5-year Risk Of Death Research Articles

Association and Prognostic Implication of C-Reactive Protein with Risk of 1-Year Death or Disabling Stroke After Transcatheter Aortic Valve Replacement

ABSTRACT Background : Recent data suggest that serum biomarkers may predict worse outcomes in patients undergoing transcatheter aortic valve replacement (TAVR). We examined the association and predictive value of preprocedural levels of C-reactive protein (CRP) with clinical outcomes after TAVR. Methods : We evaluated 243 patients who had undergone successful TAVR and had a valid measurement of baseline CRP level between March 2010 and February 2017. The primary endpoint was the composite of death from any cause or disabling stroke at 12 months. Results : During follow-up (median, 13.7 months), primary outcome events occurred in 18 patients (8.2%), including 14 deaths (6.7%) and 5 disabling strokes (2.1%). Patients with high serum levels of CRP (≥3.0 mg/L) had a significantly higher 1-year rate of death or disabling stroke compared to those with normal CRP levels (16.7% vs. 5.5%, P = 0.009). In the multivariate Cox-proportional hazard model, an elevated level of CRP was identified as an independent predictor of 1-year death or disabling stroke (hazard ratio, 2.84; 95% confidence interval, 1.10–7.34; P = 0.03). After the addition of information about CRP concentration to the Society of Thoracic Surgeons (STS) score model, the C-index for the prediction of death or disabling stroke substantially increased from 0.655 to 0.710, and a continuous net reclassification improvement of 0.529 (0.054–1.004) was noted. And there was no significant relationship between the primary outcome and other biomarkers, included B-type natriuretic peptide (BNP) and troponin I, in our study. Conclusions : In patients undergoing TAVR, elevated CRP levels were significantly associated with an increased risk of death or disabling stroke and also augmented event prediction, suggesting that CRP could be used as biomarker into a risk prediction model for TAVR.

Influenza vaccination and 1-year risk of myocardial infarction, stroke, heart failure, pneumonia, and mortality among intensive care unit survivors aged 65years or older: a nationwide population-based cohort study.

We examined whether influenza vaccination affects 1-year risk of myocardial infarction, stroke, heart failure, pneumonia, and death among intensive care unit (ICU) survivors aged ≥ 65years. Danish Intensive Care Database data on all elderly ( ≥ 65 years) patients hospitalized in Danish ICUs in the period 2005-2015, and subsequently discharged, were linked with data from other medical registries, including data on uptake of the seasonal influenza vaccine. We computed these patients' 1-year risk of hospitalization for myocardial infarction, stroke, heart failure, or pneumonia, and their 1-year risk of all-cause mortality. Hazard ratios (HRs) with 95% confidence intervals (CIs) were computed using Cox proportional hazards regression, with adjustment and propensity score matching applied to handle confounding. The study included 89,818 ICU survivors. The influenza vaccinated patients (n = 34,871, 39%) were older, had more chronic diseases, and used more prescription medications than the unvaccinated patients. Adjusted 1-year mortality was decreased among the vaccinated versus the unvaccinated patients (19.3% versus 18.8%; adjusted HR, 0.92; 95% CI 0.89-0.95). Influenza vaccination was also associated with a decreased risk of stroke (adjusted HR, 0.84; 95% CI 0.78-0.92), but only a small, non-significantly decreased risk of myocardial infarction (adjusted HR, 0.93; 95% CI 0.83-1.03). There was no association between vaccination and subsequent hospitalization for heart failure or pneumonia. Propensity score matched analyses confirmed these findings. Compared with the unvaccinated ICU survivors, the influenza vaccinated ICU survivors had a lower 1-year risk of stroke and a lower 1-year risk of death, whereas no substantial association was observed for the risk of hospitalization for myocardial infarction, heart failure, or pneumonia. Our findings support influenza vaccination of individuals aged ≥ 65years.

Atrial Fibrillation Known Before or Detected After Stroke Share Similar Risk of Ischemic Stroke Recurrence and Death.

