports the contribution of platelets and, possibly, inflammation through the activity of cyclooxygenase (COX)-isozymes and thromboxane (TX) A2 biosynthesis. However, the relevance of this pathway in melanoma initiation and progression is unknown.
Materials and Methods: In vivo TXA2 biosynthesis was investigated in patients with melanoma and in control subjects by measuring urinary excretion of the major enzymatic metabolite of TXA2/TXB2 (i.e. 11-dehydroTXB2 [U-TXM]), with a previously described and validated immunoassay (Pagliaccia et al. Clin Lab 2014;60:105–11).
Results: Thirty-four patients with skin melanoma (mean age 58 ± 16 years, 24 males), 21 with non-metastatic and 13 with metastatic disease were studied. U-TXM was measured in 65 heathy controls (mean age 39 ± 13 years, 47 males). Urinary 11-dehydro-TXB2 excretion was significantly higher in patients with melanoma (1,728 ± 963 pg/mg creatinine; mean ± SD) compared to healthy controls (482 ± 235 pg/mg creatinine, p<0.01). No statistically significant differences were observed between patients with or without metastases (2,186 ± 1,406 and 1,642 ± 953 pg/mg creatinine, respectively; p=0.2). On-going histological studies are investigating the pattern of expression of COX-1 and -2 in tumour and control skin specimens.
Conclusion: Patients with melanoma have increased TXA2 biosynthesis. These data are consistent with data demonstrating enhanced TXA2dependent platelet activation in non-cutaneous solid tumours (Joharatnam-Hogan et al. Br J Cancer 2023;129:706–20).
EP.04.06
Platelet Maturity and Reactivity Determined by Multicolour Flow Cytometry Using SYTO-13 Staining in Patients with Acute ST-segment Elevation Myocardial Infarction
O Pedersen,1 A-M Hvas,2 PH Nissen,3,4 L Pasalic,5,6 SD Kristensen1,4 and EL Grove1,4
1. Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; 2. Faculty of Health, Aarhus University, Aarhus, Denmark; 3. Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark; 4. Department of Clinical Medicine, Aarhus University, Faculty of Health, Aarhus, Denmark; 5. Institute of Clinical Pathology and Medical Research, Westmead Hospital, Sydney, Australia; 6. Westmead Clinical School, University of Sydney, Faculty of Medicine and Health, Sydney, Australia
Correspondence: Oliver Pedersen, olihped@gmail.com
Background: Reduced effect of antiplatelet therapy has been reported in patients with ST-segment elevation myocardial infarction (STEMI). Multiple factors may concur to explain this, including increased amount of highly reactive immature platelets. The aim of this study was to investigate the association between platelet maturity and reactivity determined with multicolour flow cytometry using the SYTO-13 dye in STEMI patients.
Materials and Methods: An observational study of 59 patients with acute STEMI undergoing primary percutaneous coronary intervention was conducted. Blood samples were obtained within 24 hours after admission and after loading doses of dual antiplatelet therapy. For comparison, samples were obtained from 50 healthy individuals. Platelet maturity and reactivity were investigated using multicolour flow cytometry, including SYTO-13 dye that binds to platelet RNA and thus provides a method for subdividing platelets into immature and mature platelets.
Results: Platelets were categorised and analysed in three groups: (1) all platelets; (2) the 20% platelets with the highest amount of SYTO-13 (SYTO13 high) corresponding to immature platelets; and (3) the 20% platelets with the lowest amount of SYTO-13 (SYTO-13 low) corresponding to mature platelets. Compared to the SYTO-13 low platelets and all platelets, the SYTO-13 high platelets had significantly higher platelet reactivity demonstrated by both a higher percentage of platelets positive for the reactivity markers and for fluorescence intensity of the reactivity markers of bound-fibrinogen, CD63 and P-selectin expression in both STEMI patients and healthy individuals (p<0.05).
Conclusion: Immature platelets identified with a novel multicolour flow cytometric method using the SYTO-13 dye are more reactive than mature platelets in patients with acute STEMI and in healthy individuals. The presence of immature platelets may be important for the overall platelet reactivity, which may have implications for the effect of antiplatelet therapy.
EP.04.07
Non-Steroidal
Anti-inflammatory Drugs and
Risk
of Pulmonary Embolism
in Patients
with Inflammatory Joint Disease: Results from the Nationwide Norwegian Cardio Rheuma Registry
E Ikdahl,1 S Rollefstad,1 A Kazemi,1 SA Provan,1 T-L Larsen2 and AG Semb1
EP04.07. Figure 1: Incidence Rate Ratios for Pulmonary Embolism during NSAIDs Treatment versus Periods without NSAIDs in IJD and non-IJD Populations
axSpA = axial spondylarthritis; IJD = inflammatory joint disease; IRR = incidence rate ratio; NSAIDs = non-steroidal anti-inflammatory drugs; RA = rheumatoid arthritis; PE = pulmonary embolism; PsA = psoriatic arthritis; tNSAIDs = traditional NSAIDs.
1. REMEDY Center for Treatment of Rheumatic and Musculoskeletal Diseases, Oslo, Norway; 2. Akershus University Hospital, Lorenskog, Norway
Correspondence: Anne Grete Semb, anne.semb@yahoo.no
Background: Patients with inflammatory joint diseases (IJD), including rheumatoid arthritis (RA), psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA) have increased rates of pulmonary embolism (PE). Non-steroidal anti-inflammatory drugs (NSAIDs) use is associated with PE in the general population. The aim of this study was to evaluate the association between NSAIDs use and PE in IJD patients.
Materials and Methods: Using individual-level registry data from the whole Norwegian population, including data from the Norwegian Patient Registry and the Norwegian Prescription Database, this study evaluated PE risk in IJD compared to non-IJD individuals and applied the selfcontrolled case series method to evaluate if PE risks were associated with use of traditional NSAIDs (tNSAIDs) and selective COX-2 inhibitors (coxibs).
Results: After a 1-year wash-out period, 4,660,475 adults were followed, including 74,001 with IJD (RA 39,050; PsA 20,803; axSpA 18 591) for a median of 9 years. Crude PE incidence rates per 1,000 patient years were 2.02 in IJD and 1.01 in non-IJD individuals. Age and sex-adjusted HRs for PE events were 1.57 for IJD patients compared to non-IJD. Incidence rate ratios (IRR) (95% CI) for PE during tNSAIDs use were 0.78 (0.64–0.94, p=0.010) in IJD and 1.68 (1.61–1.76, p<0.001) in non-IJD. IRR (95% CI) for PE during coxibs use was 1.75 (1.10–2.79, p=0.018) in IJD and 2.80 (2.47–3.18, p<0.001) for non-IJD.
Conclusion: Pulmonary embolism rates were higher in IJD than in non-IJD subjects. tNSAIDs may protect against PE in IJD patients, while coxibs are associated with increased PE risk.
Cardiovascular Therapy in Patients with Diabetes: Antithrombotic Drugs and Heart Failure
EP.05.02
The ApoB/LDL-C Ratio Predicts Major Cardiovascular Events in Cardiovascular Disease Patients Independent of Type 2 Diabetes Status
B Larcher,1,2 M Maechler,1,2 L Sprenger,1,2 A Mader,1,2,3
A Vonbank,1,2,3 T Plattner,1,2,3 A Leiherer,1,3,4
A Muendlein,1 H Drexel1,3,5,6 and CH Saely1,2,3
1. Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Feldkirch, Austria; 2. Medicine, Academic Teaching Hospital Feldkirch, Feldkirch, Austria; 3. Private University in the Principality of Liechtenstein, Triesen, Liechtenstein; 4. Medical Central Laboratories, Feldkirch, Austria; 5. Vorarlberger Landeskrankenhaus Betriebsgesellschaft, Feldkirch, Austria; 6. Drexel University College of Medicine, Philadelphia, PA, US
Correspondence: Andreas Leiherer, vivit@lkhf.at
Background: A high ApoB/LDL-C ratio reflects small LDL particle size which, like type 2 diabetes (T2DM), is associated with insulin resistance. Whether the ApoB/LDL ratio and the presence of T2DM are mutually independent predictors of major cardiovascular events (MACE) is unclear and is addressed in the present study.
Materials and Methods: This study enrolled a large high-risk cohort of 1,689 patients with established cardiovascular disease (1,391 patients with angiographically proven stable coronary artery disease (CAD) and 298 patients with sonographically proven peripheral artery disease). T2DM was diagnosed according to current American Diabetes Association guidelines. Prospectively, MACE, including death from cardiovascular cause, non-fatal stroke and non-fatal MI were recorded over a mean follow-up period of 9.6 ± 5.1 years.
Results: At baseline, the ApoB/LDL-C ratio was significantly higher in patients with T2DM (n=561) than in those who did not have T2DM (0.82 ± 0.19 versus 0.74 ± 0.15 p<0.001). During follow-up, 668 patients had MACE. The Apo B/LDL-C ratio predicted MACE in univariate analysis (HR 1.12 [1.04–1.20]; p= 0.002), and the event rate was higher in patients with than in those without T2DM (49.1% versus 34.9%; p<0.001). In a multivariate adjusted Cox regression model, both ApoB/LDL-C ratio and T2DM significantly predicted MACE in a mutually independent manner, with standardised adjusted HRs of 1.17 (1.05–1.30); p=0.005 and 1.49 (1.26–1.75); p<0.001, respectively.
Conclusion: In subjects with established cardiovascular disease ApoB/ LDL-C and T2DM are mutually independent predictors of MACE.
