1-year Cardiac Mortality Research Articles

Granulocyte colony-stimulating factor for stem cell mobilisation in acute myocardial infarction: a randomised controlled trial

BackgroundTo determine whether granulocyte colony-stimulating factor (G-CSF) improves clinical outcomes after large ST-elevation myocardial infarction (STEMI) when administered early in patients with left ventricular (LV) dysfunction after successful percutaneous coronary...

Prognostication and Interventional Guidance Using Acceleration-Ejection Time Ratio in Undifferentiated Paradoxical Low-Flow Low-Gradient Aortic Stenosis

BackgroundStudies in paradoxical low-flow low-gradient aortic stenosis (PLFAS) have demonstrated conflicting outcomes with variable survival advantage from aortic valve replacement (AVR). PLFAS is a heterogeneous composition of patients with uncertainty regarding true stenosis severity that continues to confound decision-making for AVR. ObjectivesThe purpose of this study was to investigate the utility of the Doppler acceleration (AT) to ejection (ET) time ratio (AT:ET) for prediction of prognosis and benefit from AVR in undifferentiated PLFAS. MethodsPatients with echocardiographic findings of PLFAS (aortic valve area <1.0 cm2 or indexed aortic valve area <0.6 cm2/m2, mean gradient <40 mm Hg, indexed stroke volume <35 mL/m2, and left ventricular ejection fraction ≥50%) were identified and grouped according to an AT:ET cutoff of 0.35. The primary outcome was a 5-year composite of cardiac mortality or AVR. Secondary outcomes included the individual components of the primary endpoint and all-cause mortality at 5 years. Effect of AVR was analyzed in the AT:ET <0.35 and ≥0.35 groups. ResultsA total of 171 PLFAS patients (median age 77.0 years, 57% women) were followed for a median of 8.9 years. AT:ET ≥0.35 was an independent predictor of the primary outcome (HR: 4.77 [95% CI: 2.94-7.75]; P < 0.001) with incremental value over standard indices of stenosis severity (net reclassification improvement: 0.57 [95% CI: 0.14-0.84]). AT:ET ≥0.35 also remained predictive of increased cardiac death (HR: 2.91 [95% CI: 1.47-5.76]; P = 0.002) and AVR (HR: 8.45 [95% CI: 4.16-17.1]; P < 0.001), respectively, following competing risk analysis. No difference in all-cause mortality was observed. AVR in the AT:ET ≥0.35 group was associated with significant reductions in 5-year cardiac (HR: 0.09 [95% CI: 0.02-0.36]; P < 0.001) and all-cause mortality (HR: 0.16 [95% CI: 0.07-0.38]; P < 0.001). No improvement in survival from AVR was demonstrated in AT:ET <0.35 patients. ConclusionsAT:ET ≥0.35 in PLFAS predicts poorer outcomes and/or need for AVR. In undifferentiated PLFAS patients, AT:ET may have a potential role in improving patient selection for prognostic AVR.

Long-term outcomes of IVUS-guided and angiography-guided drug-eluting stent implantation for left main coronary artery disease: a retrospective consort study

BackgroundIn patients with unprotected left main coronary artery disease (ULMCAD), this study compared the long-term prognosis of drug-eluting stent insertion guided by intravascular ultrasonography (IVUS) vs. angiography.Patients and methodsThis retrospective consort investigation was performed in December 2021. This analysis included 199 patients who underwent IVUS-guided (IVUS group, n = 81) or angiography-guided (angiography group, n = 118) drug-eluting stent implantation at the Affiliated Hospital of Inner Mongolia Medical University between September 2013 and September 2018. Major adverse cardiac events (MACE) were defined as cardiovascular death, sudden cardiac death, myocardial infarction.ResultsThe IVUS group had considerably lower proportions of MACE within 1 year postoperatively (P = 0.002) and cardiac mortality within 3 years postoperatively (P = 0.018) compared to the angiography group. However, after adjusting for confounding variables, the hazard ratio for 3-year cardiac mortality was similar between the two groups (P = 0.28). In the IVUS group, there was considerably greater minimum lumen diameter (MLD) (P = 0.046), and reduced frequencies of target vessel restenosis (P < 0.050) and myocardial infarction (MI) (P = 0.024) compared to the angiography group. Cox regression analysis for 3-year cardiac mortality found that MSD was independently associated with low cardiac mortality (HR = 0.1, 95% CI: 0.01–14.92, P = 0.030).ConclusionIVUS-guided drug-eluting stent implantation may lead to better long-term prognosis in patients with ULMCAD, and MSD may be a predictor for lower cardiac mortality.

