GALECTIN-3 PREDICTS LONG TERM CARDIOVASCULAR DEATH IN HIGH-RISK CORONARY ARTERY DISEASE PATIENTS

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1 GALECTIN-3 PREDICTS LONG TERM CARDIOVASCULAR DEATH IN HIGH-RISK CORONARY ARTERY DISEASE PATIENTS Table of Contents List of authors pag 2 Supplemental figure I pag 3 Supplemental figure II pag 4 Supplemental figure III pag 5 Supplemental figure IV pag 6 Supplemental figure V pag 7 Supplemental figure VI pag 8 Supplemental table I pag 9 Supplemental table II pag 10 Supplemental table III pag 11 Supplemental table IV pag 12 Supplemental table V pag 13 Supplemental table VI pag 14 Supplemental table VII pag 15 Supplemental table VIII pag 16 Supplemental table IX pag 17

2 Giuseppe Maiolino* 2, MD, PhD, Giacomo Rossitto* 2, MD, Luigi Pedon 1, MD, Maurizio Cesari 2, MD, PhD, Anna Chiara Frigo 3, MS, Matteo Azzolini 2, MD, Mario Plebani 4, MD, Gian Paolo Rossi 2, MD. 1 Divisione di Cardiologia Ospedale di Cittadella, Italy 2 Dept. of Medicine -Internal Medicine 4 University of Padua, Italy 3 Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Italy 4 Dept. of Medicine - Laboratory Medicine University of Padua, Italy SUPPLEMENTAL MATERIAL Figures 6, Tables 9 There is no conflict of interest and no financial disclosure concerning this manuscript to be disclosed. * These Authors have equally contributed to this manuscript. Correspondence to: Prof. Gian Paolo Rossi, MD. FACC, FAHA. DIMED- Clinica Medica 4 University Hospital via Giustiniani, Padova, Italy phone: 39-(0) or 2279 Fax: gianpaolo.rossi@unipd.it 2

$ventricular ejection fraction (bottom).$

3 Fig. I suppl: Occurrence of Acute Myocardial Infarction (AMI) in the whole cohort (top), CAD patients (mid) and CAD patients with preserved left ventricular ejection fraction (bottom). Kaplan-Meier curves for AMI in the high (dashed line), mid (dotted line) and low (solid line) Gal-3 tertiles. 3

4 Fig. II suppl: Occurrence of Stroke in the whole cohort (top), CAD patients (mid) and CAD patients with preserved left ventricular ejection fraction (bottom). Kaplan-Meier curves for Stroke in the high (dashed line), mid (dotted line) and low (solid line) Gal-3 tertiles. 4

5 Fig. III supplemental: Receiver-operating characteristic (ROC) curve for Galectin-3. The ROC analysis for Gal-3 showed a c-statistic of (p < ) (solid line) with a 95% confidence interval of (dotted lines). Y.I.: Youden Index. 5

6 Fig. IV suppl: Cardiovascular events, CAD patients. Cardiovascular death and events rate in patients with angiographically documented CAD by tertiles of Gal-3 (the absolute number of events is shown above each column). CV deaths X 2 = 26.3, p < 0.001; CV events X 2 = 6.1, p = 0.047; Fatal ischemic events X 2 = 7.8, p = CV: cardiovascular. 6

7 Fig. V suppl: Cardiovascular deaths (top), CV events (mid), and fatal ischemic events (bottom) in the CAD patients. Kaplan-Meier curves show that patients in the high Gal-3 tertile (dashed line) had a significantly higher cardiovascular (CV) deaths, CV events, and fatal ischemic events than the patients in the mid (dotted line) and low (solid line) Gal-3 tertiles. 7

8 Fig. VI suppl: Cardiovascular events, CAD patients with preserved LVEF. Cardiovascular death and events rate in patients with angiographically proven CAD and preserved LVEF (> 50%) by tertiles of Gal-3 (the absolute number of events is shown above each column). CV deaths X 2 = 4.2, p = 0.118; CV events X 2 = 1.5, p = 0.473; Fatal ischemic events X 2 = 5.0, p = CV: cardiovascular. 8