EP.05.03
Cystatin C Predicts Major Cardiovascular Events in Patients with Coronary Artery Disease Both Among Patients with and Among Those without Metabolic Syndrome
A Mader,1,2,3 M Maechler,1,2 B Larcher,1,2 L Sprenger,1,2 A Leiherer,1,3,4 A Muendlein,1 A Vonbank,1,2,3 T Plattner,1,2,3 H Drexel1,3,5,6 and CH Saely1,2,3
1. Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Feldkirch, Austria; 2. Medicine, Academic Teaching Hospital Feldkirch, Feldkirch, Austria; 3. Private University in the Principality of Liechtenstein,
Triesen, Liechtenstein; 4. Medical Central Laboratories, Feldkirch, Austria; 5. Vorarlberger Landeskrankenhaus Betriebsgesellschaft, Feldkirch, Austria; 6. Drexel University College of Medicine, Philadelphia, US
Correspondence: Andreas Leiherer, vivit@lkhf.at
Background: Cystatin C is an established biomarker of renal function, and given the close association of chronic kidney disease and cardiovascular disease, might indicate new-onset or deteriorating cardiovascular disease. However, evidence for cystatin C as a predictor of cardiovascular events is limited and controversial.
Materials and Methods: This study investigated the role of cystatin C as a predictor of future major adverse cardiovascular events (MACE) in a high-risk cohort of patients with established coronary artery disease (CAD). Cardiovascular events in 1,481 patients with angiographically verified CAD were prospectively recorded over a mean follow-up period of 10.0 ± 5.2 years.
Results: At baseline, 684 patients had metabolic syndrome (MetS) and 797 did not. During follow-up, 578 (39%) of patients had MACE. Cystatin C was a strong and independent predictor for MACE in the total study cohort (standardised adjusted HR 1.56 [1.34–1.83], p<0.001). When MetS status was taken into account, cystatin C significantly predicted major cardiovascular events both in patients with MetS (HR 1.56 [1.28–1.90], p<0.001) and in non-MetS patients (HR 1.44 [1.12–1.84], p=0.004).
Conclusion: Cystatin C predicts major cardiovascular events in patients with CAD both among patients with MetS and in non-MetS individuals.
Evolving Fields in Cardiovascular Pharmacotherapy Targets (Basic Science-oriented): microRNAs, Myosin Activators and Inhibitors
EP.06.02
Regulation of NLRP3 Inflammasome
Activation in Atrial Cardiomyocytes of Patients with Postoperative Atrial Fibrillation
T Poppenborg,1 I Abu-Taha,1 AC Fender,1
M Kamler2 and D Dobrev1
1. Institute of Pharmacology, University of Duisburg-Essen, Essen, Germany; 2. Department of Thoracic and Cardiovascular Surgery, University of Duisburg-Essen, Essen, Germany
Correspondence: Theresa Poppenborg, theresa.poppenborg@uk-essen.de
Background: NLRP3 inflammasome is a multiprotein platform for the auto-activation of caspase-1 and the subsequent maturation and secretion of interleukins (IL)-1β and IL-18. Its activation in atrial cardiomyocytes contributes to the development of postoperative atrial fibrillation (POAF). In immune cells, assembly of NLRP3 inflammasome requires NIMA-related kinase NEK7. NEK7 activity is promoted by NIMA-related kinase NEK9 and suppressed by polo-like kinase (PLK)4. This study investigated the upstream mechanisms of NLRP3 inflammasome activation in atrial cardiomyocytes.
Materials and Methods: The expression of NEK7 in atrial tissue of POAFprone patients collected prior to cardiac surgery was examined and the importance of NEK7 in controlling caspase-1 activation in HL-1 mouse
atrial cardiomyocytes was determined. Protein levels were quantified by immunoblotting or ELISA, while mRNA expression was assessed using qPCR. Caspase-1 activity was determined with a caspase activity assay. Knockdown of NEK7 in HL-1 cells was achieved using shRNA-adenoviral infection. In vitro tachypacing of HL-1 cells at 5 Hz versus 1 Hz was used to mimic the effects of the high atrial rate during AF.
Results: Protein and mRNA levels of NEK7 were elevated in the atrial myocardium of patients with POAF compared to patients who remained in sinus rhythm after surgery. Protein levels of NEK9 were elevated, while protein abundance of PLK4 was decreased. Consequently, IL-18 levels were significantly higher in patients with POAF. Downregulation of NEK7 in HL-1 cells reduced NLRP3 inflammasome activity, pointing to a causal contribution of NEK7. Tachypacing of HL-1 cells at 5 Hz (versus 1 Hz) increased NEK7 protein expression, NLRP3/NEK7 interaction, and IL-18 production.
Conclusion: The study data indicate that NEK7 is a major trigger of NLRP3 inflammasome activation in atrial cardiomyocytes of POAF patients. Selective targeting of NEK7 in atrial cardiomyocytes could constitute an effective option to prevent NLRP3 inflammasome activation and the development of POAF.
EP.06.03
Internalised Lipopolysaccharide Activates
Non-canonical NLRP3 Inflammasome in Atrial Cardiomyocytes
M Pascal,1 P Theresa,1 K Markus,2 A-T Issam1 and D Dobromir1 1. Institute of Pharmacology, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany; 2. Department of Thoracic and Cardiovascular Surgery, University of Duisburg-Essen, Essen, Germany
Correspondence: Martsch Pascal, pascal.martsch@uk-essen.de
Background: Although aberrant NLRP3 inflammatory signalling contributes to AF, the mechanisms of its activation are poorly understood. In immune cells, NLRP3 inflammasome-induced interleukin (IL)1β secretion is mediated by gasdermin D (GSDMD). GSDMD is cleaved by either caspase1 (canonical pathway) or caspase-4/5/11 (non-canonical pathway) with the resulting GSDMD-N terminus (GSDMD-NT)-forming pores in the plasmalemma. Extracellular lipopolysaccharide (LPS) transcriptionally primes NLRP3 and pro-caspase-1, while internalised LPS directly activates caspase-4/5/11. Whether atrial cardiomyocytes respond to LPS via the non-canonical pathway is unknown. Here, the impact of internalised LPS on atrial cardiomyocytes was studied.
Materials and Methods: Protein expression of NLRP3, GSDMD, and IL-1β was assessed by immunoblotting in mouse atrial HL-1 cardiomyocytes. GSDMD levels were determined by immunoblotting and immunocytochemistry in right atrial tissue of control and atrial fibrillation (AF) patients. The role of GSDMD pore formation was studied in HL-1 cardiomyocytes subjected to CRISPR-Cas9 knockout of GSDMD. Escherichia coli outer membrane vesicle LPS (OMV-LPS) was used to activate caspase-4/5/11. Caspase-1 and caspase-4/5/11 activities were determined by caspase activity assays.
Results: GSDMD was expressed in the plasmalemma of human atrial cardiomyocytes. GSDMD protein levels and caspase-4/5/11 activity were increased in AF versus control patients, pointing to a role of the
caspase-4/5/11/GSDMD pathway in AF. The stimulation of HL-1 cardiomyocytes with OMV-LPS increased both caspase-4/5/11 and caspase-1 activities, along with an increase in GSDMD-NT and IL-1β protein levels, pointing to activation of the non-canonical pathway with secondary stimulation of the canonical NLRP3 system. Upon OMV-LPS stimulation, knockout of GSDMD decreased caspase-1 and caspase-4/5/11 activities in HL-1 cardiomyocytes.
Conclusion: Internalised LPS activates the non-canonical NLRP3 inflammasome in atrial cardiomyocytes, which is attenuated by GSDMD deficiency. The results of this study provide novel insights into the role of caspase-4/5/11 and GSDMD in atrial cardiomyocytes, which could constitute new therapeutic targets for AF.
EP.06.04
Adipocyte-derived Interleukin-1β Upregulates NLRP3 Inflammasome in Atrial Cardiomyocytes
L Oehlke, S Plank, M Gawalko, I AbuTaha, A Fender and D Dobrev
1. Institute of Pharmacology, West German Heart and Vascular Center, Faculty of Medicine, University of Duisburg-Essen, Essen, Germany
Correspondence: Lisa Oehlke, lisa.oehlke@uk-essen.de
Background: Activation of NLRP3 inflammasome signalling and production of interleukin(IL)-1β contribute causally to atrial fibrillation (AF) pathophysiology. Although pericardial fat and fibro-fatty infiltration into the atria have been linked with enhanced proinflammatory signalling, proarrhythmic remodelling and clinical AF, there is no direct demonstration for NLRP3 inflammasome activation in adipocytes with subsequent paracrine crosstalk with atrial cardiomyocytes.
Materials and Methods: Differentiated 3T3-L1 adipocytes were stimulated with lipopolysaccharide (LPS 100 ng/ml, 2 hours) and nigericin (6.7 µm, final 1 hour) to transcriptionally prime and trigger the NLRP3 inflammasome. Conditioned supernatant (1:5 diluted) of LPS-stimulated and nonstimulated adipocytes was added to HL-1 atrial cardiomyocytes for up to 12 hours. A set of cardiomyocytes was pre-incubated with the IL-1β receptor antagonist anakinra (100 ng/ml, 1 hour). Expression of inflammasome components was assessed by qPCR, caspase activity by a custom-designed and validated assay, secreted IL-1β by ELISA.
Results: Conditioned medium from LPS-stimulated adipocytes contained higher levels of IL-1β than supernatant from non-stimulated adipocytes. This was associated with an upregulation of NLRP3 mRNA in HL-1 cells, pointing to priming of the HL-1 cell NLRP3 system. Expression and activities of caspase-1 (canonical pathway) and caspase-11 (non-canonical pathway) were also increased in recipient HL-1 cardiomyocytes, indicating triggering of NLRP3 inflammasome. Anakinra prevented the stimulated adipocyte-induced upregulation of the NLRP3 inflammasome in HL-1 cells, pointing to adipocyte-derived IL-1β as a potential upstream mechanism of NLRP3 activation in HL-1 cells.