Long-term outcome and prognostic value of angiographic slow/no-reflow phenomenon after emergency percutaneous coronary intervention for ST-elevation myocardial infarction.

The coronary slow flow/no-reflow phenomenon (CSF/NRP) is a common complication of emergency percutaneous coronary intervention (PCI) for ST-elevated myocardial infarction (STEMI). Its long-term prognostic value, however, remains unclear. This study investigated the long-term outcome and prognostic value of CSF/NRP after emergency PCI for STEMI. This retrospective, multicenter registry-based cohort study was conducted in STEMI patients who underwent emergency PCI between 2015 and 2016. Incidence of in-hospital mortality, major adverse cardiac and cerebrovascular events (MACCEs), and all-cause mortality during long-term follow-up were compared between CSF/NRP patients and the normal flow group. Cox proportional-hazards regression model was performed to identify the predictive impact of CSF/NRP in short- and long-term outcomes. A total of 649 STEMI patients were included in the study, of whom 193 (29.7%) developed CSF/NRP following emergency PCI. The CSF/NRP group had a higher incidence of in-hospital mortality than the non-CSF/NRP group (8.2 vs. 4.3%, P = 0.04). All-cause mortality incidence was also higher in the CSF/NRP group during 5-year follow-up (22.2 vs. 16.2%, P = 0.04). The Cox proportional hazards model adjusting for demographic and clinical variables identified the NRP as an independent predictor of 5-year cardiac mortality [hazard ratio: 1.89; 95% confidence interval (CI): 1.07-3.31; P = 0.02]. In a landmark analysis, no difference was seen in overall mortality among the two study groups between 1 month and 5-year follow-up (hazard ratio: 1.33; 95% CI: 0.80-2.21, P -value: 0.23). Kaplan-Meier analysis showed lower 3-year cumulative MACCE-free survival in the CSF/NRP group compared with the normal flow group ( P = 0.02). CSF/NRP in STEMI patients is associated with a worse short- and long-term prognosis. These results, however, are mostly related to the acute phase, and CSF/NRP had limited influence on clinical outcomes in early survivors of STEMI.

Predictive Factors of Cardiac Mortality Following TEER in Patients with Secondary Mitral Regurgitation

Background: Transcatheter edge-to-edge mitral valve repair (TEER) has emerged as a viable approach to addressing substantial secondary mitral regurgitation. In the contemporary landscape where ultimate heart failure-specific therapies, such as cardiac replacement modalities, are available, prognosticating a high-risk cohort susceptible to early cardiac mortality post-TEER is pivotal for formulating an effective therapeutic regimen. Methods: Our study encompassed individuals with secondary mitral regurgitation and chronic heart failure enlisted in the multi-center (Optimized CathEter vAlvular iNtervention (OCEAN)-Mitral registry. We conducted an assessment of baseline variables associated with cardiac death within one year following TEER. Results: Amongst the 1517 patients (median age: 78 years, 899 males), 101 experienced cardiac mortality during the 1-year observation period after undergoing TEER. Notably, a history of heart failure-related admissions within the preceding year, utilization of intravenous inotropes, and elevated plasma B-type natriuretic peptide levels emerged as independent prognosticators for the primary outcome (p &lt; 0.05 for all). Subsequently, we devised a novel risk-scoring system encompassing these variables, which significantly stratified the cumulative incidence of the 1-year primary outcome (16%, 8%, and 4%, p &lt; 0.001). Conclusions: Our study culminated in the development of a new risk-scoring system aimed at predicting 1-year cardiac mortality post-TEER.