9 Galectin- 3 Tertile Variable 1 (n=348, 34.4%) 2 (n=329, 32.5%) 3 (n=336, 33.2%) P Clinical condition/hx (%) Hx of stroke 4 (1.2) 5 (1.5) 9 (2.7) = Hx of AMI 105 (30.2) 120 (36.6) 124 (36.9) = Hx of Bypass 35 (10.1) 32 (9.7) 29 (8.7) = Hx of PTCA 34 (9.8) 23 (7.1) 14 (4.2) = Medications at baseline (%) Statins 110 (32.3) 95 (29.1) 105 (31.8) = Oral antiplatelet agents 252 (73.9) 237 (72.7) 220 (66.7) = Calcium channel blockers 136 (39.9) 128 (39.3) 113 (34.2) = Beta- blockers 142 (41.6) 122 (37.4) 116 (35.2) = ACE inhibitors 138 (40.5) 140 (42.9) 186 (56.4) < Heparin 67 (19.6) 84 (25.8) 60 (18.2) = Diuretics 69 (20.2) 97 (29.8) 161 (48.8) < Digoxin 25 (7.3) 35 (10.7) 60 (18.2) < Supplemental Table I. Past medical history and medications at baseline of the whole cohort classified by Galectin-3 tertiles. Results are expressed as absolute number (percentage); comparisons across Galectin-3 tertiles were made by Χ 2. AMI, acute myocardial infarction; Bypass, coronary artery bypass; Hx, history; PTCA, percutaneous transluminal coronary angioplasty; ACE, angiotensin converting enzyme. n =

10 Galectin- 3 Tertile: CAD Patients Variable 1 (n=267, 34.2%) 2 (n=255, 32.6%) 3 (n=260, 33.2%) P Age (yrs) 61 [54-67]* 65 [57-71] # 69 [63-74] <0.001 Gender M (%) 240 (89.9) 203 (79.6) 193 (74.2) <0.001 Risk factors Non- Smokers/Smokers/Ex (%) 85/51/130 (32/19/49) 96/36/123 (38/14/48) 97/35/128 (37/14/49) =0.306 Hypertension (%)* 142 (53.0) 156 (61.2) 171 (65.8) =0.018 Systolic BP (mmhg) 133 ± ± ± Diastolic Diastolic BP (mmhg) BP (mmhg) 78 ± ± 9 78 ± Diabetes (%) 36 (13.5) 37 (14.7) 54 (20.9) =0.021 BMI (Kg/m 2 ) 26.7 ± ± ± 3.6 =0.156 Heart disease Left Ventricular EF (%) 65 [56-71] 64 [54-72] # 59 [47-68] <0.001 Atherosclerotic burden (Duke score) 32 [23-48] 37 [23-48] 37 [23-48] =0.022 Serum Creatinine (µμmol/l) 88 [71-97] 88 [71-97] # 96 [80-115] <0.001 egfr (ml/min) 87.5 ± 26.7* 79.9 ± 24.9 # 70.9 ± 30.5 <0.001 Serum K + (mmol/l) 4.2 ± ± ± 0.5 =0.012 Serum Na + (mmol/l) 140 ± ± ± 3 <0.001 Serum Glucose (mmol/l) 6.2 ± ± ± 2.3 =0.084 Total Cholesterol (mg/dl) 202 [ ] 206 [ ] 199 [ ] =0.035 HDL- Cholesterol (mg/dl) 46 [40-51] 46 [40-52] # 43 [36-49] =0.003 LDL- Cholesterol (mg/dl) 131 [ ] 131 [ ] 131 [ ] =0.014 Triglycerides (mg/dl) 126 [91-169] 122 [90-163] 126 [93-175] =0.503 Homocysteine (µμmol/l) 11.7 ± ± 7.0 # 14.5 ± 8.5 <0.001 Supplemental Table II. Demographic and clinical characteristics of the CAD subjects classified by Galectin-3 tertiles (n=782). Results are expressed as mean ± SD, absolute numbers (percentage), or median and interquartile range; comparisons across Galectin-3 tertiles were made by ANOVA and Bonferroni tests, after log or square root transformation if needed, or Χ 2, as appropriate. BMI, body mass index; egfr, estimated glomerular filtration rate; K +, potassium; Na +, sodium; BP, Blood Pressure; HDL, high density lipoprotein; LDL, low density lipoprotein; EF, ejection fraction. Bonferroni test: * I vs II tertile, # II vs III tertile, I vs III tertile. P < 0.05 for significance. *Systolic and diastolic BP and BMI values did not differ across Gal-3 tertiles. 10