Conclusion: NLRP3 inflammasome is present in adipocytes. IL-1β secretion from activated adipocytes propagates the proinflammatory NLRP3 signal to atrial cardiomyocytes, which results in activation of their own NLRP3 inflammasome system. These findings provide insights into the role of pericardial and intra-atrial fat in the evolution of AFpromoting atrial NLRP3 signalling and position IL-1β as a potential drug target in AF.
EP.06.05
Protein Profiling of the Human Electrical Conduction System
A Krawczyk-Ozog,1 J Batko,1 A Stachowicz,2 G Szoniec3 and M Holda11. Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland; 2. Department of Pharmacology, Jagiellonian University Medical College, Krakow, Poland; 3. Center for Medical Genomics
OMICRON, Jagiellonian University Medical College, Krakow, Poland
Correspondence: Agata Krawczyk-Ozog, krawczyk.ozog@gmail.com
Background: The proteomic profile of the human heart, and in particular its individual areas, is poorly understood. Understanding the proteomic profiles of the sinoatrial (SAN) and atrioventricular (AVN) nodes can prove instrumental in developing effective treatments and diagnostic methods for arrhythmias, as well as assessing the efficacy of antiarrhythmic drugs. The objective was to assess the changes in protein abundance in the human electrical conduction system.
Materials and Methods: Ten pairs of samples (SAN and AVN) were obtained post-mortem from 10 human donors with no evidence of cardiovascular disease (12–24 hours after death). Protein identification and quantification was performed using iTRAQ method.
Results: One hundred and twenty-nine proteins differentially regulated in both SAN and AVN (83 upregulated in SAN and 46 in AVN) were identified. High expression of proteins related to alcohol metabolic process and fluid level regulation was observed in both tissues. In SAN, proteins associated with regulation of fluid levels were upregulated, and in AVN proteins associated with metabolism of glycerolipids, glycerophospholipids and organophosphates were upregulated. Bone morphogenetic protein-10 (BMP-10) is upregulated more than twofold at SAN, which is required for maintenance of proliferative activity of embryonic cardiomyocytes. Natriuretic peptide A was also upregulated more than twofold in SAN. In AVN, more than twofold upregulation of 1-acyl-sn-glycerol-3-phosphate acyltransferase epsilon, thrombospondin-4, aldo-keto reductase family 1 member B1, was detected.
Conclusion: Protein differences between SAN and AVN are mainly associated with their localisation in different cardiac tissues. However, a different expression of thrombospondin-4 and BMP-10 reveals nodespecific protein upregulation, which may be associated with the specialised function of those tissues.
This work was supported by the National Science Centre, Poland (2018/29/N/NZ5/00643).
EP.06.06
Enhanced Nucleoside Diphosphate Kinase-C Causes Proarrhythmic Calcium-handling
Abnormalities in Canine Atrial Cardiomyocytes
I Abu Taha,1 J Heijman,2 X-Y Qi,3 M Kamler,4 S Nattel3 and D Dobrev1
1. Institute of Pharmacology, West German Heart and Vascular Center, Faculty of Medicine, University of Duisburg-Essen, Essen, Germany; 2. Department of Cardiology, Cardiovascular Research Institute Maastricht, Faculty of Health, Medicine and Life Sciences, Maastricht, Netherlands; 3. Department of Medicine, Montreal Heart Institute and Université de Montréal, Montreal, Canada; 4. Department of Thoracic
and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany
Correspondence: Issam Abu Taha, issam.abu-taha@uk-essen.de
Background: Atrial fibrillation is associated with increased cAMPsignalling and abnormal sarcoplasmic reticulum (SR) calcium-handling. Nucleoside diphosphate kinases (NDPKs) form complexes with G proteins and modulate cAMP signalling via receptor-independent G protein activation. NDPK-C is the limiting factor for the complex formation of NDPKs with G proteins and is responsible for scaffolding G protein at the plasmalemma. Although NDPK-C protein expression is elevated in atrial fibrillation (AF) patients, the role of NDPK-C in the development of a proarrhythmic substrate in AF is unknown. This study investigated the role of NDPK-C in aberrant SR calcium-handling in atrial cardiomyocytes (CMs).
Materials and Methods: Canine atrial cardiomyocytes were in vitro paced at 1 Hz (P1) or 3 Hz (P3). NDPK-C was adenovirally overexpressed in cCMs. Protein levels were quantified by immunoblot, cAMP by immunoassay. Fractional shortening and calcium-transients (CaT) were recorded in cCMs overexpressing NDPK-C or EGFP-control.
Results: In cCMs, protein expression of NDPK-C, Gαs, and cAMP levels were higher at P3 (versus P1), mimicking clinical AF. Overexpression of NDPK-C in cCMs increased Gαs protein expression and enhanced cAMP levels. CM fractional shortening and CaT amplitude were increased in NDPK-C overexpressing cCMs. The susceptibility of CMs to potentially proarrhythmic spontaneous calcium release events, triggered action potentials and calcium alternans was higher in cCMs overexpressing NPDK-C versus EGFP-control.
Conclusion: Results from this study position NDPK-C upregulation as a significant contributor to AF-promoting calcium-handling abnormalities in atrial cardiomyocytes, making it a potential target for future therapeutic interventions.
Ischaemic Heart Disease – Angina –INOCA Management – Antianginals –Combination Therapy
EP.07.02
Revisiting Cardiac Targets of Ivabradine in Human Atrial Preparations: Evidence for Antimuscarinic Properties
M Gencarelli,1 A Laurino,1 V Balducci,1 V Spinelli,1 M Cameli,2 R Pecori,3 G Vistoli,4 R Matucci,1 E Cerbai1 and L Sartiani1
1. Department of Neurosciences, Psychology, Drug Research and Child Health, University of Firenze, Firenze, Italy; 2. Santa Maria alle Scotte Polyclinic, Department of Cardiovascular Diseases, University of Siena, Siena, Italy; 3. German Cancer Research Center, Division of Immune Diversity, Heidelberg, Germany; 4. Department of Pharmacological Sciences, University of Milan, Milan, Italy
Correspondence: Laura Sartiani, laura.sartiani@unifi.it
Background: Ivabradine (IVA) is a blocker of hyperpolarisation-activated cyclic nucleotide-gated (HCN) channels, which play definite electrophysiological function in cardiac pacemaking. Owing to this action, IVA has become the first-in-class specific bradycardic agent used for uncontrolled angina and heart failure with reduced ejection fraction.
Accumulating evidence suggests IVA has a more complex pharmacological profile, including targets beyond HCN channels. Data on experimental atrial fibrillation and detrusor contraction led to the hypothesis that muscarinic receptors (mAChRs) may represent still-unexplored targets of IVA. We therefore studied the effect of IVA on acetylcholine-gated inwardrectifier K+-current (IKACh), the main effector of atrial mAChRs, and assessed whether it interacts directly with human atrial and recombinant mAChRs.
Materials and Methods: Patch-clamp recordings were performed on human atrial myocytes (hAMs) isolated from atrial appendages of patients in sinus rhythm. Radioligand binding assays were performed on hAM preparations and mAChRs(1,2,3) expressed in heterologous systems.
Results: Patch-clamp recordings showed IVA suppresses IKACh, suggesting a functional antagonism on human atrial native mAChRs. Competition binding assays on hAM membranes revealed IVA binds to mAChRs with affinities close to the muscarinic ligands carbachol (CCh) and gallamine (Gal). Competition assays on recombinant mAChR(1,2,3) (functionally relevant in hAMs) showed IVA behaves as muscarinic ligand with affinities close to CCh and Gal. Dissociation assays on mAChR(2) lacking the allosteric site showed it also acts as allosteric ligand. Docking studies confirmed IVA has the structural requirements necessary to interact with the allosteric and the orthosteric site of mAChR(2).
Conclusion: This study demonstrates IVA directly interacts with mAChR expressed in hAMs, showing antimuscarinic activity on IKACh. This is likely dependent on a double interaction with the orthosteric and the allosteric site of mAChR(2). mAChRs represent novel pharmacological targets of IVA in human atria, which may have important consequences for the function of the healthy and diseased atrium.
EP.07.04
Exploring Efficacy in Post-coronary Intervention Care: A Network Meta-analysis of Randomised Controlled Trials on the Reduction of Potent P2Y12 Antagonistbased Dual Antiplatelet Therapy
O El Alaoui El Abdallaoui,1 D Tornyos,2 R Lukács2 and A Komócsi2
1. Doctoral School of Health Sciences, Faculty of Health Sciences, University of Pécs, Pécs, Hungary; 2. Department of Interventional Cardiology, Heart Institute, Medical School, University of Pécs, Pécs, Hungary
Correspondence: Oumaima El Alaoui El Abdallaoui, oumaimaelalaouielabdallaoui@gmail.com
Background: In acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI), dual antiplatelet therapy (DAPT) involving prasugrel or ticagrelor is standard. Given bleeding concerns, trials have explored strategies for reducing therapy intensity, such as uniform or guided de-escalation from potent P2Y12 inhibitor (P2Y12-De) to P2Y 12 inhibitor monotherapy (P2Y12-Mo), yielding varied outcomes. This study conducts a systematic review and network meta-analysis to assess the effects of DAPT intensity reduction strategies in PCI patients.
Materials and Methods: Relevant randomised clinical studies assessing post-PCI patient outcomes were identified through electronic database searches. Frequentist network meta-analysis evaluated adverse event
rates. Risk estimates were synthesised using a random-effects model, presenting RRs with 95% CIs. Primary endpoints included major adverse cardiac events (MACE; comprising cardiovascular mortality, MI and stroke) and bleeding.