Comparison of percutaneous coronary intervention versus medication in dialysis patients with coronary artery disease

Abstract Background There is a lack of evidence for the optimal management of dialysis patients complicated with coronary artery disease (CAD). Based on the favorable results from patients with normal or near-normal kidney function, percutaneous coronary intervention (PCI) has extended to patients on maintenance dialysis. However, it is unknown whether this extrapolation is accurate. Purpose We sought to investigate the benefits of PCI in dialysis patients with CAD. Methods Between January 2015 and June 2021, 455 617 consecutive cardiac catheterizations from 30 cardiac centers in China were reviewed retrospectively through medical records. Patients with normal coronary anatomy, those who did not receive dialysis therapy or received dialysis for less than 3 months, those who received coronary artery bypass grafting, repeat admissions, and those with less than one year of follow-up were excluded. Patients were followed up via telephone interviews or clinic visits until June 2022. The primary outcome of interest was 1-year all-cause mortality, and the secondary outcome of interest was 1-year cardiac death. Cox proportional hazards regression model was used to assess the association of PCI with outcomes. Inverse probability of treatment weighting was used to control for imbalances in patient characteristics. Results Of 1 119 patients who met the final criteria, 799 (71.4%) received PCI. The mean age was 61.9±10.6 years, and 828 (74.0%) were male. Compared with medically treated patients, patients in the PCI group were more likely to present with a high Gensini score, be with multivessel diseases, and receive dual antiplatelet and statin therapy. Overall, 201 (16.4%) all-cause deaths were documented, with 153 (13.7%) cardiac deaths. Patients treated with PCI experienced significantly lower cumulative rates of 1-year all-cause deaths (15.5% vs. 24.1%, log-rank p&amp;lt;0.001) as well as cardiac deaths (11.5% vs. 19.1%, p&amp;lt;0.001). Multivariate analyses showed that PCI was independently associated with a lower risk of either all-cause deaths (hazard ratio 0.48, 95% confidence interval 0.36-0.64, p&amp;lt;0.001) or cardiac mortality (hazard ratio 0.45, 95% confidence interval 0.30-0.61, p&amp;lt;0.001). These findings were further confirmed in the inverse probability of treatment weighting cohort. Conclusion This cohort study found that in real-world practice, among dialysis with CAD, use of PCI was associated with significantly lower risks for 1-year all-cause death or cardiac mortality compared with medical management. Further prospective studies are needed to confirm these findings.

Abstract 18392: Sedentary Behavior and Risk of 1-Year Cardiac Events and Mortality After Suspected Acute Coronary Syndrome

Background: Patients hospitalized with acute coronary syndrome (ACS) remain at high risk for recurrent cardiac events in the first year after discharge, necessitating a need to identify modifiable targets to improve outcomes. While moderate-vigorous physical activity (MVPA) is a hallmark of secondary prevention in this population, sedentary behavior (SB) has emerged as a potentially unique aspect of the physical activity profile that may also have prognostic relevance. Yet little is known regarding whether SB confers risk independent from MVPA and what types of activity should be substituted for SB to impart health benefit among ACS patients in the first year after discharge. Aim: Examine the association between SB and risk of 1-year cardiac events and mortality among patients evaluated for ACS. Methods: Patients (n=609, 52% male, 62 ± 13 y) evaluated in the emergency room for ACS were fitted with a GENEActiv wrist accelerometer in-hospital and wore the device for 30 days post discharge to measure SB, light intensity physical activity (LIPA), MVPA, and sleep. Major adverse cardiovascular events 1-year post discharge were defined as the composite of unstable angina, myocardial infarction, or death. Results: Over follow up, 50 patients (8%) had a major adverse cardiovascular event. SB was associated with an increased risk of 1-year major adverse cardiovascular events after adjusting for demographic and disease severity indicators (HR per 1 h/d increase: 1.33, 95% CI: 1.12, 1.58). The association remained significant after adjusting for MVPA (HR per 1 h/d increase: 1.30, 95% CI: 1.06, 1.59). In isotemporal substitution analyses there were beneficial associations for replacing SB with sleep (per 30 min HR: 0.89, 95% CI: 0.81, 0.97), LIPA (per 30 min HR: 0.51, 95% CI: 0.34, 0.76), and MVPA (per 30 min HR: 0.32, 95% CI: 0.12, 0.85) on 1-year major adverse cardiovascular event risk. Conclusion: SB was associated with increased risk of 1-year cardiac events and mortality among patients evaluated for ACS, independent of MVPA. Replacing SB with sleep, LIPA, or MVPA was associated with lower risk. These findings suggest reducing SB may improve outcomes in ACS survivors and support the public health message that ACS patients should sit less and move or sleep more to mitigate risk.

