- Email: [email protected]
Association of Idiopathic Inflammatory Myositis with Statin Exposure: A Population Based Case Control Study
Abstracts
score in each patient (i.e. Age <20%, 20-39%, 40-59%,> 60%; Cr <20%, 20-29%, >30%). The interactions between GRACE score, invasive management, and age or renal function contributions were explored using general estimating equations. Results: In total 17,140 of patients were included, of whom 30.4% were STEMI. An increasing GRACE score was associated with a greater benefit from invasive management. However, a higher contribution of age to the score was associated with a lower impact on mortality from invasive-management. (Relative risk reduction with invasive management: Age% < 20%-82%; 20-39%-66%; 40-59%- 54%: 60%- 15%, interaction p value <0.001). The benefit from invasive management was constant (no interaction) regardless the contribution of renal function to GRACE score. Conclusion: GRACE score identifies patients benefiting from invasive management. However, with increasing contribution of age to absolute risk, the benefits of invasive management are reduced. http://dx.doi.org/10.1016/j.hlc.2016.06.068 68 Assessment of Functional Significance of Coronary Artery Disease of Indeterminate Severity with Fractional Flow Reserve in Patients with Aortic Stenosis Undergoing Transcatheter Aortic Valve Implantation V. Subban 1,2 , M. Savage 1 , J. Crowhurst 1 , B. Robinson 1 , K. Poon 1 , A. Incani 1 , N. Gaikwad 1,∗ , D. Murdoch 1 , C. Aroney 1 , C. Raffel 1 , N. Bett 1 , D. Walters 1 1 The
Prince Charles Hospital, Australia Medical Mission, Chennai, India
2 Madras
Background: Coronary artery disease is common in elderly patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI) and is associated with poor outcomes. Measurement of myocardial fractional flow reserve may be valuable for assessing the haemodynamic significance of moderate coronary artery lesions, but few have studied this in patients with severe AS. Methods: We report our experience with twelve patients whose evaluation for transcatheter aortic valve replacement included measurement of myocardial fractional flow reserve to assess coronary artery disease, which appeared on angiography to be of intermediate severity. Results: Following the infusion of adenosine during this procedure two patients exhibited transient hypotension and third degree atrioventricular block and hypotension. One patient had a negative FFR (0.90) of her LAD, but collapsed 1 hour later with asystole. She was successfully resuscitated, and subsequently underwent balloon aortic valvuloplasty and dialysis. Due to dementia, renal dysfunction and general frailty, she did not qualify for TAVI. Four patients with haemodynamically significant disease underwent percutaneous coronary intervention with drug-eluting stents. Eleven underwent successful TAVI. Although one died three months later following an intracranial haemorrhage, ten were in NYHA class I or II at follow-up of 523 ± 347 days.
S31
.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
Conclusion: Measurement of myocardial fractional flow reserve may be used to evaluate the haemodynamic significance of coronary lesions of indeterminate severity in patients with severe aortic stenosis but haemodynamic instability related to the infusion of adenosine is a concern. http://dx.doi.org/10.1016/j.hlc.2016.06.069 69 Association of Idiopathic Inflammatory Myositis with Statin Exposure: A Population Based Case Control Study G. Gabb 1,2,∗ , G. Caughey 3 , S. Ronson 4 , M. Ward 4 , C. Hill 5,6,7 , V. Limaye 1,2,3,4,5,6,7 1 General Medicine, Royal Adelaide Hospital, Adelaide, Australia 2 Discipline of Medicine, University of Adelaide, Adelaide, Australia 3 Quality Use of Medicines and Pharmacy Research Centre, Sansom Institute for Health Research, School of Pharmacy and Medical Sciences, University of South Australia, Australia 4 School of Pharmacy and Medical Science, University of South Australia, Adelaide, Australia 5 Department of Rheumatology, The Queen Elizabeth Hospital, Woodville, Australia 6 The Health Observatory, Discipline of Medicines, University of Adelaide, Adelaide, Australia 7 Rheumatology Unit, Royal Adelaide Hospital, Adelaide, Australia
Statins are widely prescribed for cardiovascular risk reduction. The well-known muscle adverse effects include myalgia and rhabdomyolysis. Idiopathic inflammatory myositis (IIM) is a rare, severe, debilitating condition, most commonly presenting with painless proximal limb girdle weakness. It requires aggressive immunosuppressive therapy and may result in permanent disability or death. The relationship between statin use and IIM is less certain. Objective: To examine the association between IIM and prior exposure to statins. Methods: A retrospective case control study of all cases of IIM in adults aged 40 and older (1990-2014) from the South Australian Myositis Database. Data on exposure to statins was obtained from medical records and compared to population-based controls matched 3:1 (age, sex) from the North West Adelaide Health Study. The prevalence and odds ratio (95% CI) for statin exposure were calculated. Results: There were 221 cases and 662 controls. Polymyositis (n=87, 39.4%), was most common, followed by inclusion body myositis (n=66, 29.9%), dermatomyositis (n=26, 11.8%), necrotising myositis (n=24, 10.9%) and non-specific chronic inflammatory myositis (n=18, 8.1%). 30.8% of cases were exposed to statins, compared to 21.6% controls. Odds of exposure to statins was 1.6 (95% CI 1.15-2.27, p<0.001) in patients with IIM, and increased to 2.11(95% CI 1.33-3.35 p=0.0015) with stratification of analysis by time of exposure.