Background and Purpose- We aim to compare the risk of 1-year ischemic stroke recurrence and death for atrial fibrillation diagnosed after stroke (AFDAS), atrial fibrillation known before stroke (KAF), and sinus rhythm (SR). Methods- From June 2012 to January 2013, 19 604 patients with acute ischemic stroke were admitted to 219 urban hospitals in the China National Stroke Registry II. Based on heart rhythm assessed during admission, we classified patients as AFDAS, KAF, or SR. We explored the relationship between heart rhythm groups and 1-year ischemic stroke recurrence or death by using Cox regression adjusted for multiple covariates. Considering that death is a competing risk for stroke recurrence, we used the competing risks analysis of Fine and Gray and subdistribution Cox proportional hazards to test the association between heart rhythm and 1-year outcomes. Results- Among 19 604 ischemic stroke patients, 17 727 had SR, 495 AFDAS, and 1382 KAF. At 1 year, 54 (10.9%) patients with AFDAS, 182 (13.2%) with KAF, and 1008 (5.7%) with SR had recurrent ischemic strokes ( P<0.0001). Mortality was 22.0% in patients with AFDAS, 22.1% in patients with KAF, and 7.0% in patients with SR ( P<0.0001). AFDAS-related ischemic stroke recurrence adjusted risk was higher than that of SR (adjusted subdistribution hazard ratios, 1.61; 95% CI, 1.29-2.01) but not different from that of KAF (adjusted subdistribution hazard ratio, 1.12; 95% CI, 0.87-1.45]). The adjusted risk of 1-year death for AFDAS was also higher than that of SR (hazard ratio, 1.70; 95% CI, 1.37-2.12) and not different from that of KAF (hazard ratio, 1.10; 95% CI, 0.86-1.41). Conclusions- This study showed that AFDAS had similar risk of 1-year ischemic stroke recurrence and mortality when compared with KAF and higher risk when compared with SR. The potential risk of AFDAS should be given more emphasis, and appropriate treatment is needed to achieve reduction in the incidence of stroke recurrence and mortality.

Abstract 125: Atrial Fibrillation Known Before Stroke or Detected After Stroke Shares Similar Risk of Ischemic Stroke Recurrence and Death

Objective: To compare the risk of 1-year ischemic stroke recurrence and death between atrial fibrillation (AF) diagnosed after stroke (AFDAS), AF known before stroke (KAF) and sinus rhythm (SR). Methods: From June 2012 to January 2013, 19 604 patients with acute ischemic stroke were admitted to 219 urban hospitals voluntarily participating in the China National Stroke Registry II. Based on heart rhythm assessed during admission, we classified patients as AFDAS, KAF, or SR. We explored the relationship between heart rhythm groups and 1-year ischemic stroke recurrence and death by using Cox regression adjusted for multiple covariates. Considering death is the competing risk of stroke recurrence, we used the competing-risks analysis of Fine and Gray to assess the association between heart rhythm and stroke recurrence. Results: Among 19604 ischemic stroke patients, 17727 had SR, 495 AFDAS, and 1382 KAF. At 1 year, 54 (10.9%) patients with AFDAS, 182 (13.2%) with KAF, and 1008 (5.7%) with SR had recurrent ischemic strokes (p&lt; 0.0001). The mortality was 22.0% in patients with AFDAS , 22.1% in patients with KAF, and 7.0% in patients with SR (p&lt; 0.0001). AFDAS-related ischemic stroke recurrence adjusted risk was higher than that of SR (hazard ratio 1.48 [95% confidence interval 1.19, 1.85]; p = 0.0005) but not different from that of KAF (hazard ratio 1.09 [95% confidence interval 0.85, 1.40]; p = 0.51). The adjusted risk of 1-year death for AFDAS was also higher than that of SR (hazard ratio 1.60 [95% confidence interval 1.29, 2.00]; p &lt;0.0001) and not different from that of KAF (hazard ratio 1.09 [95% confidence interval 0.85, 1.40]; p = 0.49). Conclusions: The higher 1-year ischemic stroke recurrence and mortality between AFDAS and SR together with the lack of difference between AFDAS and KAF suggest the similar potential risk of AFDAS.

Intrahepatic Mass-forming Cholangiocarcinoma: Arterial Enhancement Patterns at MRI and Prognosis.