Results: Among the identified 10 studies involving 42,511 patients randomised, 6,359 patients transitioned to P2Y12-De, while 13,062 patients shifted to P2Y12-Mo. The P2Y12-De approach displayed a 24% reduction in MACE risk, with P2Y12-Mo showing a 14% reduction when compared to DAPT involving potent P2Y12 inhibitors (RR 0.76 [0.62–0.94] and RR 0.86 [0.75–0.99], p<0.05 for both). Monotherapy exhibited a significant 35% risk reduction in major bleeding (RR 0.65 [0.46–0.91]), whereas the de-escalation strategy did not yield a significant effect (RR 0.84 [0.57–1.22]). Both strategies showed reductions in all bleeding and minor bleeding events. Indirect comparisons between P2Y12-Mo and P2Y12-De indicated their similarity as viable alternatives without significant differences.
Conclusion: Both P2Y 12 -De and P2Y12-Mo strategies lead to decreased ischaemic events and bleeding in ACS patients undergoing PCI. While the ischaemic advantage is more pronounced with P2Y12-De, the noteworthy reduction in major bleeding is exclusively observed with the P2Y12-Mo approach.
EP.07.05
Association Between Ranolazine, Ischaemic Preconditioning and Cardioprotection in Patients Undergoing Scheduled Percutaneous Coronary Intervention
A Bourazana,1 K Kourtis,2 A Xanthopoulos,1 E Skoularigki1 E Papadakis,2 S Patsilinakos2 and J Skoularigkis1
1. Department of Cardiology, University Hospital of Larissa, Larissa, Greece; 2. Department of Cardiology, Konstantopouleio General Hospital, Athens, Greece
Correspondence: Angeliki Bourazana, angi3bou@gmail.com
Background: Remote ischaemic preconditioning (RIPC) has been shown to confer protection against myocardial ischaemia-reperfusion injury
EP07.05. Figure 1: Longitudinal Changes of Ranolazine in Three Study Groups
when performed prior to percutaneous coronary revascularisation. In addition, ranolazine has been used as an anti-ischaemic drug to reduce ischaemic events in patients with chronic angina. However, to date, no trials have investigated the associations of ranolazine pretreatment with RIPC in patients scheduled for percutaneous coronary interventions.
Materials and Methods: A retrospective, observational study was performed of 150 patients who were scheduled for coronary revascularisation. Of these, 50 patients were assigned to the control group in which, except for the coronary intervention, no further treatment was practiced; 50 patients were assigned to the RIPC group, in which RIPC was applied to either of the upper limbs for 5 minutes with a cuff pressure of 200 mmHg and followed by a 60-second period of reperfusion; and 50 patients were submitted to RIPC before PCI, already treated with 500 mg ranolazine twice daily with the indication of stable angina. Analysis of variance (ANOVA) and Kruskal–Wallis test were computed for the comparison of mean values. Statistical significance was defined as p<0.05.
Results: Ranolazine administration along with RIPC resulted in (A) a significantly lower increase of TNI levels in comparison to the RIPC or control group (Figure 1); (B) significantly lower levels of CPK at 4, 10 and 24 hours compared to the RIPC group (p=0.020, p=0.020 and p=0.019, respectively) and significantly lower levels of CPK compared to the control group at 10 hours (p=0.050); and (C) significantly lower levels of CK-MB at 10 hours compared to the control group (p=0.050).
Conclusion: RIPC applied before a scheduled coronary procedure when combined with ranolazine pretreatment may be associated with reduced ischaemia induction, as reflected by myocardial enzyme levels.
Lipid-lowering Therapy: Recent Advances
EP.08.02
Combination Therapy with Oral Bempedoic Acid to Reach LDL Cholesterol Targets (COBALT): A Projected Real-world Secondary Prevention Setting Study
O Weingärtner,1 T Asendorf,2 S Sossalla3 and R Klingenberg4
1. Department of Cardiology, University Hospital Jena, Jena, Germany; 2. University Medicine Göttingen, Institute for Medical Statistics, Göttingen, Germany; 3. Department of Cardiology, University Hospital Regensburg, Regensburg, Germany; 4. Department of Cardiology, Kerckhoff Heart Center, Bad Nauheim, Germany
Correspondence: Roland Klingenberg, rklingenberg@gmx.de
Background: Combination therapy enables better control of LDL-C levels reaching current goals based on cardiovascular (CV) risk (EAS/ESC 2019 guidelines). In Germany, a stepwise algorithm has been approved for secondary prevention, starting with a statin, followed by ezetimibe, then bempedoic acid, then PCSK9 inhibitor therapy and finally lipoprotein apheresis. Adding bempedoic acid 180 mg daily to existing therapy consisting of a statin and ezetimibe may provide incremental benefit in secondary prevention.
Materials and Methods: This is an all-comer observational secondary prevention study of very high CV risk patients, aged 18–90 years, on lipidlowering therapy consisting of a statin and ezetimibe who are not at LDL-C goal (n=500 recruited within 12 months). Statin-intolerant patients
and patients who already receive bempedoic acid or a PCSK9-inhibitor and those at LDL-C goal based on CV risk are not eligible. The primary endpoint of the study is attainment of an LDL-C level ≤3.1 mmol within 3 months after treatment escalation by adding bempedoic acid or switching to the fixed-dose combination with ezetimibe expressed as percentage of total. Secondary endpoints of the study are absolute LDL-C reduction in mmol and relative (%) within 3 months, and cost efficiency calculation as euros saved per patient-year comparing PCSK9 inhibitor therapy with bempedoic acid based on attainment of LDL-C target levels within 3 months.
Results: The proportion of patients with LDL-C reduction to or below target level will be reported with 95% CI. Secondary endpoints absolute LDL-C and relative (%) reduction are analysed using mixed linear models with timepoint of treatment and further prognostic variables as covariates. Cost efficiency is calculated using the proportion of patients estimated from the primary endpoint. Subgroup analyses will be performed based on CV risk and drugs used.
Conclusion: Based on the log–linear relation between LDL-C and CV events, COBALT will clarify the role of bempedoic acid in lipid-lowering therapy.
EP.08.03
Remnant Cholesterol Predicts Major Cardiovascular Events in Cardiovascular Disease Patients with Non-alcoholic Fatty Liver Disease
B Larcher,1,2 A Mader,1,2,3 L Sprenger,1,2 A Vonbank,1,2,3 M Maechler,1,2 T Plattner,1,2,3 A Leiherer,1,3,4 A Muendlein,1 H Drexel1,3,5,6 and CH Saely1,2,3
1. Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Feldkirch, Austria; 2. Medicine, Academic Teaching Hospital Feldkirch, Feldkirch, Austria; 3. Private University in the Principality of Liechtenstein, Triesen, Liechtenstein; 4. Medical Central Laboratories, Feldkirch, Austria; 5. Vorarlberger Landeskrankenhaus Betriebsgesellschaft, Feldkirch, Austria; 6. Drexel University College of Medicine, Philadelphia, US
Correspondence: Andreas Leiherer, vivit@lkhf.at
Background: Remnant cholesterol has attracted interest as a marker of cardiovascular event risk. The power of remnant cholesterol to predict major cardiovascular events (MACE) in patients with non-alcoholic fatty liver disease (NAFLD) is unclear and is addressed in the present study.
Materials and Methods: A high-risk cohort of 1,420 consecutive patients with established cardiovascular disease (1,183 patients with stable coronary artery disease and 237 patients with peripheral artery disease) was enrolled in the study. NAFLD was diagnosed using the validated fatty liver index (FLI). Prospectively, MACE, including cardiovascular death, nonfatal MI and non-fatal stroke, were recorded over a mean follow-up period of 9.6 ± 5.0 years.
Results: At baseline, remnant cholesterol was significantly higher in patients with NAFLD (n=683) than in patients without NAFLD (1.6 ± 1.4 mmol versus 1.1 ± 0.9 mmol; p<0.001). During follow-up, 570 patients had MACE. Remnant cholesterol in Cox regression models adjusting for age, sex, hypertension, smoking, diabetes, BMI and LDL cholesterol independently predicted MACE in the total study population (standardised adjusted HR 1.15 [1.06–1.24], p<0.001), and both in patients with NAFLD as
well as in those without NAFLD (standardised adjusted HR 1.16 [1.03–1.30], p=0.012 and HR 1.14 [1.02-1.27], p=0.028, respectively).
Conclusion: Remnant cholesterol is a predictor of MACE in cardiovascular disease patients with NAFLD.
EP.08.04
Ceramide Markers Outperform LDL
Cholesterol in Predicting Cardiovascular Mortality in a Biased Patient Cohort
A Leiherer,1,3,4 A Muendlein,1 CH Saely,1,2,3 R Laaksonen,7 T Plattner,1,2,3 A Vonbank,1,2,3 A Mader,1,2,3 L Sprenger,1,2 M Maechler,1,2 B Larcher1,2 P Fraunberger3,4 and H Drexel1,3,5,6 1. Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Feldkirch, Austria; 2. Medicine, Academic Teaching Hospital Feldkirch, Feldkirch, Austria; 3. Private University in the Principality of Liechtenstein, Triesen, Liechtenstein; 4. Medical Central Laboratories, Feldkirch, Austria; 5. Vorarlberger Landeskrankenhaus Betriebsgesellschaft, Feldkirch, Austria; 6. Drexel University College of Medicine, Philadelphia, US; 7. Zora Biosciences, Espoo, Finland
Correspondence: Andreas Leiherer, vivit@lkhf.at
Background: The power of risk prediction is biased by confounders like advanced age, comorbidities and medical treatment, which are all known to impact cholesterol levels. Consequently, such confounded patient cohorts have often been reported to feature a U-shaped or even inverse association between cardiovascular or overall mortality risk and LDL-C. However, it is not clear whether these constraints for risk prediction may likewise apply to other lipid risk markers in particular ceramides.