11 Galectin- 3 Tertile - CAD patients Variable 1 (n=267, 34.2%) 2 (n=255, 32.6%) 3 (n=260, 33.2%) P Clinical condition/hx (%) Hx of stroke 3 (1.1) 5 (2.0) 5 (1.9) = Hx of AMI 93 (34.7) 108 (42.5) 123 (47.3) = Hx of Bypass 30 (11.2) 34 (13.3) 26 (10.0) = Hx of PTCA 31 (11.7) 22 (8.7) 14 (5.4) = Medications at baseline (%) Statins 97 (36.9) 86 (34.0) 94 (36.6) = Oral antiplatelet agents 216 (82.1) 201 (79.4) 201 (78.2) = Calcium channel blockers 114 (43.3) 108 (42.7) 95 (37.0) = Beta- blockers 124 (47.1) 102 (40.3) 106 (41.2) = ACE inhibitors 96 (36.5) 103 (40.7) 139 (54.1) < Heparin 56 (21.3) 68 (26.9) 55 (21.4) = Diuretics 39 (14.8) 62 (24.5) 107 (41.6) < Digoxin 10 (3.8) 15 (5.9) 31 (12.1) = Supplemental Table III. Past medical history and medications at baseline of the CAD patients classified by Galectin-3 tertiles. Results are expressed as absolute number (percentage); comparisons across Galectin-3 tertiles were made by Χ 2. AMI, acute myocardial infarction; Bypass, coronary artery bypass; Hx, history; PTCA, percutaneous transluminal coronary angioplasty; ACE, angiotensin converting enzyme. N =

12 Galectin- 3 Tertile - CAD pts with LVEF > 50% Variable 1 (n=199, 33.4%) 2 (n=201, 33.8%) 3 (n=195, 32.8%) P Clinical condition/hx (%) Hx of stroke 0 (0.0) 5 (2.5) 4 (2.1) = Hx of AMI 59 (29.6) 66 (32.8) 71 (36.4) = Hx of Bypass 20 (10.1) 26 (12.9) 19 (9.7) = Hx of PTCA 23 (11.7) 21 (10.4) 12 (6.2) = Medications at baseline (%) Statins 70 (36.1) 72 (35.8) 64 (33.0) = Oral antiplatelet agents 159 (82.0) 164 (81.6) 158 (81.4) = Calcium channel blockers 96 (49.5) 97 (48.3) 86 (44.3) = Beta- blockers 90 (46.4) 87 (43.3) 84 (43.3) = ACE inhibitors 62 (32.0) 70 (34.8) 93 (47.9) = Heparin 43 (22.2) 47 (23.4) 45 (23.2) = Diuretics 22 (11.3) 38 (18.9) 58 (29.9) < Digoxin 5 (2.6) 7 (3.5) 16 (8.2) = Supplemental Table IV. Past medical history and medications at baseline of the CAD patients with preserved LVEF classified by Galectin-3 tertiles. Results are expressed as absolute number (percentage); comparisons across Galectin-3 tertiles were made by Χ 2. AMI, acute myocardial infarction; Bypass, coronary artery bypass; Hx, history; PTCA, percutaneous transluminal coronary angioplasty; ACE, angiotensin converting enzyme. 12

13 Follow- up cases available vs lost Overall model statistics Adjusted R 2 = F = p = Variables in the model β P Variables in the model β P Age Left Ventricular EF (%) Gender Atherosclerotic burden (Duke score) Smoke (0N1Y) Hx of AMI BMI Hx of Bypass egfr Hx of PTCA Serum K + (mmol/l) Hx of Diabetes Serum Na + (mmol/l) Statins Serum Glucose (mmol/l) Oral antiplatelet agents HDL- Cholesterol (mg/dl) LDL- Cholesterol (mg/dl) Beta- blockers ACE inhibitors Triglycerides (mg/dl) Heparin Systolic Blood Pressure (mmhg) Diastolic Blood Pressure (mmhg) Diuretics Digoxin Gal Supplemental Table V. Multiple regression analysis showing no difference between cases lost and those available at follow-up 13

14 CV Events HR 95%CI Wald P Model 1 Age ( increase) 1.22 ( ) 5.04 = LVEF ( increase ) 0.80 ( ) = CAD Duke Index Score 1.12 ( ) 9.86 = s- K ( ) 4.14 = Tot cholesterol (Ln increase) 0.39 ( ) 5.92 = Galectin- 3 (Ln increase) 1.15 ( ) = Model 2 Age ( increase) 1.26 ( ) 6.99 = LVEF ( increase ) 0.76 ( ) < CAD Duke Index Score 1.09 ( ) 6.70 = s- K ( ) 3.84 = Tot cholesterol (Ln increase) 0.37 ( ) 6.95 = Galectin- 3 (Ln increase) 1.16 ( ) = Supplemental Table VI. Predictors of CV events at Cox regression analysis. Model 1, adjusted for age; gender; left ventricular ejection fraction; coronary atherosclerotic burden (Duke score); total, HDL and LDL (high and low density lipoprotein, respectively) cholesterol; BMI (body mass index); hypertension; diabetes; serum sodium; serum potassium; egfr (estimated glomerular filtration rate); homocysteine; history of myocardial infarction, revascularization by PTCA (Percutaneous transluminal coronary angioplasty), peripheral vascular disease; use of ACE-inhibitors, beta-blockers, diuretics, digoxin, heparin. Model 2, adjusted for aforementioned variables excluding drug therapy. CI, confidence interval; HR, hazard ratio; LVEF, left ventricular ejection fraction; s-na +, serum sodium; ACE, angiotensin converting enzyme. P for significance < 0.05; n =