Purpose To identify whether arterial enhancement pattern at MRI could predict the prognosis after surgical resection of intrahepatic mass-forming cholangiocarcinoma (IMCC). Materials and Methods Patients who underwent curative hepatic resection and preoperative MRI for IMCC from November 2007 to September 2016 were retrospectively evaluated. MRI enhancement pattern was classified by two radiologists. Recurrence and death data were retrieved until September 31, 2017. Prognostic factor analysis was performed by using preoperative and postoperative clinical-pathologic factors, as well as imaging findings. Results Data in 134 patients (median age, 63.0 years; 87 men and 47 women) were evaluated; median tumor size was 4.5 cm. Arterial phase MRI showed diffuse hypoenhancement in 33 patients, peripheral rim enhancement in 81 patients, and diffuse hyperenhancement in 20 patients. The 5-year risk of death in patients with IMCC with diffuse hyperenhancement was lower than that of patients with diffuse hypoenhancement or peripheral rim enhancement (5-year risk of death: 5.9% vs 87.9% vs 59.2%). Diffuse hypoenhancement (hazard ratio [HR], 41; 95% confidence interval [CI]: 5, 312; P < .01) and peripheral rim enhancement (HR, 11; 95% CI: 2, 85; P = .02) were associated with an increased risk of death compared with diffuse hyperenhancement. Patients with diffuse hyperenhancement of IMCCs had more frequent chronic liver disease (13 of 20; 65%), less frequent vascular invasion (six of 20; 30%), and less frequent tumor necrosis (three of 20; 15%) than other enhancement group (P < .05 for all). Conclusion The MRI arterial enhancement pattern was a prognostic marker in the preoperative evaluation of patients with resectable intrahepatic mass-forming cholangiocarcinoma. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Yoon and Lee .

Impact of PCSK9 loss-of-function genotype on 1-year mortality and recurrent infection in sepsis survivors.

BackgroundReduced activity of proprotein convertase subtilisin/kexin type 9 (PCSK9) has been associated with decreased short-term death in patients with septic shock. Whether PCSK9 genotype influences long-term outcomes in sepsis survivors is unknown.MethodsWe evaluated the impact of PCSK9 loss-of-function (LOF) genotype on both 1-year mortality and infection-related readmission (IRR) after an index sepsis admission. The Derivation cohort included 342 patients who survived 28 days after a sepsis admission in a tertiary hospital (Vancouver/Canada, 2004–2014), while an independent Validation cohort included 1079 septic shock patients admitted at the same hospital (2000–2006). All patients were genotyped for three common missense PCSK9 LOF variants rs11591147, rs11583680, rs562556 and were classified in 3 groups: Wildtype, single PCSK9 LOF, and multiple PCSK9 LOF, according to the number of LOF alleles per patient. We also performed a meta-analysis using both cohorts to investigate the effects of PCSK9 genotype on 90-day survival.FindingsIn the Derivation cohort, patients carrying multiple PCSK9 LOF alleles showed lower risk for the composite outcome 1-year death or IRR (HR: 0.40, P = 0.006), accelerated reduction on neutrophil counts (P = 0.010), and decreased levels of PCSK9 (P = 0.037) compared with WT/single LOF groups. Our meta-analysis revealed that the presence of multiple LOF alleles was associated with lower 90-day mortality risk (OR = 0.69, P = 0.020).InterpretationThe presence of multiple PCSK9 LOF alleles decreased the risk of 1-year death or IRR in sepsis survivors. Biological measures suggest this may be related to an enhanced resolution of the initial infection.FundingCanadian Institutes of Health Research (PJT-156056).

Depressive Symptoms at HIV Testing and Two-Year All-Cause Mortality Among Men Who Inject Drugs in Vietnam.

People who inject drugs (PWID) with HIV experience an elevated risk of death. A potentially important determinant of survival is the high burden of depression. This study examined the relationship of depressive symptoms at HIV testing with 2-year all-cause mortality among newly diagnosed HIV-positive PWID in Vietnam. At HIV testing, 141 PWID (42%) experienced severe depressive symptoms, and over the 2years following diagnosis, 82 PWID (24%) died. Controlling for potential confounders, the 2-year risk of death among those with depressive symptoms was 9.7% (95% CI - 1.2, 20.6%) higher than the risk among those without depressive symptoms. This increased risk of mortality for PWID with depressive symptoms was relatively consistent throughout the 2-year period: at 6, 12, and 18months, the risk difference was 12.6% (5.5-19.7%), 13.9% (4.6-23.2%), and 11.0% (0.9-21.1%), respectively. HIV diagnosis may provide an important opportunity for depression screening and treatment, subsequently improving survival in this key population.Trial registry: ClinicalTrials.gov NCT01689545.