Comparisons of Patients Living Alone versus Living with Others in Acute Coronary Syndrome.

We aimed to examine the relationship of living arrangements (i.e., living alone or living with others) with background, clinical severity, preintervention culprit lesion plaque morphology, and clinical outcomes in patients with acute coronary syndrome (ACS). Among 1,683 consecutive patients with ACS, we retrospectively compared patients living alone ( n = 318) versus living with others ( n = 1,362). Optical coherence tomography (OCT) findings, which are high-resolution intracoronary imaging devices, were analyzed in patients with preintervention OCT and compared between patients living alone ( n = 174) versus those living with others ( n = 665). Older (median; 69 vs. 67 y, p = 0.046) and female (31 vs. 17%, p < 0.001) patients more frequently lived alone. Frequency of achieving a time interval of 6 hours or less from ACS onset to admission was lower in patients living alone (56 vs. 63%, p = 0.022). Clinical presentation was more severe in patients living alone (Killip II/III/IV; 27 vs. 22%, p = 0.029). Plaque morphology evaluated by OCT was similar between groups (plaque rapture; 48 vs. 48%, p = 0.171). Kaplan-Meier analyses revealed higher rates of cardiac mortality during 2-year follow-up period in patients living alone [13.9 vs. 8.5%, hazard ratio (HR) 1.604, 95% confidence interval (CI) 1.112-2.313, p = 0.010]. After traditional cardiovascular risk factors and clinical severity upon admission had been adjusted, living alone was an independent predictor of cardiac mortality in ACS patients (HR 1.582, 95% CI 1.056-2.371, p = 0.026). Living alone was independently associated with 2-year cardiacmortality in ACS patients after adjusting for background and presentation and might be unrelated to the development of atherosclerosis.

Long-term use of renin-angiotensin-system inhibitors after acute myocardial infarction is not associated with survival benefits: Analysis of data from the Korean acute myocardial infarction registry-national institutes of health registry.

IntroductionRenin-angiotensin-system inhibitors (RASi) have shown survival benefits after acute myocardial infarction (MI), but the role of routine long-term use of RASi remains unclear. Thereby, we explored the therapeutic effects of RASi medication at 1-year follow-up from acute MI.MethodsUsing the nationwide Korea Acute Myocardial Infarction Registry-National Institutes of Health (KAMIR-NIH) registry, we included and analyzed 10,822 subjects. Patients were stratified into those taking RASi at 1-year follow-up (n = 7,696) and those not taking RASi at 1-year follow-up (n = 3,126). Patients were followed up for 2-years from the 1-year follow-up; 2-year all-cause mortality and cardiac mortality were analyzed as primary and secondary outcomes, respectively.ResultsThe use of RASi at 1-year follow-up was not associated with decreased all-cause mortality (log-rank P = 0.195) or cardiac mortality (log-rank P = 0.337). In multivariate analyses, RASi medication at 1-year follow-up did not reduce all-cause mortality (P = 0.758) or cardiac mortality (P = 0.923), while RASi medication at discharge substantially reduced 1-year all-cause and cardiac mortality. Treatment with either an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker at 1-year follow-up did not show survival benefits from 1-year follow-up, respectively. The use of RASi at 1-year follow-up did not show a prognostic interaction between previous history of chronic kidney disease, post-MI acute heart failure, concomitant use of beta-blockers at 1-year follow-up, or 1-year LVEF.ConclusionAcute MI patients taking RASi at 1-year follow-up were not associated with improved 2-year all-cause mortality or cardiac mortality from the 1-year follow-up. This study provides valuable information regarding tailored medication strategy after acute MI.Clinical trial registration[www.ClinicalTrials.gov], identifier [KCT0000863].