Abstracts
S32
Conclusion: Patients with IIM had an increased likelihood of prior statin exposure compared with the general population. This warrants further investigation in view of increasing population exposure to statins and severity of disease outcome. http://dx.doi.org/10.1016/j.hlc.2016.06.070 70 Australian 6 Year Trends of Prescribing Rates and Costs of Clopidogrel, Prasugrel and Ticagrelor I. Tsay ∗ , C. Chow, I. Subiakto, A. Castles, W. van Gaal The Northern Hospital, Epping, Australia Background: Clopidogrel, prasugrel or ticagrelor in combination with aspirin has been shown to prevent adverse cardiovascular (CV) events in patients who suffer acute coronary syndromes (ACS). All three agents are listed on the PBS for post-ACS indications. Prasugrel and clopidogrel are available for ACS managed with coronary intervention (PCI). Reductions in adverse CV events after ACS were observed for prasugrel with PCI (TRITON-TIMI 38, ARR 2.2%) and ticagrelor (PLATO, ARR 1.9%) when compared to clopidogrel. We sought to evaluate cost differences and prescribing patterns of each agent for cardiac indications on the PBS. Methods: Item numbers for post-ACS and PCI indications were selected. 2010-2014 data of costs and script volumes for each agent were compared (graphs). Assuming stable prescribing, 2015 costs were estimated (est) by multiplying data in the first 6 months by 2. Results: Antiplatelet agents are increasingly prescribed in Australia at >2.5 times increased script volume over 5 years. Relative cost increases appear driven by the use of newer agents, led by ticagrelor. Conclusions: With multiple indications, clopidogrel was the most commonly prescribed agent, and its use was associated with cost reductions over time. Cost-efficiency assessments of each agent would aid our understanding of their long-term impact on healthcare outcomes and expenditures.
http://dx.doi.org/10.1016/j.hlc.2016.06.071
.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .
71 Bioengineering Synthetic Silk Conduits for Arterial Revascularisation E. Filipe 1,∗ , M. Santos 1 , J. Hung 1 , J. Rnjak-Kovacina 2 , M. Ng 1,3 , S. Wise 1 1 The
Heart Research Institute, 7 Eliza Street, Newtown, Australia 2 Graduate School of Biomedical Engineering, UNSW Australia, Sydney, Australia 3 Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, Australia Background: There are currently no effective synthetic conduits for small diameter vascular grafting e.g. coronary artery bypass surgery. Silk fibroin is a versatile natural polymer with remarkable mechanical properties and tuneable biodegradation that is extremely well tolerated in vivo. Silk grafts were engineered using electrospinning to obtain a woven mesh of silk nanofibers.