Materials and Methods: In this observational cohort study cardiovascular mortality was recorded for up to 16 years in 1,195 patients with a median age of 67 years. All of them had a high pre-existing cardiovascular risk and 51.3% were under statin therapy before baseline.
Results: A U-shaped association between cardiovascular mortality and LDL-C was found. The population was stratified from bottom into high (>8.3 mmol) and lower LDL-C (<8.3 mmol). A Cox regression analysis revealed that LDL-C and other cholesterol species failed to predict cardiovascular risk in both subgroups. In contrast, no U-shaped, but a linear association was found for ceramide-based markers, and they were able to significantly predict the cardiovascular risk in both subgroups even after multivariate adjustment.
Conclusion: In view of existing confounders in cardiovascular disease patients, ceramide- and phosphatidylcholine-based predictors rather than cholesterol species may be used for a more accurate cardiovascular risk prediction in those patients.
EP.08.05
Ceramides Predict the Development of Type 2 Diabetes
A Leiherer,1,3,4 A Muendlein,1 T Plattner,1,2,3 A Vonbank,1,2,3 A Mader,1,2,3 L Sprenger,1,2 M Maechler,1,2 B Larcher,1,2 R Laaksonen,7 P Fraunberger,3,4 H Drexel1,3,5,6 and CH Saely1,2,3 1. Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Feldkirch, Austria; 2. Medicine, Academic Teaching Hospital Feldkirch, Feldkirch, Austria; 3. Private University in the Principality of Liechtenstein, Triesen, Liechtenstein; 4. Medical Central
Laboratories, Feldkirch, Austria; 5. Vorarlberger Landeskrankenhaus Betriebsgesellschaft, Feldkirch, Austria; 6. Drexel University College of Medicine, Philadelphia, US; 7. Zora Biosciences, Espoo, Finland
Correspondence: Andreas Leiherer, vivit@lkhf.at
Background: Ceramides have attracted interest as a marker of cardiovascular event risk. However, little is known about their role in the development of type 2 diabetes (T2D).
Materials and Methods: The ceramide ratio Cer d 18:18/Cer d 18:24:0 (CerRatio) was analysed in 894 consecutive patients who were referred to angiography for the evaluation of established or suspected stable coronary artery disease (CAD). T2DM was diagnosed according to American Diabetes Association criteria. The incidence of T2D was recorded over a follow-up period of up to 16 years (median 13 [8–14] years).
Results: At baseline, the CerRatio was significantly higher in T2DM (n=239) than in non-diabetic patients (4.6e-2 versus 3.9e-2, p<0.001). During follow-up, diabetes was newly diagnosed in 71 patients (i.e. in 11% of the initially non-diabetic subjects). The CerRatio strongly predicted the incidence of T2DM, both univariately (standardised OR 1.47 [1.11–1.96]; p=0.008) and in a multivariate adjusted model comprising age, sex, BMI, presence of significant CAD at angiography and HbA1c (OR 1.45 [1.07–1.98]; p=0.018). Though the CerRatio was significantly correlated with BMI (r=0.138, p<0.001) and HbA1c (r=0.137, p<0.001), applying a mediation analysis revealed that BMI and HbA1c had only marginal indirect effects (5.7% and 3.6%, respectively) on the association of the CerRatio with T2DM incidence.
Conclusion: Ceramides strongly and independently predict the development of diabetes.
EP.08.06
Omega-3 Fatty Acid Therapy for Patients with Ischaemic Heart Disease and Hypertriglyceridaemia: A Cross-sectional Analysis for Targeted Secondary Prevention
O Abukhalaf, E Sykes, A Kalansooriya and R Jaumdally Walsall Hospital/NHS Trust, Walsall, UK
Correspondence: Omran Abukhalaf, omran.abukhalaf@nhs.net
Background: National Institute for Health and Care Excellence (NICE) guidance recommends that patients with established atherosclerotic cardiovascular disease (ASCVD) with hypertriglyceridaemia are eligible for treatment as secondary prevention with omega-3 fatty acids. This is based on the REDUCE-IT trial, which suggests that icosapent ethyl reduces the risk of cardiovascular events compared to placebo.
Materials and Methods: The clinical patient criteria for omega-3 fatty acid therapy for hypertriglyceridaemia are patients with ischaemic heart disease who are being treated with a statin and have an LDL-C >1.04 and <2.60 mmol/l and fasting triglyceride >1.7 mmol/l. A total of 952 patients with lipid profile performed between 1 and 28 March 2023 were identified. Of these patients, 140 met the lipid criteria and were screened for history of ischaemic heart disease; 28 had a clear ASCVD history.
Results: In the REDUCE-IT trial, 71% of the 8,179 randomised patients had an LDL-C >1.04 and <2.60 mmol/l and fasting triglyceride >1.7 mmol/l for
EP08.07. Figure 1: Proportion of Patients Reaching Lipid Targets of LDL Cholesterol
EP08.06. Table 1: Patient Demographics
Ethnicity
White British
Other white
Asian
Black
Other
IHD = ischaemic heart disease.
secondary prevention. In the present study, the prevalence in ‘real life’ was 15% meeting the lipid criteria and of these patients, 20% had IHD and were receiving statin therapy as secondary prevention. In the intentionto-treat population study, the HRs for cardiovascular death (HR 0.80, 95% CI [0.66–0.98]) and death from any cause (HR 0.87, 95% CI [0.74–1.02]) were larger than for the composite five-point MACE (HR 0.75, 95% CI [0.68–0.83]). On this conservative estimate of 0.80, therapy with icosapent ethyl in 28 patients could reduce the risk of cardiovascular events in at least six patients.
Conclusion: Of a total of 952 patient blood screens, 28 patients with ischaemic heart disease were identified as eligible for omega-3 fatty acid treatment on secondary prevention grounds as the NICE guidance: they will be invited to a nurse-led cardiology clinic to discuss. The present analysis suggests novel opportunities to offer enhanced treatment to dyslipidaemic patients with established ischaemic heart disease.
EP.08.07
Attainment of Guideline-recommended Cholesterol Goals in Cardiovascular Prevention: Results from a Preventive Cardio Rheuma Clinic in Norway
E Sollerud, J Sexton, E Ikdahl, A Eirheim and AG Semb Diakonhjemmet Hospital, Oslo, Norway
Correspondence: Anne Grete Platou Semb, anne.semb@yahoo.no
Background: There is a large gap between European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) guideline recommendations and LDL cholesterol (LDL-C) goal achievement in routine clinical practice. The aim of this study was to evaluate attainment of recommended LDL-C in a patient group with high risk of atherosclerotic cardiovascular disease (ASCVD) and inflammatory joint diseases (IJD).
Materials and Methods: Patients with IJD, rheumatoid arthritis (RA), spondyloarthritis (SpA) and psoriatic arthritis (PsA), were referred to the Preventive Cardio Rheuma clinic for an ASCVD risk evaluation between 2019 and 2023 and classified as high and very high risk according to guidelines. The LDL-C goals for patients with high and very high risk was 1.8 mmol/l and 1.4 mmol/l, respectively, or a 50% LDL-C reduction from baseline. The patients received atorvastatin 20–40 mg or rosuvastatin 5–40 mg, some in a combination with ezetimibe 10 mg. The patients had lipid level controls 1–3 months after lipid-lowering treatment initiation.
Results: In total, 186 of the 320 referred patients (RA, n=166; SpA, n=80; PsA, n=74) were classified to high (n=20) and very high (n=166) risk classes. The mean ± SD age was 55 ± 11.2 years. Baseline LDL-C was 3.3 ± 1.0 mmol/l. Fourteen per cent of patients were smokers, 26% had hypertension and 49% had established ASCVD. Eighty-five per cent
attained recommended LDL-C, using a median (IQR) of three (2.0, 4.0) consultations. Ten per cent and 23% only obtained a 50% LDL-C reduction and were then considered to attain recommended targets. Fifteen per cent did not obtain LDL-C goals due to unwillingness to take lipid-lowering medications, comorbidity issues or intolerable side-effects of treatment (Figure 1).
Conclusion: Recommended LDL-C goal attainment according to guidelines is achievable in a high proportion of patients with IJD on few consultations. These results indicate that frequent lipid control consultations after treatment initiation may be the key to success in LDL-C goal attainment.
EP.08.10
Bembedoic Acid and Reduction of Carotid Atherosclerosis
G Fazio
Triolo Zancla Hospital, Palermo, Italy
Correspondence: Giovanni Fazio, faziogiova@gmail.com
Background: Bempedoic acid was indicated to reduce hypercholesterolaemia added to statin and ezetimibe therapy. This study investigated the effect of the same treatment in carotid atherosclerosis after a follow-up period of 6 months.
Materials and Methods: A continuous series of 22 patients were enroled in a prospective analysis. All patients started therapy with bempedoic acid for hypercholesterolaemia added to rosuvastatin or atorvastatin plus ezetimibe therapy for insufficient reduction of cholesterol. Mean LDL was 5.6 mmol. All patients were high or very high-risk. In all patients bempedoic acid was added to optimal medical therapy without new symptoms in ambulatory. The recruitment period was 1 month. After recruitment the patient was followed up for another 6 months. Evaluation was performed at the start and at the end of the follow-up period. Atherosclerosis was evaluated via ultrasound doppler of carotids. Data were collected in Excel and analysed using QR-Calc.
Results: The mean age of patients was 68 years; 44% were female and 33% were diabetic. Hypertension was present in 73%, hypercholesterolemia in 100%. 11% were smokers, 94% were white. Mean weight was 75 kg at the first control, mean height was 174 cm. All patients performed a cardiological control in which the medical doctor prescribed bempedoic acid. 100% of patients assumed a statin and ezetimibe. After 6 months mean LDL was 4.3 mmol. Doppler showed plaques in 89% of patients. The mean plaques occluded the lumen for 37% before the bempedoic acid and 30% after with a reduction of 7% (p=0,03%). In 50% of patients there was a reduction of atherosclerosis (in this subgroup the reduction was 11%).