Long-Term Outcomes of Perioperative Versus Nonoperative Myocardial Infarction: A Danish Population-Based Cohort Study (2000-2016).

Perioperative myocardial infarction is a serious cardiovascular complication of noncardiac surgery. The clinical course of perioperative myocardial infarction, other than all-cause mortality, is largely unknown. We examined long-term fatal and nonfatal outcomes of perioperative myocardial infarction compared with nonoperative myocardial infarction. We conducted a population-based cohort study of first-time myocardial infarction in Denmark from 2000 to 2016. We calculated cumulative incidence of all-cause mortality, cardiac mortality, recurrent myocardial infarction, heart failure, stroke, venous thromboembolism, acute kidney injury, and kidney failure with replacement therapy. We computed 5-year risk ratios adjusted for age, sex, year of diagnosis, educational level, and comorbidities. We identified 5068 patients with perioperative myocardial infarction and 137 862 patients with nonoperative myocardial infarction. The 5-year risk of all-cause mortality was 67.5% (95% CI, 66.1%-69.0%) for perioperative myocardial infarction patients and 38.0% (95% CI, 37.7%-38.3%) for nonoperative myocardial infarction patients. The adjusted risk ratio of all-cause mortality was 1.13 (95% CI, 1.11-1.16) at 5 years. After adjustment, we found no association between patients with perioperative myocardial infarction and 5-year cardiac mortality, recurrent myocardial infarction, heart failure, stroke, or kidney failure with replacement therapy when compared with nonoperative myocardial infarction patients. Perioperative myocardial infarction patients had a higher relative risk of venous thromboembolism (5-year risk ratio, 1.21 [95% CI, 1.01-1.46]) and acute kidney injury (5-year risk ratio, 1.37 [95% CI, 1.22-1.53]). Compared with nonoperative myocardial infarction patients, perioperative myocardial infarction patients had elevated risk of all-cause mortality, venous thromboembolism, and acute kidney failure. In addition to the myocardial infarction component of perioperative myocardial infarction, this poor prognosis seemed associated with the surgery or underlying comorbidities. These findings warrant further research on strategies to reduce the risk of perioperative myocardial infarction and on strategies to manage perioperative myocardial infarction.

Late Progression of Tricuspid Regurgitation After Transcatheter Aortic Valve Replacement.

Few studies have investigated the progression of baseline mild or less tricuspid regurgitation (TR) after transcatheter aortic valve replacement (TAVR). The aim of this study was to investigate the prevalence and predictors of late progression of baseline mild or less TR and the impact of late progression on outcomes after TAVR. We reviewed 1615 patients who had baseline mild or less TR and 1-year echocardiographic follow-up registered in the Optimized Catheter Valvular Intervention-Transcatheter Aortic Valve Implantation registry. We compared outcomes including 2-year all-cause mortality, cardiac mortality, and heart failure hospitalization between groups with and without progression of TR on 1-year transthoracic echocardiography (TTE) and investigated predictors of progression of TR after TAVR. On 1-year TTE, TR worsened to a moderate or severe grade in 87 patients (5.4%). The group with TR progression had higher 2-year all-cause mortality, cardiac mortality, and heart failure hospitalization than the group without TR progression. The multivariable analysis showed that TR progression was significantly associated with all-cause mortality (hazard ratio, 4.08; 95% CI, 1.92-8.67; P < .001) and heart failure hospitalization (hazard ratio, 2.85; 95% CI, 1.64-4.93; P < .001). Independent predictors of TR progression included atrial fibrillation, transaortic mean pressure gradient <40​mm Hg on pre-TAVR TTE, and systolic pulmonary artery pressure ≥40​mm Hg. TR progression from mild or less to moderate or severe after TAVR was more likely observed in patients with low transaortic gradients, atrial fibrillation, or pulmonary hypertension. TR progression after TAVR was associated with increased all-cause mortality and heart failure hospitalization.