Methods and Results: Our silk materials are uniquely electrospun and subsequently cross-linked using water only, enhancing their biocompatibility. Silk scaffolds enhanced endothelial cell proliferation by almost 5-fold, from day 1 to 6, significantly greater than ePTFE controls (p<0.01). Silk conduits demonstrated similar elasticity to rat aorta (5.4±1.6 MPa vs 2.1±1.0 MPa) and were significantly more elastic than ePTFE (31.9±3.5 MPa, p<0.001). Burst pressures >800 mmHg were achieved with conduits with wall thickness of only 400 m. Implanted into the abdominal aortas of rats, silk conduits were well tolerated up to 24 weeks, showing only low levels of inflammatory cells and neointimal hyperplasia. Controlled biodegradation of the outer most layer of the conduits was evident, facilitating cell infiltration at longer time points. Complete re-endothelialisation of silk grafts was observed by 12-weeks, in contrast to ePTFE controls which were only partially endothelialised at this time. Conclusion: Silk fibroin can be engineered to have physical and biologic properties that make a highly suitable building block for the engineering of synthetic arterial conduits. Ultimately, this may lead to the development of silk-based grafts for a wide of vascular applications, thereby meeting a large unmet need in cardiovascular medicine. http://dx.doi.org/10.1016/j.hlc.2016.06.072
score in each patient (i.e. Age <20%, 20-39%, 40-59%,> 60%; Cr <20%, 20-29%, >30%). The interactions between GRACE score, invasive management, and age or renal function contributions were explored using general estimating equations. Results: In total 17,140 of patients were included, of whom 30.4% were STEMI. An increasing GRACE score was associated with a greater benefit from invasive management. However, a higher contribution of age to the score was associated with a lower impact on mortality from invasive-management. (Relative risk reduction with invasive management: Age% < 20%-82%; 20-39%-66%; 40-59%- 54%: 60%- 15%, interaction p value <0.001). The benefit from invasive management was constant (no interaction) regardless the contribution of renal function to GRACE score. Conclusion: GRACE score identifies patients benefiting from invasive management. However, with increasing contribution of age to absolute risk, the benefits of invasive management are reduced. http://dx.doi.org/10.1016/j.hlc.2016.06.068 68 Assessment of Functional Significance of Coronary Artery Disease of Indeterminate Severity with Fractional Flow Reserve in Patients with Aortic Stenosis Undergoing Transcatheter Aortic Valve Implantation V. Subban 1,2 , M. Savage 1 , J. Crowhurst 1 , B. Robinson 1 , K. Poon 1 , A. Incani 1 , N. Gaikwad 1,∗ , D. Murdoch 1 , C. Aroney 1 , C. Raffel 1 , N. Bett 1 , D. Walters 1 1 The
Prince Charles Hospital, Australia Medical Mission, Chennai, India
2 Madras
Background: Coronary artery disease is common in elderly patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI) and is associated with poor outcomes. Measurement of myocardial fractional flow reserve may be valuable for assessing the haemodynamic significance of moderate coronary artery lesions, but few have studied this in patients with severe AS. Methods: We report our experience with twelve patients whose evaluation for transcatheter aortic valve replacement included measurement of myocardial fractional flow reserve to assess coronary artery disease, which appeared on angiography to be of intermediate severity. Results: Following the infusion of adenosine during this procedure two patients exhibited transient hypotension and third degree atrioventricular block and hypotension. One patient had a negative FFR (0.90) of her LAD, but collapsed 1 hour later with asystole. She was successfully resuscitated, and subsequently underwent balloon aortic valvuloplasty and dialysis. Due to dementia, renal dysfunction and general frailty, she did not qualify for TAVI. Four patients with haemodynamically significant disease underwent percutaneous coronary intervention with drug-eluting stents. Eleven underwent successful TAVI. Although one died three months later following an intracranial haemorrhage, ten were in NYHA class I or II at follow-up of 523 ± 347 days.
S31
.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
Conclusion: Measurement of myocardial fractional flow reserve may be used to evaluate the haemodynamic significance of coronary lesions of indeterminate severity in patients with severe aortic stenosis but haemodynamic instability related to the infusion of adenosine is a concern. http://dx.doi.org/10.1016/j.hlc.2016.06.069 69 Association of Idiopathic Inflammatory Myositis with Statin Exposure: A Population Based Case Control Study G. Gabb 1,2,∗ , G. Caughey 3 , S. Ronson 4 , M. Ward 4 , C. Hill 5,6,7 , V. Limaye 1,2,3,4,5,6,7 1 General Medicine, Royal Adelaide Hospital, Adelaide, Australia 2 Discipline of Medicine, University of Adelaide, Adelaide, Australia 3 Quality Use of Medicines and Pharmacy Research Centre, Sansom Institute for Health Research, School of Pharmacy and Medical Sciences, University of South Australia, Australia 4 School of Pharmacy and Medical Science, University of South Australia, Adelaide, Australia 5 Department of Rheumatology, The Queen Elizabeth Hospital, Woodville, Australia 6 The Health Observatory, Discipline of Medicines, University of Adelaide, Adelaide, Australia 7 Rheumatology Unit, Royal Adelaide Hospital, Adelaide, Australia
Statins are widely prescribed for cardiovascular risk reduction. The well-known muscle adverse effects include myalgia and rhabdomyolysis. Idiopathic inflammatory myositis (IIM) is a rare, severe, debilitating condition, most commonly presenting with painless proximal limb girdle weakness. It requires aggressive immunosuppressive therapy and may result in permanent disability or death. The relationship between statin use and IIM is less certain. Objective: To examine the association between IIM and prior exposure to statins. Methods: A retrospective case control study of all cases of IIM in adults aged 40 and older (1990-2014) from the South Australian Myositis Database. Data on exposure to statins was obtained from medical records and compared to population-based controls matched 3:1 (age, sex) from the North West Adelaide Health Study. The prevalence and odds ratio (95% CI) for statin exposure were calculated. Results: There were 221 cases and 662 controls. Polymyositis (n=87, 39.4%), was most common, followed by inclusion body myositis (n=66, 29.9%), dermatomyositis (n=26, 11.8%), necrotising myositis (n=24, 10.9%) and non-specific chronic inflammatory myositis (n=18, 8.1%). 30.8% of cases were exposed to statins, compared to 21.6% controls. Odds of exposure to statins was 1.6 (95% CI 1.15-2.27, p<0.001) in patients with IIM, and increased to 2.11(95% CI 1.33-3.35 p=0.0015) with stratification of analysis by time of exposure.