Conclusion: Bempedoic acid reduced carotid atherosclerosis by 7% in a continuous series of 23 patients.
EP.08.11
Statin Therapy Effect on Inflammatory Biomarkers in a Cohort of Patients with Peripheral Artery Disease Undergoing Cardiac Rehabilitation
C Adam, D Marcu, F Mitu
Grigore T. Popa University of Medicine and Pharmacy, Department of Medical Specialties I, Iași, Romania
Correspondence: Cristina Adam, adam.cristina93@gmail.com
Background: Atherosclerosis is a multifactorial process in which inflammation plays a key role in both atheroma plaque formation and progression, leading to vascular complications with high morbimortality, transforming it into an inflammatory vascular disease. This study assessed the impact of maximising hypolipidaemic treatment on functional status and novel, easily dosed, reproducible inflammatory markers, such as neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), mean thrombocyte volume (MPV), leukocyte/MPV ratio (WMR) and lymphocyte/C-reactive protein (LCR) ratio in patients with peripheral artery disease (PAD) undergoing a cardiac rehabilitation programme (CR).
Materials and Methods: A prospective cohort study was conducted of 97 patients diagnosed with PAD and dyslipidaemia who underwent an integrative, multidisciplinary CR program at the clinic. A variety of parameters at enrolment and at 6-month follow-up was analysed, focusing on newly defined inflammatory biomarkers.
Results: The study cohort included predominantly male patients with a mean age of 69.66 ± 8.60 years. Hypolipaemiant treatment was adjusted and maximum tolerated doses were reached. According to the functional status assessed by cardiopulmonary exercise testing performed at 6 months, two groups were formed: patients with mild and moderate functional limitation (n=54) and patients with moderate to severe functional limitation (n=43). After 6 months there was an improvement in total cholesterol (p=0.716), serum triglycerides (p=0.515) and serum HbA1c (p=0.061) in the second group. hs-CRP (p=0.035), NLR (p=0.029), LCR (p=0.015) and PLR (p=0.001) are statistically significant parameters. hs-CRP (p<0.001), NLR (p=0.007) and WMR (p=0.007) correlated with VO2 peak when analysing the whole group. In the second group, hs-CRP (p<0.001), NLR (p=0.019) and WMR (p=0.039) are positively correlated with VO2 peak, being predictive factors with both therapeutic and prognostic roles.
Conclusion: Maximising hypolipaemiant agents in patients with PAD helps improve proinflammatory status and implicitly to the increase of functional status and quality of life.
New Drug Treatments for the Cardiomyopathies
EP.09.01
Dapagliflozin Acutely Affects the Electrical Properties of Left Ventricular Cardiomyocytes from Patients with Primary or Secondary Ventricular Hypertrophy
L Santini,1 R Coppini,1 C Palandri,1 L Giammarino,1 M Musumeci,1 C Ferrantini,2 B Colombini2 and E Cerbai1,3
1. Department of Neurofarba, University of Florence, Florence, Italy; 2. Department of Physiology, University of Florence, Florence, Italy;
3. LENS – European Laboratory for Non-Linear Spectroscopy, University of Florence, Florence, Italy
Correspondence: Lorenzo Santini, lorenzo.santini@unifi.it
Background: Dapagliflozin is a sodium-glucose cotransporter 2 (SGLT-2) inhibitor that has been introduced in the therapeutic management of type 2 diabetes. Large clinical trials correlated dapagliflozin and favourable cardiovascular effects (reduction of the hospitalisation risk for heart failure) in type 2 diabetes patients, also highlighting a reduction of worsening heart failure or death from cardiovascular causes in patients with heart failure and reduced ejection fraction (HFpEF). To investigate the
mechanisms underlying this effect, the acute effects of dapagliflozin in cardiomyocytes isolated from ventricular samples of patients undergoing cardiac surgery to relieve left ventricular outflow tract obstruction-related symptoms were studied.
Materials and Methods: Human septal specimens from seven patients with hypertrophic cardiomyopathy (primary hypertrophy [HCM]) and five patients with severe aortic stenosis (secondary hypertrophy [StAo]) were collected from the operating theatre and used to isolate single cardiomyocytes from the left ventricle. Patch-clamp experiments in the ruptured configuration (current clamp mode) were performed on viable cardiomyocytes, measuring action potentials and Na currents (peak and late INa) at multiple pacing rates (0.2–0.5–1 Hz), while exposing cells to 1 μM and 10 μM dapagliflozin.
Results: Dapagliflozin dose-dependently reduced late INa in both HCM and StAo cardiomyocytes at all frequencies of stimulation, thus hastening action potential kinetics, with a larger effect in primary versus secondary hypertrophy. Conversely, no effects were observed on action potential upstroke and amplitude or peak INa.
Conclusion: The ability of dapagliflozin to affect the electrical properties of left ventricular cardiomyocytes is likely to come from direct late INa inhibition. As consequence, the larger effect observed in primary cardiac hypertrophy can be ascribed to the larger INa current recorded in HCM cardiomyocytes compared to StAo cells.
EP.09.02
Cardiac Safety Evaluation of a Novel Recombinant Bispecific Anti-targeting the Ether-à-go-go-related Gene 1 (hERG1)-β1
Integrin Macromolecular Complex
M Musumeci,1 L Santini,1 C Duranti,2 C Palandri,1 L Giammarino,1 L Carlucci,3 C Capitani,2 R Colasurdo,2 F Recchia,3 E Cerbai,1 R Coppini1 and A Arcangeli2
1. Department of Neurosciences, Psychology, Drug Research and Child Health, Firenze, Italy; 2. Department of Experimental and Clinical Medicine, Section of Internal Medicine, Firenze, Italy; 3. Institute of Life Sciences, Scuola Superiore Sant’Anna, Pisa, Italy
Correspondence: Monica Musumeci, monica.musumeci@unifi.it
Background: In recent decades ion channels have become an interesting anti-tumoral target. The human ether-á-go-go-related gene (hERG1) potassium channel regulates cardiac repolarisation through IKr and plays a
EP09.03. Figure 1: Summary of Study Timetable
key role in different cancers where hERG1 binds to the β1 subunit of integrin adhesion receptors; however, in the heart this does not occur. Based on these evidence, hERG1-β1 could represent an ideal target for anti-cancer therapy. To this aim, several antibodies have been developed: bispecific anti-scDb-hERG1-β1, the full length anti-hERG1 monoclonal anti-(mAb-hERG1) and the anti-hERG1 single-chain fragment variable. The main goal of this work was to evaluate their effect on the action potential duration (APD).
Materials and Methods: Viable cardiomyocytes were obtained from surgical septal and atrial samples after enzymatic and mechanical digestion. The cells were incubated at 37°C for 1 hour with each antibody (10 µg/ml) and patch-clamp experiments were performed to measure APD with and without the specific hERG1-blocker E4031.
Results: mAb-hERG1 and scFv-hERG1 significantly prolonged APD of left ventricular and atrial cardiomyocytes compared to vehicle, at all frequencies tested. This did not occur with scDb-hERG1-β1, where APD was shorter than mAb-hERG1 or scFv-hERG1 and comparable to the vehicle. Moreover, the specific hERG1-blocker E4031 (5 µM) confirmed that the prolongation of APD was the direct consequence of hERG1 block.
Conclusion: This study tested the cardiac safety of a novel recombinant bispecific anti-targeting hERG1-β1 integrin complex on human atrial and ventricular cardiomyocytes, evaluating its effect on the electrical properties of the cells. No changes in APD kinetics were observed in cells incubated with the scDb-hERG1-β1 compared to the vehicle. Conversely, both the mAb-hERG1 and the scFv-hERG1 produced a prolongation of APD. This evidence suggests that scDb-hERG1-β1 could be applied to anticancer therapy, preventing a pathological prolongation of repolarisation that could lead to the long QT type 2 (LQT2) syndrome and the related fatal arrhythmia.
EP.09.03
Empaglifozin in Hypertrophic Cardiomyopathies: Effects on Disease Progression (EFCARISTO): Design of a Randomised, Open-label, Multicentric Study
C Morelli,1,2 R Coppini,2 C Ferrantini,3,4 G Petrucci,5 B Rocca,5 I Olivotto6,3 and E Cerbai2
1. Department of Life Science and Public Health, Catholic University School of Medicine, Rome, Italy; 2. Department of Neurofarba, University of Florence, Florence, Italy; 3. Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; 4. European Laboratory for Nonlinear Spectroscopy, University of Florence, Florence, Italy; 5. Section of Pharmacology, Department of Safety and Bioethics,
Catholic University School of Medicine, Rome, Italy; 6. Meyer University Children Hospital and Care, Florence, Italy
Correspondence:
Cristina Morelli, morelli.cri@gmail.comBackground: Sodium-glucose cotransporter 2 inhibitors (SGLT2i) have demonstrated benefit in heart failure with preserved ejection fraction (HFpEF) patients. Hypertrophic cardiomyopathy (HCM) was an exclusion criterion in all phase III trials, so the SGLT2i therapeutic potential in HCM patients is unknown.
