Multimethod survival analysis of mortality predictors in advanced heart failure: a cohort study from Pakistan

Cardiac Biomarkers, Mortality, and Post-Traumatic Stress Disorder in Military Veterans

Immunological processes are implicated in the multifactorial pathophysiology of heart failure (HF). The multifunctional chemokine fractalkine (CX3CL1) promotes the extravasation of cytotoxic lymphocytes into tissues. We aimed to assess the prognostic value of fractalkine in HF. Fractalkine plasma levels were determined in 349 patients with advanced systolic HF (median 75 years, 66% male). During a median follow-up of 4.9 years (interquartile range: 4.6-5.2), 55.9% of patients died. Fractalkine was a significant predictor of all-cause mortality (p<0.001) with a hazard ratio of 2.78 (95% confidence interval: 1.95-3.95) for the third compared to the first tertile. This association remained significant after multivariable adjustment for demographics, clinical predictive variables and N-terminal pro-B-type natriuretic peptide (NT-proBNP, p=0.008). The predictive value of fractalkine did not significantly differ between patients with ischaemic and non-ischaemic HF aetiology (p=0.79). The predictive value of fractalkine tertiles was not significantly modified by tertiles of NT-proBNP (p=0.18) but was more pronounced in the first and third tertile of NT-proBNP. Fractalkine was also an independent predictor of cardiovascular mortality (p=0.015). Fractalkine levels were significantly lower in patients on angiotensin-converting enzyme inhibitor therapy (p<0.001). In conclusion, circulating fractalkine with its pro-inflammatory and immunomodulatory effects is an independent predictor of mortality in advanced HF patients. Fractalkine improves risk prediction beyond NT-proBNP and might therefore help to identify high risk patients who need special care. Our data indicate the implication of immune modulation in HF pathology.

Child, MELD, hyponatremia, and now portal pressure

Independent prognostic value of echocardiography and N-terminal pro–B-type natriuretic peptide in patients with heart failure

Predictors of two-year mortality in Asian patients with heart failure and preserved ejection fraction

High serum phosphate has been identified as an important contributor to the vascular calcification seen in patients with chronic kidney disease (Block et al., Am J Kidney Dis 1998; 31: 607). In patients on hemodialysis, elevated serum phosphate levels are an independent predictor of mortality (Block et al., Am J Kidney Dis 1998; 31: 607; Block, Curr Opin Nephrol Hypertens 2001; 10: 741). The aim of this study was to investigate whether an elevated serum phosphate level was an independent predictor of mortality in patients with a renal transplant. Three hundred seventy-nine asymptomatic renal transplant recipients were recruited between June 2000 and December 2002. Serum phosphate was measured at baseline and prospective follow-up data were collected at a median of 2441 days after enrolment. Serum phosphate was significantly higher in those renal transplant recipients who died at follow-up when compared with those who were still alive at follow-up (P<0.001). In Kaplan-Meier analysis, serum phosphate concentration was a significant predictor of mortality (P=0.0001). In multivariate Cox regression analysis, serum phosphate concentration remained a statistically significant predictor of all-cause mortality after adjustment for traditional cardiovascular risk factors, estimated glomerular filtration rate, and high sensitivity C reactive protein (P=0.036) and after adjustment for renal graft failure (P=0.001). The results of this prospective study are the first to show that a higher serum phosphate is a predictor of mortality in patients with a renal transplant and suggest that serum phosphate provides additional, independent, prognostic information to that provided by traditional risk factors in the risk assessment of patients with a renal transplant.

The Importance of Heart Rate Recovery in Patients With Heart Failure or Left Ventricular Systolic Dysfunction

Red cell distribution width (RDW) has been shown to be an independent predictor of mortality in patients with coronary artery disease and in patients with heart failure. The current study evaluated the prognostic utility of RDW in patients undergoing percutaneous coronary intervention (PCI). We evaluated 859 patients who underwent PCI during January 2003 to August 2005. After a median follow up of four (interquartile range 3.1 to 4.4) years, there were a total of 95 (11%) deaths. RDW was analysed as a categorical variable with empirically determined cut points of 13.3 and 15.7 (low RDW <13.3, medium RDW > or = 13.3 to <15.7, high RDW > or = 15.7) based on differences in hazard ratio (HR) for death among RDW deciles. In univariate analysis, higher RDW was a significant predictor of mortality (p < 0.001). In multivariate analysis there was a significant two-way interaction between RDW and haemoglobin (Hgb). RDW was not an independent predictor of mortality in patients with Hgb <10.4. However, among patients with Hgb >10.4, high RDW was a strong and independent predictor of mortality. For patients with Hgb > or = 10.4 to <12.7, HR for death in patients with high RDW relative to low RDW was 5.2 (95% confidence intervals [CI]: 2.0-13.3). For patients with Hgb > or = 12.7, HR for death in patients with high RDW relative to low RDW was 8.6 (CI:2.8-28.6). Higher RDW was a strong and independent predictor of long-term mortality in patients undergoing PCI who were not anaemic at baseline.