Abstracts
S32
Conclusion: Patients with IIM had an increased likelihood of prior statin exposure compared with the general population. This warrants further investigation in view of increasing population exposure to statins and severity of disease outcome. http://dx.doi.org/10.1016/j.hlc.2016.06.070 70 Australian 6 Year Trends of Prescribing Rates and Costs of Clopidogrel, Prasugrel and Ticagrelor I. Tsay ∗ , C. Chow, I. Subiakto, A. Castles, W. van Gaal The Northern Hospital, Epping, Australia Background: Clopidogrel, prasugrel or ticagrelor in combination with aspirin has been shown to prevent adverse cardiovascular (CV) events in patients who suffer acute coronary syndromes (ACS). All three agents are listed on the PBS for post-ACS indications. Prasugrel and clopidogrel are available for ACS managed with coronary intervention (PCI). Reductions in adverse CV events after ACS were observed for prasugrel with PCI (TRITON-TIMI 38, ARR 2.2%) and ticagrelor (PLATO, ARR 1.9%) when compared to clopidogrel. We sought to evaluate cost differences and prescribing patterns of each agent for cardiac indications on the PBS. Methods: Item numbers for post-ACS and PCI indications were selected. 2010-2014 data of costs and script volumes for each agent were compared (graphs). Assuming stable prescribing, 2015 costs were estimated (est) by multiplying data in the first 6 months by 2. Results: Antiplatelet agents are increasingly prescribed in Australia at >2.5 times increased script volume over 5 years. Relative cost increases appear driven by the use of newer agents, led by ticagrelor. Conclusions: With multiple indications, clopidogrel was the most commonly prescribed agent, and its use was associated with cost reductions over time. Cost-efficiency assessments of each agent would aid our understanding of their long-term impact on healthcare outcomes and expenditures.
http://dx.doi.org/10.1016/j.hlc.2016.06.071
.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .
71 Bioengineering Synthetic Silk Conduits for Arterial Revascularisation E. Filipe 1,∗ , M. Santos 1 , J. Hung 1 , J. Rnjak-Kovacina 2 , M. Ng 1,3 , S. Wise 1 1 The
Heart Research Institute, 7 Eliza Street, Newtown, Australia 2 Graduate School of Biomedical Engineering, UNSW Australia, Sydney, Australia 3 Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, Australia Background: There are currently no effective synthetic conduits for small diameter vascular grafting e.g. coronary artery bypass surgery. Silk fibroin is a versatile natural polymer with remarkable mechanical properties and tuneable biodegradation that is extremely well tolerated in vivo. Silk grafts were engineered using electrospinning to obtain a woven mesh of silk nanofibers.
Methods and Results: Our silk materials are uniquely electrospun and subsequently cross-linked using water only, enhancing their biocompatibility. Silk scaffolds enhanced endothelial cell proliferation by almost 5-fold, from day 1 to 6, significantly greater than ePTFE controls (p<0.01). Silk conduits demonstrated similar elasticity to rat aorta (5.4±1.6 MPa vs 2.1±1.0 MPa) and were significantly more elastic than ePTFE (31.9±3.5 MPa, p<0.001). Burst pressures >800 mmHg were achieved with conduits with wall thickness of only 400 m. Implanted into the abdominal aortas of rats, silk conduits were well tolerated up to 24 weeks, showing only low levels of inflammatory cells and neointimal hyperplasia. Controlled biodegradation of the outer most layer of the conduits was evident, facilitating cell infiltration at longer time points. Complete re-endothelialisation of silk grafts was observed by 12-weeks, in contrast to ePTFE controls which were only partially endothelialised at this time. Conclusion: Silk fibroin can be engineered to have physical and biologic properties that make a highly suitable building block for the engineering of synthetic arterial conduits. Ultimately, this may lead to the development of silk-based grafts for a wide of vascular applications, thereby meeting a large unmet need in cardiovascular medicine. http://dx.doi.org/10.1016/j.hlc.2016.06.072