Materials and Methods: A multicentre, randomised, open-label, intervention study was designed to evaluate the effect of SGT2is in HCM patients, focusing on biomarkers surrogate of HF severity. Adult patients with obstructive (oHCM) and non-obstructive HCM (noHCM) and a documented left ventricular ejection fraction (LVEF) ≥55%, symptomatic (New York Heart Association [NYHA] class II or III) despite best medical therapy (BMT), will be randomised to continuing BMT alone or with empaglifozin 10 mg once daily. The exclusion criteria will be severe HF symptoms (NYHA class IV), recipients of heart transplant or being a candidate for heart transplantation, AF, clear indication for antiplatelet and/or anticoagulant drugs, severe renal dysfunction (an estimated glomerular filtration rate [GFR] <20 ml/min per 1.73 m2 of surface area), symptomatic hypotension, hypersensitivity to empaglifozin, and history of recurrent urinary or genital tract infections. The primary endpoint will be the change from baseline in NT-proBNP after 6 months. Exploratory secondary endpoints will investigate symptoms as well as biomarkers of inflammation ex vivo, oxidative status in vivo and cardiac fibrosis. The study will have a power of at least 80% with a type I error of 0.05 and type II error of 0.20 to detect a relative reduction of N-terminal pro-B-type natriuretic peptide (NT-proBNP) between the intervention versus standard-
EP09.04. Figure 1: 12-lead ECG during Tachycardia
of-care arms of at least 40% of ln(NT-proBNP) after 6 months. Thus, assuming a dropout of 10%, the total sample size will recruit 136 patients.
Results: Figure 1 shows a summary of the study timetable.
Conclusion: The EF-CARISTO study is designed to provide exploratory data on the effects of SGLT2i on biomarkers of cardiac function, and exercise capacity in obstructive and non-obstructive HCM.
EP.09.04
New Solutions for Old Challenges: Could Ivabradine be the Answer for Incessant Automatic Atrial Tachycardia?
A Ivanescu,1 S Totolici,2 E Badila1 and G-A Dan1
1. Carol Davila University of Medicine, Colentina Clinical Hospital, Bucharest, Romania; 2. Colentina Clinical Hospital, Bucharest, Romania
Correspondence: Andreea-Cristina Ivanescu, andreea.cardio@gmail.com
Background: Automatic atrial tachycardia (AAT) is a form of focal atrial tachycardia (FAT) due to enhanced automaticity, responsible for tachycardiomyopathy because of its incessant nature. Automaticity is suggested by facilitation by catecholamines, failure to induce/terminate the tachycardia by programmed stimulation, as well as by the warm-up/cooldown phenomena. The ionic currents responsible for FAT have not been elucidated. Ivabradine is a selective inhibitor of the If current blocking the hyperpolarization and cyclic nucleotide (HCN) channels. They are present mostly in the sinoatrial node; however, their presence has also been signaled in other sites. To this point, there are only sparse data regarding the effectiveness of ivabradine in AAT, which is particularly refractory to antiarrhythmic drugs. Research of the literature shows only a small number of case reports of FAT treated with ivabradine, as bridge to catheter ablation.
EP09.04. Figure 2: Onset of Tachycardia during Holter Monitoring
EP09.03. Figure 3: Termination of Tachycardia during Holter Monitoring
Materials and Methods: Presented here is the case of a paucisymptomatic 78-year-old woman diagnosed during a routine medical evaluation, with a narrow QRS tachycardia of 140 BPM, 1:1 atrioventricular conduction, with ECG characteristics of AAT. The arrhythmia was incessant, with spontaneous onset and offset. Otherwise, the patient’s clinical, biological, and echocardiographic findings were within normal limits.
Results: For the next 6 months, she was prescribed sequentially metoprolol, verapamil and propafenone which were ineffective for control of either rhythm or rate. She refused repeated electrical cardioversion and the electrophysiology study. Lastly, ivabradine 10 mg/day was given in addition to metoprolol 50 mg/day, with conversion to sinus rhythm within a few hours. For the following 12 months, she remained asymptomatic. Although Holter monitoring showed several short recurrences of AAT, HR during tachycardia was predominantly below 100 BPM.
Conclusion: A successful response to ivabradine implies involvement of HCN channels in AAT pathogenesis and may be considered a marker of automaticity as the underlying mechanism. Nodal-like tissue at ectopic sites with consequent activation of HCN channels might be involved. This case supports consideration of ivabradine for selected cases of AAT.
EP.09.05
Human Induced Pluripotent Stem Cellderived Engineered Heart Tissues to Test New Compounds for Inherited Cardiomyopathies
L Giammarino,1 M Langione,2 C Palandri,1 M Musumeci,1 L Santini,1 I Della Corte,2 B Scellini,2 A Fornaro,3 E Cerbai,1,4 C Tesi,2 M Regnier,5 C Poggesi,2 DL Mack,5 C Ferrantini,2 R Coppini1 and JM Pioner6
1. Department of Neurofarba, University of Florence, Florence, Italy; 2. Department of Physiology, University of Florence, Florence, Italy; 3. Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy; 4. European Laboratory for Non-Linear Spectroscopy (LENS), University of Florence, Florence, Italy; 5. Department of Bioengineering, University of Washington, Seattle, US; 6. University of Florence, Department of Biology, Florence, Italy
Correspondence: Lucrezia Giammarino, lucrezia.giammarino@unifi.it
Background: Human pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs) represent a powerful model to investigate inherited cardiomyopathies, preserving the genetic profile of patients and allowing the identification of pharmacological therapies. In particular, hypertrophic cardiomyopathy (HCM) and dilated cardiomyopathy associated to
Duchenne Muscular dystrophy (DMD) do not have a specific treatment.
Materials and Methods: Starting from hiPSC-CMs derived from DMD and HCM patients, we generated engineered heart tissues (EHTs), 3D models that allow to overcome the limitations of 2D culture, such as immature mechanical and electrophysiological phenotype. We tested two pharmacological molecules: a myosin inhibitor, mavacamten, (0.3 µM and 0.75 µM) on HCM-EHTs and a membrane repairer, poloxamer 188 (1 mg/ ml), on DMD-EHTs. Then, at specific timepoints of maturation, we performed evaluation of auxotonic spontaneous contractions by optical tracking and after 20 days of treatment we carried out mechanical investigations in isometric conditions, under field stimulation. In addition, we measured action potential and Ca2+ transients using fluorescent indicators (FluoVolt and Cal590, respectively).
Results: After treatment with mavacamten, HCM-EHTs showed reduced contractile force compared to the untreated HCM-EHTs, and force was consistently reduced with reduced duration of contraction. Conversely, DMD-EHTs produced less contractile force and reduced spontaneous beating frequency compared to control EHTs. In isometric conditions and physiological calcium concentration, DMD-EHTs showed reduced tension compared to controls. Moreover, after P188 treatment DMD-EHTs showed higher active tension compared to untreated DMD-EHTs. Finally, preliminary results using a dual fluorescent recording showed no major difference in action potential and calcium transient duration in both lines tested.
Conclusion: Engineered heart tissues can reflect more closely physiological cardiac tissues, leading cardiomyocytes alignment and maturation appearing to qualitatively reflect the contraction parameters of native myocardium. Moreover, this evidence will contribute to determine whether EHTs are clinically relevant models for mechanistic insights of cardiomyopathy and represent a useful tool for studying the acute and long-term effects of specific pharmacological agents.
EP.09.06
Thrombin Receptors as Candidate Therapeutic Targets to Reduce the Vulnerable Substrate for Postoperative Atrial Fibrillation
A Fender,1 C Mittendorf,1 I Abu-Taha,1 M Kamler2 and D Dobrev1
1. Institute for Pharmacology, Essen University Hospital, Essen, Germany; 2. Department of Cardiac Surgery, Essen University Hospital, Essen, Germany
Correspondence: Anke Fender, anke.fender@uk-essen.de
Background: Postoperative atrial fibrillation (POAF) develops in up to 30% of patients undergoing cardiac surgery, increasing morbidity and mortality. Therapeutic management is challenging. A pre-existing atrial cardiomyopathy with calcium-handling abnormalities and an overactive NLRP3-inflammasome/CaMKII axis predisposes to POAF by providing a vulnerable substrate for proinflammatory perioperative triggers. Surgery elicits sustained activation of thrombin, which provokes proinflammatory effects via protease-activated receptors (PAR). The role of atrial PAR as causal players and candidate therapeutic targets in the context of POAF is unknown.
Materials and Methods: Human atrial myocardium was collected prior to cardiac surgery from patients with no history of AF. Murine atrial myocardium was obtained from male PAR4-/- and wild-type mice , as well
as from mice subjected to sham surgery and left to recover for up to 48 hours. HL-1 murine atrial cardiomyocytes were exposed to thrombin (1 U/ ml, 24 hours). Tissue and cell lysates were assessed by western blot.
Results: Atria from patients who developed POAF showed higher atrial abundance of PAR1 and PAR4 compared to patients remaining in sinus rhythm after surgery. POAF-prone atria also expressed higher levels of the NLRP3 inflammasome effector caspase-1, the caspase-1 maturation product IL-1β, and phosphorylated CaMKII and mTOR. The same pattern (increased caspase-1, IL-1β, phospho-CaMKII and phospho-mTOR) was seen in cultured HL-1 atrial cardiomyocytes exposed to thrombin and in atria from mice subjected to sham surgery, coinciding with transiently upregulated PAR4 expression. Atria from PAR4-/- mice showed lower abundance of caspase-1, IL-1β, phospho-CaMKII and phospho-mTOR compared to atria from wild-type littermates.
Conclusion: Increased expression of PAR1 and PAR4 thrombin receptors may contribute to the molecular substrate predisposing to POAF, by promoting pro-arrhythmic signaling through the CaMKII/mTOR/NLRP3 inflammasome axis in atrial cardiomyocytes. The selective PAR4 antagonists currently in clinical development as safer antiplatelet drugs with low adverse bleeding risk provide a therapeutic perspective to improve management of POAF.
EP.09.07
Effects of S-isomer of Cibenzoline in the Myocardium of Patients with Hypertrophic Cardiomyopathy
R Coppini, L Santini, C Palandri, M Musumeci and E Cerbai University of Florence, Firenze, Italy
Correspondence: Raffaele Coppini, raffaele.coppini@unifi.it
Background: Cibenzoline has been clinically employed as a negativeinotropic drug to treat patients with obstructive hypertrophic cardiomyopathy (oHCM). S-isomer of cibenzoline (CT-G20) is in clinical development for oHCM. This study sought to determine the effects of CTG20 on action potentials (APs), ion currents and Ca-transients in human ventricular cardiomyocytes, in comparison with racemate-cibenzoline.
