Berger, Jeffrey S.

Introduction: CHIP is associated with CAD and mortality. The prognostic relevance of CHIP for high-risk patients with confirmed CAD is unknown. Hypothesis: CHIP variants are associated with cardiovascular (CV) events and mortality in high-risk patients with known CAD in the ISCHEMIA Trials Biorepository. Methods: 895 ISCHEMIA and ISCHEMIA-CKD (hereafter, ISCHEMIA Trials) participants with moderate-severe ischemia and next-generation sequencing performed for CHIP variant allele fractions of ≥2% (CHIP) and ≥10% (large CHIP) were included. Unadjusted and multivariable adjusted (age, sex, diabetes, eGFR not on HD, HD, and LVEF) associations of CHIP and large CHIP with a) ISCHEMIA Trials initial phase primary endpoint (CV death, myocardial infarction (MI), or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest, RCA) and b) ISCHEMIA Trials combined initial and extended follow-up phase (hereafter, Cumulative) endpoint of all-cause death . Results: Median (IQR) age of sequenced participants was 67 (56 – 79) years, 19% were female, 83% white, and 6% Hispanic. Hypertension (84%), diabetes (45%) and obesity (47%) were common, 26% had an eGFR <60 ml/min/1.73m 2 . The prevalence of CHIP and large CHIP was 23% and 7%, and both increased with age ( Figure 1a ). CHIP mutations in DNMT3A were detected in 106 (12%), TET2 CHIP in 44 (5%), and ASXL1 CHIP in 21 (2%) participants ( Figure 1b ). DNMT3A, TET2, and CREBBP mutations collectively comprised 199 (52%) of overall CHIP mutations, including individuals with multiple mutations in the same gene (N overall = 385); 67 participants (7%) had mutations in >1 gene. Over 3.1 years of RCT follow-up there were 135 (20%), 32 (16%) and 15 (18%) primary endpoints for no CHIP, CHIP and large CHIP, respectively. Over 6.8 years of EXTEND follow-up, there were 126 (18%), 47 (23%) and 24 (29%) deaths in the no CHIP, CHIP and large CHIP groups, respectively. After multivariable adjustment there was no association between CHIP or large CHIP and CV events or mortality ( Figure 1c ). Conclusion: Neither CHIP nor large CHIP was associated with adverse outcomes in 895 high-risk individuals with confirmed CAD, despite a high prevalence of these mutations.

Introduction: Circulating biomarkers may improve prediction of cardiovascular (CV) events in chronic coronary disease (CCD). The incremental value of biomarkers in CCD after adjustment for clinical factors, inducible ischemia and coronary artery disease (CAD) severity is uncertain. Methods: 756 ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) participants with site-determined moderate-severe ischemia and 9 assayed biomarkers (Figure) were included. Among participants with interpretable stress tests for ischemia and CAD by computed coronary tomography angiography (CCTA) (N=507), associations of biomarkers with the primary (CV death, myocardial infarction (MI), or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest) or secondary endpoints (CV death or MI) were evaluated using sequentially adjusted multivariable Cox proportional hazards models (Model 1=unadjusted, Model 2=clinical features, Model 3=Model 2 + multivessel CAD by CCTA, and Model 4=Model 3 + severe ischemia). Results: Median (IQR) participant age was 64 (57-70) years, 19% were female, 81% white, and 5% Hispanic. Hypertension (85%), diabetes (46%) and obesity (45%) were common, 28% had an estimated glomerular filtration rate <60 ml/min/1.73m 2 . Severe ischemia was present in 44%, and 39% had multivessel CAD (≥70% stenosis) by CCTA. Over 3.5 (2.4-4.7) years of follow-up there were 146 (19%) primary and 128 (17%) secondary endpoints. Soluble CD40L, GDF-15, NT-proBNP, hsTnT were associated with the primary and secondary endpoints in univariable and multivariable (adjusting for clinical features, multivessel CAD and severe ischemia) models. Conclusion: Biomarkers of inflammation (GDF-15), thrombosis (sCD40L), myocardial stretch (NT-proBNP) and injury (hs-troponin) were associated with CV endpoints in the ISCHEMIA trial independent of clinical features, multivessel CAD and severe ischemia.

Introduction: Chronic coronary disease (CCD) is a leading cause of death worldwide. Whole blood (WB) transcriptomic (RNA-seq) and methylation ‘omics’ data can discern molecular underpinnings of CCD and create molecular subtypes to aid risk prediction. Methods: Of 1,064 participants with moderate-severe ischemia (Age: 67.1±6.2, 19.4% Female, 17% non-White) from the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) biorepository, 646 participants had available WB RNA-seq and 737 had WB methylation data ( Fig 1A ). Unsupervised clustering and differential analyses identified omics-derived molecular subtypes. We identified co-regulated gene modules of each subtype, performed subtype-level enrichment of clinical variables, and performed Kaplan-Meier analyses for time to cardiovascular (CV) death or myocardial infarction (MI). Results: Multi-omic analysis revealed 4 RNA-seq-derived subtypes (RS) and 3 methylation-derived subtypes (MS). RNA-seq Subtype 1 (RS1) was enriched for molecular drivers indicative of an adaptive immune response, had clinical enrichment of female sex, statin use, and greater ischemia, and had decreased risk of CV death or MI ( Fig 1B ). RNA-seq Subtype 2 (RS2) was enriched for innate immune response pathway, and patients who were older and White, and was associated with increased risk of CV death or MI. Similarly, methylation subtypes also yielded a high-risk subtype (MS3) and a low-risk subtype (MS2) ( Fig 1C ). Integration of transcriptomic and methylomic subtypes led to further distinction of resilient and vulnerable subgroups. Conclusions: WB RNA-seq and methylation data identified molecularly-defined subtypes that informed the underlying disease pathology of CCD patients in ISCHEMIA. These subgroups were differentially enriched for clinical characteristics and event outcomes, demonstrating the potential use for blood-based omics tests to aid in the prognosis of CCD.