Validation of a Claims-Based Frailty Index Against Physical Performance and Adverse Health Outcomes in the Health and Retirement Study.

A claims-based frailty index (CFI) was developed based on a deficit-accumulation approach using self-reported health information. This study aimed to independently validate the CFI against physical performance and adverse health outcomes. This retrospective cohort study included 3,642 community-dwelling older adults who had at least 1 health care encounter in the year prior to assessments of physical performance in the 2008 Health and Retirement Study wave. A CFI was estimated from Medicare claims data in the past year. Gait speed, grip strength, and the 2-year risk of death, institutionalization, disability, hospitalization, and prolonged (>30 days) skilled nursing facility (SNF) stay were evaluated for CFI categories (robust: <0.15, prefrail: 0.15-0.24, mildly frail: 0.25-0.34, moderate-to-severely frail: ≥0.35). The prevalence of robust, prefrail, mildly frail, and moderate-to-severely frail state was 52.7%, 38.0%, 7.1%, and 2.2%, respectively. Individuals with higher CFI had lower mean gait speed (moderate-to-severely frail vs robust: 0.39 vs 0.78 m/s) and weaker grip strength (19.8 vs 28.5 kg). Higher CFI was associated with death (moderate-to-severely frail vs robust: 46% vs 7%), institutionalization (21% vs 5%), activity of daily living disability (33% vs 9%), instrumental activity of daily living disability (100% vs 22%), hospitalization (79% vs 23%), and prolonged SNF stay (17% vs 2%). The odds ratios per 1-SD (=0.07) difference in CFI were 1.46-2.06 for these outcomes, which remained statistically significant after adjustment for age, sex, and a comorbidity index. The CFI is useful to identify individuals with poor physical function and at greater risks of adverse health outcomes in Medicare data.

Dyskalemias and adverse events associated with discharge potassium in acute myocardial infarction

BackgroundThe incidence of dyskalemias and associated outcomes in acute myocardial infarction (AMI) are unknown in real-world settings and likely differ from the controlled environment of randomized controlled trials. MethodsWe examined consecutive survivors of an AMI during 2006-2011 in SWEDEHEART registry and with plasma potassium at discharge (exposure). Study outcomes were 1-year risk of hyperkalemia (potassium >5.0 mmol/L), hypokalemia (potassium <3.5 mmol/L), and others (1-year risk of death, new myocardial infarction, heart failure, and de novo atrial fibrillation). Covariates included demographics, comorbidities, hospital procedures, and medications. ResultsWe included 4,861 patients (65% male, age 71.4 ± 12.6 years) with mean discharge potassium of 4.0 ± 0.4 mmol/L. Within 1 year, 784 (16.1%) new hyperkalemic and 991 (20.4%) new hypokalemic events occurred. Discharge potassium and kidney dysfunction were independent predictors of their occurrence. Compared with discharge potassium of 4.0 to <4.5 mmol/L, the adjusted risk of incident hyperkalemia was 1.71 (95% confidence interval 1.41-2.06) for potassium of 4.5-5.0 mmol/L and 2.38 (1.69-3.35) for potassium of >5.0 mmol/L; the adjusted risk of incident hypokalemia was 1.43 for potassium of 3.5 to <4.0 mmol/L (1.23-1.66) and 3.12 (2.58-3.77) for potassium of <3.5 mmol/L. A U-shaped association was observed between discharge potassium and the risk of death (n = 718), with increased hazards for potassium <3.5 and >4.5 mmol/L. No association was found between discharge potassium and the risk of new myocardial infarction, heart failure, or de novo atrial fibrillation. ConclusionsAmong real-world AMI survivors, both hyperkalemia and hypokalemia are frequent. Discharge potassium and kidney function strongly predicted their occurrence, as well as the 1-year risk of death.

Melanoma of the Face and Mohs Micrographic Surgery: Nationwide Mortality Data Analysis.