Materials and Methods: Single cardiomyocytes, isolated from the surgical ventricular specimens of 18 oHCM patients and from left-atrial samples of 14 valvular patients, were employed to measure APs, L-type Ca-current (ICaL), peak Na-current (INa-Peak), late Na-current (INaL), K+currents and Ca-transients, while exposing cells to different concentrations of CT-G20 or racemate-cibenzoline (0.4–10 μM). Intact trabeculae were used to measure twitch force.
Results: In oHCM cardiomyocytes, CT-G20 induced a dose-dependent AP-shortening and reduced INa peak, INaL and ICaL. The racematecibenzoline also shortened AP duration in a dose-dependent manner, though its potency was lower than CT-G20, owing to the less pronounced inhibition of peak and late Na currents. Both compounds exerted a slight inhibition of delayed-rectifier K+-currents. CT-G20 also dose-dependently reduced Ca-transient amplitude and myocardial twitch force, while also decreasing diastolic [Ca2+] and accelerating Ca-reuptake. Racematecibenzoline exerted a less potent reduction of Ca-transients and force, with no significant effects on the kinetics of Ca-transient decay. In atrial myocardium, CT-G20 has no major effects on AP duration, and the negative inotropic effects are observed only at the highest concentrations.
Conclusion: CT-G20 is a potent blocker of Na-currents, with an increased selectivity on late-over peak-current compared with the racematecibenzoline. Owing to its favourable ion-channel inhibition profile, leading to pronounced AP-shortening and potent negative inotropism, CT-G20 may have increased antiarrhythmic effects, lower risk of QT-prolongation and higher efficacy in reducing left-ventricular outflow-tract gradients. Therefore, CT-G20 could be safely and effectively employed to treat patients with oHCM.
EP.09.08
Yield of Genetic Testing in Paediatric Cardiomyopathies: Implications for Pharmacological Treatment
A Ballerini,1 A Gozzini,1 F Girolami,1 S Passantino,2 A Tomberli,2 S Favilli,2 G Porcedda,2 M Zampieri,2 E Bennati,2 G Spaziani,2 A Marchi,2 GB Calabri2 and I Olivotto2,3
1. Lab. Cardiogenetica, AOU Meyer IRCCS, Florence, Italy; 2. SOC Cardiologia Pediatrica e della Transizione, AOU Meyer IRCCS, Florence, Italy; 3. Dip. Medicina Sperimentale e Clinica, Università degli Studi di Firenze, Florence, Italy
Correspondence: Adelaide Ballerini, adelaide.ballerini@unifi.it
Background: Paediatric cardiomyopathies (CMPs) are rare, heterogeneous and challenging conditions, often with a genetic aetiology. Despite the increased diagnostic yield of next generation sequencing (NGS), the genetic background of these diseases is often elusive. The assessment of aetiology is important to define prognosis and provide
EP09.08. Figure 1: Summary of Genetic Testing
access to advanced therapies. Notably, novel approaches, including small molecules and gene therapies, are emerging and represent the focus of growing international efforts.
Materials and Methods: The yield of NGS genetic testing in a tertiary paediatric referral centre for CMPs was assessed to evaluate the prevalence of candidacy to current or emerging treatment. After genetic counselling was offered to parents, genetic test was performed in 96 paediatric patients: 44 hypertrophic cardiomyopathy (HCM), 35 dilated cardiomyopathy (CMD), 14 arrhythmogenic cardiomyopathy (AC) and three restrictive cardiomyopathy (RCM).
Results: NGS identified a pathogenic/likely pathogenic variant in 35/96 patients (36.5%): 23/44 with HCM (52%), 7/35 with DCM (20%); 3/14 with AC (21%) and 2/3 with RCM (66%). The most common aetiology in HCM and DCM was sarcomeric, mostly involving MYH7, MYBPC3, TNNT2 and TTN. Among AC patients one DSP variant and one FLNC were identified. Additionally, of seven syndromic patients, aetiology was four with Noonan syndrome (PTPN11 and biallelic LZTR1), two with Danon disease (LAMP2) and one child affected by glycogen storage disease (PRKAG2). In the light of emerging treatment, 20/35 (57%) of the patients in whom a variant was identified were potentially eligible for small molecule or gene therapy; this subset represents 21% of the total cohort.
Conclusion: A molecular diagnosis could be obtained in about 40% of a paediatric cohort with cardiomyopathies; overall, about 21% of the whole cohort had genotypes potentially amenable to emerging precision therapies. Genetic testing may have direct implications for clinical management and represents a prerequisite to evaluate candidacy for novel treatment.
EP.09.09
Spatiotemporal Alterations of Metabolic Gene Expression Drive Onset and Progression of Arrhythmogenic Cardiomyopathy in a
Murine Model
F Bruns,1 SF Kant,2 I Abu-Taha,1 RE Leube,2 D Dobrev1, 3, 4 and CA Krusche2
1. Institute of Pharmacology, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany; 2. Institute of Molecular and Cellular Anatomy, RWTH Aachen University, Aachen, Germany; 3. Department of Integrative Physiology, Baylor College of Medicine, Houston, US; 4. Department of Medicine and Research Center, Montréal Heart Institute and Université de Montréal, Montréal, Montréal, Canada
Correspondence: Florian Bruns, florian.bruns@uk-essen.de
Background: Arrhythmogenic cardiomyopathy (AC) is an inherited cardiac disease mainly attributed to mutations in desmosomal genes. Patients commonly have arrhythmia, sudden cardiac death and heart failure. Clinical disease onset (the overt AC phase), is preceded by a concealed phase, characterised by the lack of symptoms and prognostic disease markers. Because alterations of energy metabolism have been linked to cardiomyopathy-related heart failure, this study assessed whether expression and localisation of proteins involved in cardiac energy metabolism change during disease-onset and progression in a murine AC model.
Materials and Methods: Cardiac-specific DSG2 knockout (DSG2cKO) mice recapitulating hallmarks of human AC were generated by deleting
exons 4 and 5 of the DSG2 gene using the Myh6-cre/loxP system. Expression and phosphorylation of key metabolic enzymes were assessed in a spatiotemporal manner in left and right ventricular tissue from mice aged 3 (juvenile), 5 (adolescent), 12 (young adult) and 30–36 weeks (adult) by qPCR, western blot and histology. Healthy, age-matched littermates (Dsg2flox) served as controls.
Results: At the age of 3–5 weeks, Dsg2cKO mice showed cardiomyocyte loss, inflammation and scar formation mimicking typical histopathological findings of AC. mRNA and protein levels of glucose transporter Glut1 were increased, whereas Glut4 mRNA and protein levels were downregulated. Phosphorylation of 5’AMP-activated protein kinase (AMPK) at Thr-172 was increased in both ventricles. The mRNA and protein levels of the transcription factors PPARα, Pgc1α and Pgc1β that orchestrate the adaptation of energy metabolism in growing juvenile and adolescent hearts, were reduced. In adult Dsg2cKO mice, PPARα down- and cardiomyocyte-specific Glut1 upregulation persisted, constituting potential markers of the chronic disease phase of AC.
Conclusion: This study demonstrates transient alterations in the regulatory network of cardiac energy metabolism during disease onset in DSG2cKO mice in both ventricles. Targeting of altered cardiac energy metabolism, particularly during early phase of AC, might constitute a therapeutic option.
Pharmacogenomics for Precision Pharmacology
EP.10.01
Rationale and Design of an Exploratory Study of Urinary miRNA Signatures as Potential Biomarkers of Haemodynamically Significant Patent Ductus Arteriosus and Treatment Response in Preterm Infants
E Bigagli,1 C Dani1,2 and C Luceri1
1. Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy; 2. Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy
Correspondence: Elisabetta Bigagli, elisabetta.bigagli@unifi.it
Background: Patent ductus arteriosus (PDA) is one of the most common complications in preterm infants and when haemodynamically significant (hsPDA), is associated with higher rates of mortality and multiorgan comorbidities. Ibuprofen and indomethacin are ineffective in approximately 30% of patients and increase the risk of side-effects; paracetamol is a promising alternative with a better safety profile. microRNA (miRNA) profiling has been applied to investigate potential biomarkers for early diagnosis and/or therapeutic management in several paediatric conditions but its potential to early identify infants at high risk of developing hsPDA and/or refractory to pharmacological treatment has not been explored.
Materials and Methods: Fifty infants at 23–29 weeks of gestational age or with a birth weight <1,500 g will be enroled at the Neonatal Intensive Care Unit of Careggi Hospital of Florence. Exclusion criteria are major congenital malformations, chromosomal disorders, inherited metabolic diseases, and early death. The entire miRNome will be analysed in urinary samples collected on the first 24 hours of life and after three days of treatment. Echocardiography will be performed between 24 and 72 hours of life to diagnose hsPDA and its response to the first cycle of ibuprofen (10-5-5 mg/kg/day).
Results: The entire miRNome will be analysed by microarray and validated by realtime PCR. Uni/multivariate regression models will be performed to assess the correlation between miRNAs, hsPDA and therapy response. ROC curves will be used to evaluate their accuracy in identifying hsPDA and in distinguishing responders from non-responders.
Conclusion: This exploratory study is designed to investigate, for the first time, the relevance of urinary miRNAs in predicting the development of hsPDA and patient pharmacotherapy response . The identification of noninvasive, early, and predictive urinary biomarkers may optimise the diagnosis of hsPDA and use of current pharmacological strategies to limit serious side-effects.