Mitral annular dysjunction in surgical mitral valve prolapse

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Mitral valve prolapse (MVP) affects 3% of the population and is the leading indication for mitral valve surgery.[1] Mitral annular disjunction (MAD) is a structural abnormality commonly seen in patients with MVP.[2] MAD is defined as an abnormal separation (&amp;gt;5mm) between the left atrial wall-mitral valve junction and the left ventricle myocardium,[2] associated with hypermobility and myxomatous degeneration of the mitral valve leaflets.[3] There is a paucity of literature regarding MAD, however evidence is growing that it may be associated with ventricular arrhythmia and sudden cardiac death.[3] We examined the prevalence, imaging characteristics and clinical associations of MAD among patients who have undergone mitral valve surgery for MVP. Methods Single centre cohort study of consecutive patients undergoing mitral valve surgery for MVP over a 3-year period. Patient baseline characteristics, echocardiographic parameters, surgical outcomes, frequency of arrhythmic events and 3-year cardiac and all-cause mortality were recorded. Single site data was obtained from a prospective Australia-wide cardiac surgery registry, as well as retrospective analysis of holter-monitor reports, device interrogation and review of medical records. Transthoracic echocardiogram images were re-examined, and parameters re-measured by a qualified examiner. Results Among 73 patients with surgical MVP, 20 patients had MAD (27.4%). The median MAD length was 8.1 (IQR 6.8-11.8) mm. The most severely affected patient had a disjunction length of 28 mm. MAD was associated with younger age at surgery (60 vs 66, P = 0.005), female sex (40.0% vs 22.6%, P = 0.138), bileaflet MVP (50% vs 10.6%, P = 0.004) and less cardiovascular comorbidities, including hypertension (25.0% vs 57.7%, P = 0.013) and hypercholesterolaemia (30.0% vs 61.5%, P = 0.016). Patients with MAD had greater mitral valve leaflet lengths, mitral annular diameters, and high-velocity systolic signal on tissue doppler of the mitral valve annulus (pickelhaube sign). Three patients in the MAD positive group had an arrhythmic event (VF or VT) at 3 years compared to one in the MAD negative group. There was no significant difference in 3-year cardiac or all-cause mortality between groups. Conclusion MAD is a common anatomical abnormality in patients with surgical MVP, and is easily detected on transthoracic echocardiography. It is associated with younger age at surgery, female sex, bileaflet MVP, increased leaflet length and annulus diameter. There was a signal towards increased arrhythmic events in patients with MAD despite younger age and less cardiovascular risk factors. Large longitudinal studies are needed to further assess the association of MAD with arrhythmic events to help guild appropriate investigation and risk stratification of these patients. Abstract Figure. MAD on Parasternal Long axis view Abstract Figure. Pickelhaube sign

Helicopter emergency medical service for patients with acute coronary syndrome: selection validity and impact on clinical outcomes.