Although Mohs micrographic surgery (MMS), narrow margin excision (NME), and wide margin excision (WME) are commonly used to treat melanoma of the face, there is a paucity of data comparing mortality outcomes for each method. To determine the association between surgical method used to treat cutaneous melanoma of the face and patient survival. A retrospective review of Surveillance, Epidemiology, and End Results registries for patients diagnosed with melanoma of the face between 2003 and 2012 was conducted. The authors query resulted in 43,443 records. Patients with melanoma were more likely to undergo NME (57.79%) than WME (27.86%) or MMS (14.36%). Overall 5-year risk of death was higher with WME (hazard ratio [HR], 1.11; 95% confidence interval [CI], 1.00-1.23; p = .043) and NME (HR, 1.10; 95% CI, 1.00-1.20; p = .046) relative to MMS after adjusting for patient demographics, residence socioeconomic factors, and tumor characteristics. No statistically significant difference in melanoma-specific mortality was found between different surgical methods on multivariate analysis. Patients with melanoma of the face treated with MMS had similar melanoma-specific mortality or overall survival outcome as patients treated by other surgical modalities.

TCTAP A-160 Association and Prognostic Implication of C-Reactive Protein with Risk of 1-Year Death or Disabling Stroke After Transcatheter Aortic Valve Replacement

TCTAP A-160 Association and Prognostic Implication of C-Reactive Protein with Risk of 1-Year Death or Disabling Stroke After Transcatheter Aortic Valve Replacement

Abstract 209: Education Level and Long-Term Outcomes After Acute Myocardial Infarction: The China PEACE Prospective AMI Study

Background: China has a growing burden of acute myocardial infarction (AMI) and wide variation in educational attainment. Less education is associated with worse cardiovascular outcomes in Western populations; whether this relationship exists in China is unclear. We assessed the association between educational attainment and AMI outcomes in China to inform future healthcare interventions. Methods: We used data from the prospective China PEACE-Prospective AMI study of 3369 consecutive patients hospitalized with AMI from 53 hospitals across all 21 provinces between 2012 and 2015. We collected detailed information from abstraction of hospital records, supplemented with patient interviews. Educational attainment was categorized into: high (high school, college or postgraduate degree), intermediate (junior high school), or low (primary school or illiterate). We used survival models to assess the relationship between education and 1-year all-cause mortality and major adverse cardiovascular events (MACE: all-cause death, nonfatal myocardial infarction, nonfatal stroke, heart failure), both unadjusted and after adjustment for demographic characteristics and cardiovascular risk factors. Results: The mean participant age was 60.7±11.9 years, 23.2% (781 of 3369) were women, and 33.3% (1123 of 3369) had high, 32.4% (1092 of 3369) intermediate, and 34.3% (1154 of 3369) low educational attainment. In unadjusted analysis, compared with high educational attainment, low educational attainment was associated with a higher 1-year risk of death (HR for low vs high education 3.09, 95% CI 1.69-5.65) and MACE (HR 2.41, 95% CI 1.72-3.37)(Figure). In risk-adjusted analyses, the association between education and mortality was attenuated and no longer statistically significant (adjusted HR 1.68, 95%CI 0.89-3.19, P = .11). However, the risk of MACE at one year remained significantly greater (adjusted HR 1.81, 95%CI 1.27-2.58, P = .001). Conclusions: In a national Chinese cohort of patients hospitalized with AMI, lower educational attainment was associated with a higher risk of adverse events in the year following discharge. This association highlights the need to explore mechanisms underlying this relationship, and to consider interventions for adults with lower levels of education.