ABSTRACTBackground: The alveolar–arterial oxygen (A–a) gradient measures the difference between the oxygen concentration in alveoli and the arterial system, which has considerable clinical utility.Materials and methods: It was a retrospective, observational cohort study involving the analysis of patients diagnosed with acute COVID pneumonia and required noninvasive mechanical ventilation (NIV) over a period of 3 months. The primary objective was to investigate the utility of the A–a gradient (pre-NIV) as a predictor of 28-day mortality in COVID pneumonia. The secondary objective included the utility of other arterial blood gas (ABG) parameters (pre-NIV) as a predictor of 28-day mortality. The outcome was also compared between survivors and nonsurvivors. The outcome variables were analyzed by receiver-operating characteristic (ROC) curve, Youden index, and regression analysis.Results: The optimal criterion for A–a gradient to predict 28-day mortality was calculated as ≤430.43 at a Youden index of 0.5029, with the highest area under the curve (AUC) of 0.755 (p <0.0001). On regression analysis, the odds ratio for the A–a gradient was 0.99. A significant difference was observed in ABG predictors, including PaO2, PaCO2, A–a gradient, AO2, and arterial–alveolar (a–A) (%) among nonsurvivors vs survivors (p-value <0.001). The vasopressor requirement, need for renal replacement therapy, total parenteral requirement, and blood transfusion were higher among nonsurvivors; however, a significant difference was achieved with the vasopressor need (p <0.001).Conclusion: This study demonstrated that the A–a gradient is a significant predictor of mortality in patients initiated on NIV for worsening respiratory distress in COVID pneumonia. All other ABG parameters also showed a significant AUC for predicting 28-day mortality, although with variable sensitivity and specificity.Key messages: COVID-19 pneumonia shows an initial presentation with type 1 respiratory failure with increased A–a gradient, while a subsequent impending type 2 respiratory failure requires invasive ventilation.A significant difference was observed in ABG predictors, including PaO2, PaCO2, A–a gradient, AO2, and a–A (%) among nonsurvivors vs survivors. (p-value <0.001).The vasopressor requirement, need for renal replacement therapy, total parenteral requirement, and blood transfusion need were higher among nonsurvivors than survivors; however, a significant difference was achieved with the vasopressor need (p <0.001).How to cite this article: Gupta B, Jain G, Chandrakar S, Gupta N, Agarwal A. Arterial Blood Gas as a Predictor of Mortality in COVID Pneumonia Patients Initiated on Noninvasive Mechanical Ventilation: A Retrospective Analysis. Indian J Crit Care Med 2021;25(8):866–871.

BackgroundBacterial meningitis causes high mortality rates among children. Even with early diagnosis and prompt treatment, around 15% of patients die especially in the first and second days after diagnosis. The neutrophil lymphocyte ratio has been reported to be a predicting factor of severity and outcome for patients with pneumonia and sepsis. However, only a few studies are available to rate the neutrophil lymphocyte ratio as a predictor of mortality in bacterial meningitis. This study aimed to know the role of the neutrophil lymphocyte ratio as a predictor of mortality in patients with bacterial meningitis. MethodsThis retrospective study was conducted at Dr. Sardjito General Hospital, Yogyakarta, Indonesia between January 2016 to December 2020. Multivariate analysis was used to assess the correlation between predicting factors and outcomes using logistic regression analysis. ResultsA total of 94 samples were included and analyzed in this study with bacterial meningitis. Neutrophil lymphocyte ratio >5.225 was a significant predictor of mortality in patients with bacterial meningitis with p = 0.004 and risk ratio 10.78. Other factors that were significant predictors of mortality included the pediatric coma scale ≤8 and positive cerebrospinal fluid culture. ConclusionNeutrophil lymphocyte ratio is a statistically significant predictor of mortality in patients with bacterial meningitis, and can be used as a parameter to predict outcomes in patients with bacterial meningitis.