15 Fatal Ischemic Events HR 95%CI Wald P Model 1 Age ( increase) 1.73 ( ) < s- Na ( ) 5.00 = Digoxin 3.55 ( ) 9.38 = ACE inhibitors 2.21 ( ) 4.38 = Heparin 0.27 ( ) 4.40 = Galectin- 3 (Ln increase) 2.28 ( ) 4.81 = Model 2 Age ( increase) 1.70 ( ) < LVEF ( increase ) 0.70 ( ) 6.88 = Galectin- 3 (Ln increase) 2.03 ( ) 3.94 = Supplemental Table VII. Predictors of fatal ischemic events at Cox regression analysis. Model 1, adjusted for age; gender; left ventricular ejection fraction; coronary atherosclerotic burden (Duke score); HDL and LDL (high and low density lipoprotein cholesterol, respectively); BMI (body mass index); hypertension; diabetes; serum sodium; serum potassium; egfr (estimated glomerular filtration rate); homocysteine; history of myocardial infarction, revascularization by PTCA (Percutaneous transluminal coronary angioplasty), peripheral vascular disease; use of ACE-inhibitors, beta-blockers, diuretics, digoxin, heparin. Model 2, adjusted for aforementioned variables excluding drug therapy. CI, confidence interval; HR, hazard ratio; LVEF, left ventricular ejection fraction; s-na +, serum sodium; ACE, angiotensin converting enzyme. P for significance < 0.05; n =

16 Cardiovascular Mortality - CAD pts HR 95%CI Wald P = Model 1 Age ( increase ) 1.44 ( ) 7.79 = LVEF ( increase ) 0.68 ( ) = CAD Duke Index Score 1.25 ( ) 5.71 = History of PTCA 2.43 ( ) 4.28 = Digoxin therapy 2.49 ( ) 6.06 = Galectin- 3 (Ln increase) 1.87 ( ) 4.42 = Model 2 Age ( increase) 1.55 ( ) < LVEF ( increase ) 0.59 ( ) < Diabetes 1.72 ( ) 3.98 = Galectin- 3 (1 Ln increase) 1.82 ( ) 4.33 = Supplemental Table VIII. Predictors of cardiovascular mortality at Cox regression analysis in CAD patients. Model 1, adjusted for age; gender; left ventricular ejection fraction; coronary atherosclerotic burden (Duke score); HDL and LDL (high and low density lipoprotein cholesterol, respectively); BMI (body mass index); hypertension; diabetes; serum sodium; serum potassium; egfr (estimated glomerular filtration rate); homocysteine; history of myocardial infarction, revascularization by PTCA, peripheral vascular disease; use of ACE-inhibitors, beta-blockers, diuretics, digoxin, heparin. Model 2, adjusted for aforementioned variables excluding drug therapy. CI, confidence interval; HR, hazard ratio; CAD, coronary artery cardiovascular disease; LVEF, left ventricular ejection fraction, PTCA, percutaneous transluminal coronary angioplasty. P for significance < 0.05; n =

17 Fatal Ischemic Events - CAD pts with LVEF > 50% HR 95%CI Wald P Model 1 History of PTCA 7.94 ( ) = Digoxin ( ) = ACE inhibitors 3.88 ( ) 5.70 = Galectin- 3 (Ln increase) 5.44 ( ) 9.53 = Model 2 History of PTCA 5.99 ( ) = Galectin- 3 (Ln increase) 5.65 ( ) = Supplemental Table IX. Predictors of fatal ischemic events at Cox regression analysis in CAD patients with preserved ejection fraction. Model 1 adjusted for age; gender; left ventricular ejection fraction; coronary atherosclerotic burden (Duke score); HDL and LDL (high and low density lipoprotein cholesterol, respectively); BMI (body mass index); hypertension; diabetes; serum sodium; serum potassium; egfr(estimated glomerular filtration rate); homocysteine; history of myocardial infarction, revascularization by PTCA (Percutaneous transluminal coronary angioplasty), peripheral vascular disease; use of ACE-inhibitor/ angiotensin-ii type-1 receptor blockers, beta-blockers, diuretics, digoxin, heparin. Model 2, adjusted for aforementioned variables excluding drug therapy. CI, confidence interval; HR, hazard ratio. PTCA, percutaneous transluminal coronary angioplasty. P for significance < 0.05; n =

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