Valor de la puntuación SYNTAX II para la predicción de eventos clínicos en pacientes sometidos a implante percutáneo de válvula aórtica

Introduction and objectivesThe predictive value of the SYNTAX score (SS) for clinical outcomes after transcatheter aortic valve implantation (TAVI) is very limited and could potentially be improved by the combination of anatomic and clinical variables, the SS-II. We aimed to evaluate the value of the SS-II in predicting outcomes in patients undergoing TAVI. MethodsA total of 402 patients with severe symptomatic aortic stenosis undergoing transfemoral TAVI were included. Preprocedural TAVI angiograms were reviewed and the SS-I and SS-II were calculated using the SS algorithms. Patients were stratified in 3 groups according to SS-II tertiles. The coprimary endpoints were all-cause death and major adverse cardiovascular events (MACE), a composite of all-cause death, cerebrovascular event, or myocardial infarction at 1 year. ResultsIncreased SS-II was associated with higher 30-day mortality (P=.036) and major bleeding (P=.015). The 1-year risk of death and MACE was higher among patients in the 3rd SS-II tertile (HR, 2.60; P=.002 and HR, 2.66; P<.001) and was similar among patients in the 2nd tertile (HR, 1.27; P=.507 and HR, 1.05; P=.895) compared with patients in the 1st tertile. The highest SS-II tertile was an independent predictor of long-term mortality (P=.046) and MACE (P=.001). ConclusionsThe SS-II seems more suited to predict clinical outcomes in patients undergoing TAVI than the SS-I. Increased SS-II was associated with poorer clinical outcomes at 1 and 4 years post-TAVI, independently of the presence of coronary artery disease.Full English text available from: www.revespcardiol.org/en

Characteristics of the ischemic stroke patients whose seizures occur at stroke presentation at a single institution in Eastern China

PurposeWe compared clinical characteristics and outcomes of the early-onset seizure post-stroke patients who had seizures occurring at stroke presentation (SSP) with other patients without SSP at a single institution in Eastern China. MethodsWe reviewed 20,947 ischemic stroke patients in our hospital electronic medical records system from January 2007 to December 2016. Among them, there were 91 (0.43%) patients with early-onset seizure post-stroke. Among these 91 patients, there were 35 (0.16%) SSP patients and another 56 (0.27%) were designated as non SSP patients because they also had early-onset seizure post-stroke, but without SSP. We compared the clinical presentations of the SSP patients with those of the non SSP patients including baseline stroke risk factors, and 10-year Kaplan-Meier death risk after their first stroke. ResultsIn the SSP patients, 25.7% of them presented with posterior circulation infarction, whereas only 12.5% of the non SSP patients had this condition (P<0.05). In contrast, 17.1% of the SSP patients were being treated with antiepileptic drugs at discharge whereas 37.5% of the non SSP patients received such treatment (P<0.05). The percentage of SSP patients with temporal lobe lesions was less than in non SSP patients (P<0.05). However, brain stem and thalamus lesions were more frequently seen in SSP patients than non in SSP patients (P<0.05). The risk factors for ischemic stroke including a history of hypertension, diabetes mellitus, hyperlipidemia and atrial fibrillation were the same in these two groups (P>0.05). In the SSP patients group, the 10-year risk of death was 36.9% after the initial seizure incident, and in the non SSP patients group, the 10-year death risk was 40.1%, but this difference between the two groups was not significant (P>0.05). ConclusionsIschemic stroke patients with SSP had some unique signs that included a higher incidence of posterior circulation infarction than non SSP patients.

Development and Validation of Machine Learning Models for Prediction of 1-Year Mortality Utilizing Electronic Medical Record Data Available at the End of Hospitalization in Multicondition Patients: a Proof-of-Concept Study.

Predicting death in a cohort of clinically diverse, multicondition hospitalized patients is difficult. Prognostic models that use electronic medical record (EMR) data to determine 1-year death risk can improve end-of-life planning and risk adjustment for research. Determine if the final set of demographic, vital sign, and laboratory data from a hospitalization can be used to accurately quantify 1-year mortality risk. A retrospective study using electronic medical record data linked with the state death registry. A total of 59,848 hospitalized patients within a six-hospital network over a 4-year period. The last set of vital signs, complete blood count, basic and complete metabolic panel, demographic information, and ICD codes. The outcome of interest was death within 1 year. Model performance was measured on the validation data set. Random forests (RF) outperformed logisitic regression (LR) models in discriminative ability. An RF model that used the final set of demographic, vitals, and laboratory data from the final 48h of hospitalization had an AUC of 0.86 (0.85-0.87) for predicting death within a year. Age, blood urea nitrogen, platelet count, hemoglobin, and creatinine were the most important variables in the RF model. Models that used comorbidity variables alone had the lowest AUC. In groups of patients with a high probability of death, RF models underestimated the probability by less than 10%. The last set of EMR data from a hospitalization can be used to accurately estimate the risk of 1-year mortality within a cohort of multicondition hospitalized patients.