BackgroundHepatic encephalopathy (HE) is a serious neuropsychiatric complication of liver dysfunction associated with significant morbidity and mortality.ObjectiveThe objective of this study was to evaluate the predictors of in-hospital mortality in patients with HE through retrospective analysis.MethodsThis retrospective observational cohort study was conducted at Punjab Rangers Teaching Hospital, Lahore, Pakistan, from January 2023 to January 2025. A total of 201 adult patients (≥18 years) admitted with a diagnosis of hepatic encephalopathy were included in the study. The diagnosis of HE was made clinically based on the West Haven criteria and supported by biochemical and radiological assessments as needed. Patients with both acute and chronic liver disease were considered, provided they fulfilled the diagnostic criteria for HE. Data were extracted from the hospital’s electronic medical record system using a structured questionnaire. Clinical and laboratory parameters were analyzed to identify predictors of in-hospital mortality using multivariate logistic regression.ResultsThe in-hospital mortality rate was 57 (28.4%). Non-survivors had significantly higher Model for End-Stage Liver Disease (MELD) scores (mean 29.3 vs. 24.9, p < 0.001), elevated serum ammonia levels (mean 136.2 µmol/L vs. 103.1 µmol/L, p < 0.001), more frequent renal dysfunction (37 (64.9%) vs. 41 (28.9%), p < 0.001), and hyponatremia (33 (57.9%) vs. 43 (29.6%), p = 0.002). High-grade HE (Grade III/IV) was more prevalent among non-survivors (42 (73.7%) vs. 52 (36.2%), p < 0.001). Independent predictors of mortality included MELD score ≥28, serum ammonia ≥120 µmol/L, renal dysfunction, serum sodium <130 mEq/L, and high-grade HE. The MELD score demonstrated the highest discriminatory ability (area under the curve (AUC) = 0.78).ConclusionIn patients with HE, higher MELD scores, elevated serum ammonia, renal impairment, hyponatremia, and advanced HE grades are significant predictors of mortality. These findings highlight the importance of early risk assessment and may guide decisions regarding intensive management and liver transplant referral.

Predictors of 30-day mortality in patients with refractory cardiogenic shock following acute myocardial infarction despite a patent infarct artery

BackgroundDespite recent advances in the treatments of hepatocellular carcinoma (HCC), the prognosis of HCC patients remains controversial. Lowered serum albumin in hepatocellular carcinoma, an advanced stage of liver cirrhosis, indicates a worsening condition. Hepatorenal syndrome, marked by increased serum creatinine, is a key mortality indicator. The aim of this study was to determine the serum albumin-to-creatinine ratio (sACR) as a predictor of mortality in patients with HCC and liver cirrhosis. MethodsThis retrospective cohort study included 37 patients with HCC and liver cirrhosis. Patient characteristics, sACR, model of end-stage liver disease (MELD) score, and Child-Turcotte-Pugh (CTP) score were obtained from medical records. The optimal cut-off point for the sACR was determined using receiver operating characteristic (ROC) analysis to evaluate its predictive ability for 90-day mortality. Survival analysis was conducted using the Kaplan-Meier method with a log-rank test, and Cox regression was employed to obtain hazard ratios (HR) to estimate the patient’s prognosis. ResultsA low sACR cut-off of 2.32 was identified. Kaplan-Meier analysis confirmed that sACR met the proportional hazard assumption. sACR &lt;2.32 was a significant predictor of 90-day mortality (HR 6.52; 95% CI 1.80-23.63; p=0.004), comparable to MELD 40 (HR 41.3; 95% CI 1.98-862.90; p=0.016) and CTP category (HR =2.19;95%CI: 0.79-6.06;p=0.131). Conclusion The sACR is a novel predictor of 90-day mortality in HCC patients with liver cirrhosis. Lower sACR is associated with overall survival and may help to design strategies to personalize management approaches among patients with HCC and liver cirrhosis.

Assessing prognostic outcomes in cardiac sarcoidosis with advanced heart failure: How do current guidelines fare?

Background:Cardiovascular diseases are an important cause of morbidity and mortality in chronic obstructive pulmonary disease patients. The increased inflammatory biomarker levels predict exacerbations and are associated with cardiovascular diseases in stable chronic obstructive pulmonary disease patients but their role in the settings of acute chronic obstructive pulmonary disease exacerbations has not been determined.Aims:To analyse the association between inflammatory biomarkers and heart failure and also to determine the predictors of mortality in patients with exacerbations of chronic obstructive pulmonary disease.Study Design:Prospective observational study.Methods:We analysed 194 patients admitted for acute exacerbation of chronic obstructive pulmonary disease at The Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica, Serbia. In all patients, C-reactive protein, fibrinogen, N-terminal of the pro-hormone brain natriuretic peptide and white blood count were measured and transthoracic echocardiography was performed.Results:There were 119 men (61.3%) and the median age was 69 years (interquartile range 62-74). Left ventricular systolic dysfunction (ejection fraction <50%) was present in 47 (24.2%) subjects. Patients with left ventricular systolic dysfunction had higher C-reactive protein levels (median 100 vs. 31 mg/L, p=0.001) and fibrinogen (median 5 vs. 4 g/L, p=<0.001) compared to those with preserved ejection fraction. The overall hospital mortality was 8.2% (16/178). The levels of C-reactive protein, fibrinogen, N-terminal pro-brain natriuretic peptide and ejection fraction predicted hospital mortality in univariate analysis. After adjusting for age, hypoxemia and C-reactive protein, ejection fraction remained significant predictors of hospital mortality (OR 3.89, 95% CI 1.05-15.8).Conclusion:Nearly a quarter of patients with the exacerbation of chronic obstructive pulmonary disease present with left ventricular systolic dysfunction which may be associated with mortality.