Age affects the prognostic impact of diabetes in chronic heart failure.

Increasing age is an established prognostic determinant in chronic heart failure (HF). Diabetes often complicates HF in its course and appears to worsen HF prognosis. A differential impact of diabetes depending on patients' age was not yet studied. We evaluated the impact of diabetes in the mortality of HF patients according to their age. We studied a cohort of chronic ambulatory HF patients prospectively recruited. Patients were on optimized evidence-based therapy, and they were excluded if on renal replacement therapy or if they had any therapy modification or hospitalizations in the previous 2months. Patients were followed for up to 5years; all-cause mortality was analyzed. Mortality predictors were assessed using a Cox regression. Analysis was stratified according to patient's age: cutoff 75years. Multivariate models were built. Interaction between diabetes and age was formally tested. We studied 283 chronic HF patients; mean age was 69years and 70.3% were male; 58.0% had severe systolic dysfunction; 105 (37.1%) were diabetic. In patients with less than 75years, the coexistence of diabetes predicted a multivariate adjusted 1.98 (95% CI 1.13-3.46) 5-year death risk while in older patients (≥75years) no significant association was reported. Age interacted with the prognostic impact of diabetes, p for interaction=0.04. The prognostic impact of diabetes in chronic HF depends on patient's age. In patients<75years, the coexistence of diabetes predicts an almost double risk of 5-year mortality; no such association exists in patients with 75years or above. Diabetes predicts mortality only in younger HF patients.

Mortality after deferral of treatment or no treatment for choroidal melanoma.

Purpose:To report mortality of patients who were eligible for enrollment in the Collaborative Ocular Melanoma Study (COMS) clinical trials of medium-sized choroidal melanoma or large-sized choroidal melanoma but chose to defer treatment or receive no melanoma treatment.Design:Prospective nonrandomized multicenter cohort study as an adjunct to COMS randomized clinical trials.Methods:Patient follow-up procedures included examinations, correspondence, telephone contacts, and National Death Index searches. Primary outcome was patient death measured by all-cause mortality. Secondary outcomes were melanoma treatment and melanoma metastasis.Results:Of 77 patients eligible for COMS clinical trials who chose to defer or receive no melanoma treatment, 61 were appropriate candidates and 45 (74%) enrolled in the natural history study (NHS). In all, 42 patients (42 eyes) had medium melanoma, and the median follow-up was 5.3 years (range, 4–10.7 years). In all, 22 patients (52%) had subsequent melanoma treatment, and 20 (48%) had no melanoma treatment. For the 42 patients, Kaplan–Meier estimate of 5-year mortality was approximately 30% [95% confidence interval (CI), 18%–47%]. For COMS medium melanoma trial, 5-year mortality was 18% (95% CI, 16%–20%), not statistically significantly different from the NHS patients. After adjusting for differences in age and longest basal diameter, the 5-year risk of death for NHS patients versus COMS trial patients was 1.54 (95% CI, 0.93–2.56). Three patients had large melanoma. Melanoma metastasis was confirmed or suspected in 8 (42%) of 19 deaths.Conclusion:Greater mortality and higher risk of death for NHS patients are probative but not conclusive evidence of a beneficial, life-extending effect of medium melanoma treatment.

The Value of the SYNTAX Score II in Predicting Clinical Outcomes in Patients Undergoing Transcatheter Aortic Valve Implantation

Introduction and objectivesThe predictive value of the SYNTAX score (SS) for clinical outcomes after transcatheter aortic valve implantation (TAVI) is very limited and could potentially be improved by the combination of anatomic and clinical variables, the SS-II. We aimed to evaluate the value of the SS-II in predicting outcomes in patients undergoing TAVI. MethodsA total of 402 patients with severe symptomatic aortic stenosis undergoing transfemoral TAVI were included. Preprocedural TAVI angiograms were reviewed and the SS-I and SS-II were calculated using the SS algorithms. Patients were stratified in 3 groups according to SS-II tertiles. The coprimary endpoints were all-cause death and major adverse cardiovascular events (MACE), a composite of all-cause death, cerebrovascular event, or myocardial infarction at 1 year. ResultsIncreased SS-II was associated with higher 30-day mortality (P=.036) and major bleeding (P=.015). The 1-year risk of death and MACE was higher among patients in the 3rd SS-II tertile (HR, 2.60; P=.002 and HR, 2.66; P<.001) and was similar among patients in the 2nd tertile (HR, 1.27; P=.507 and HR, 1.05; P=.895) compared with patients in the 1st tertile. The highest SS-II tertile was an independent predictor of long-term mortality (P=.046) and MACE (P=.001). ConclusionsThe SS-II seems more suited to predict clinical outcomes in patients undergoing TAVI than the SS-I. Increased SS-II was associated with poorer clinical outcomes at 1 and 4 years post-TAVI, independently of the presence of coronary artery disease.

Web-Based Tool to Facilitate Shared Decision Making With Regard to Neoadjuvant Chemotherapy Use in Muscle-Invasive Bladder Cancer.

Level 1 evidence supports the use of neoadjuvant chemotherapy (NAC) for the treatment of muscle-invasive bladder cancer (MIBC), but observational data demonstrate that this approach is underused. A barrier to shared decision making is difficulty in predicting and communicating survival estimates after cystectomy with or without NAC. We included patients with MIBC from the National Cancer Database treated with cystectomy. A state-transition model was constructed for calculating 5-year death risk using baseline patient-, tumor-, and facility-level variables. Internal-external cross-validation by geographic region was performed. The effect of NAC was integrated using a literature-derived hazard ratio. Bladder cancer-specific and other-cause mortality was estimated from all-cause mortality rates from US life tables. From the state-transition model, a Web-based tool was developed and pilot usability testing performed. A total of 9,824 patients with MIBC who underwent cystectomy were eligible for inclusion. Median overall survival was 39.6 months (95% CI, 37.4 to 42.4 months). Increasing age, higher clinical T stage, higher comorbidity index, and black race were associated with shorter survival. Private insurance, higher income, and cystectomy at a high-volume facility were associated with longer survival. The prediction model was well calibrated across geographic regions, with observed-to-predicted 5-year death risks ranging from 0.85 to 1.17. Absolute risk reductions with NAC varied from 8.6% to 10.1%. The Web-based tool allowed input of the predictor variables and a user-defined hazard ratio associated with the effect of NAC to generate individualized survival estimates. The tool demonstrated good usability with clinicians. A Web-based tool was developed to individualize outcome prediction and communication in patients with MIBC treated with cystectomy with or without NAC to facilitate shared decision making.

Predictors of all-cause mortality among 514,866 participants from the Korean National Health Screening Cohort.

BackgroundThere is not enough evidence regarding how information obtained from general health check-ups can predict individual mortality based on long-term follow-ups and large sample sizes. This study evaluated the applicability of various health information and measurements, consisting of self-reported data, anthropometric measurements and laboratory test results, in predicting individual mortality.MethodsThe National Health Screening Cohort included 514,866 participants (aged 40–79 years) who were randomly selected from the overall database of the national health screening program in 2002–2003. Death was determined from causes of death statistics provided by Statistics Korea. We assessed variables that were collected at baseline and repeatedly measured for two consecutive years using traditional and time-variant Cox proportional hazards models in addition to random forest and boosting algorithms to identify predictors of 10-year all-cause mortality. Participants’ age at enrollment, lifestyle factors, anthropometric measurements and laboratory test results were included in the prediction models. We used c-statistics to assess the discriminatory ability of the models, their external validity and the ratio of expected to observed numbers to evaluate model calibration. Eligibility of Medicaid and household income levels were used as inequality indexes.ResultsAfter the follow-up by 2013, 38,031 deaths were identified. The risk score based on the selected health information and measurements achieved a higher discriminatory ability for mortality prediction (c-statistics = 0.832, 0.841, 0.893, and 0.712 for Cox model, time-variant Cox model, random forest and boosting, respectively) than that of the previous studies. The results were externally validated using the community-based cohort data (c-statistics = 0.814).ConclusionsIndividuals’ health information and measurements based on health screening can provide early indicators of their 10-year death risk, which can be useful for health monitoring and related policy decisions.