Helicopter emergency medical service (HEMS) has the potential to improve prognosis for acute coronary syndrome (ACS). However, adequacy and effectiveness of HEMS have not been fully evaluated. A total of 862 ACS patients transferred by emergency medical services were divided into two groups: patients transferred by HEMS (n = 171) or by ground ambulance (GA; n = 691). Among them, angiography images for 718 patients (149 in HEMS and 569 in GA group) and optical coherence tomography (OCT) images for 374 patients (75 in HEMS and 299 in GA groups) were analyzed. Additional analysis to compare 2-year cardiac mortality between groups was conducted following propensity score matching to adjust for inter-group differences. ST-segment elevation myocardial infarction (81% vs. 66%, p < 0.001) and cardiogenic shock (Killip IV; 20% vs. 10%, p < 0.001) at admission were more prevalent in HEMS than GA group. Time from admission to balloon angioplasty was shorter in HEMS group (median 54min vs. 69min, p < 0.001). Antegrade coronary flow was worse in HEMS group (TIMI flow grade 0 or 1; 68% vs. 51%, p < 0.001). Plaque rupture was more frequently detected by OCT in HEMS group (68% vs. 49%, p = 0.029). Following propensity score matching, the incidence of cardiac death was significantly lower in HEMS group (6.3% vs. 14.9%, p = 0.019). In conclusion, severe ACS patients requiring early reperfusion were appropriately triaged and transferred more rapidly by HEMS. Lower mortality in HEMS group after propensity score matching suggests that HEMS may improve cardiac mortality in ACS patients.

Usefulness of the 2-year iodine-123 metaiodobenzylguanidine-based risk model for post-discharge risk stratification of patients with acute decompensated heart failure.

A four-parameter risk model that included cardiac iodine-123 metaiodobenzylguanidine (MIBG) imaging and readily available clinical parameters was recently developed for prediction of 2-year cardiac mortality risk in patients with chronic heart failure. We sought to validate the ability of this risk model to predict post-discharge clinical outcomes in patients with acute decompensated heart failure (ADHF) and to compare its prognostic value with that of the Acute Decompensated Heart Failure National Registry (ADHERE) and Get With The Guidelines-Heart Failure (GWTG-HF) risk scores. We studied 407 consecutive patients who were admitted for ADHF and survived to discharge, with definitive 2-year outcomes (death or survival). Cardiac MIBG imaging was performed just before discharge. The 2-year cardiac mortality risk was calculated using four parameters, namely age, left ventricular ejection fraction, New York Heart Association functional class, and cardiac MIBG heart-to-mediastinum ratio on delayed images. Patients were stratified into three groups based on the 2-year cardiac mortality risk: low- (< 4%), intermediate- (4-12%), and high-risk (> 12%) groups. The ADHERE and GWTG-HF risk scores were also calculated. There was a significant difference in the incidence of cardiac death among the three groups stratified using the 2-year cardiac mortality risk model (p < 0.0001). The 2-year cardiac mortality risk model had a higher C-statistic (0.732) for the prediction of cardiac mortality than the ADHERE and GWTG-HF risk scores. The 2-year MIBG-based cardiac mortality risk model is useful for predicting post-discharge clinical outcomes in patients with ADHF. UMIN000015246, 25 September 2014.

Impact of Low Body Mass Index on Features of Coronary Culprit Plaques and Outcomes in Patients With Acute Coronary Syndrome

The mechanisms behind poorer cardiac outcomes in underweight patients with acute coronary syndrome (ACS) are not understood and features of coronary culprit lesions in underweight ACS patients have not been fully examined. A total of 1,683 patients with ACS were divided into 4 groups according to body mass index (BMI): <18.5 (n=73), 18.5 to 24.9 (n=995), 25 to 29.9 (n=488), and ≥30 (n=117). Angiography and optical coherence tomography (OCT) images were analyzed for 1,428 of these patients who had primary percutaneous coronary intervention (PCI) and 838 who had primary PCI with OCT guidance, respectively. Diabetes (p <0.001), hypertension (p <0.001), and dyslipidemia (p <0.001) were less prevalent in BMI <18.5. Statin prescription at discharge was less frequent in the BMI <18.5 group (p <0.001). Quantitative coronary angiography analyses revealed smaller reference vessel (p=0.001) and minimum lumen diameters after PCI (p=0.019) and OCT revealed longer lipidic plaque length (p=0.029) in the BMI <18.5 group. Kaplan-Meier analyses revealed higher rates of cardiac mortality (p <0.001) and major bleeding (p=0.034) during the 2-year follow-up in the BMI <18.5 group. After adjusting for traditional cardiovascular risk factors, BMI <18.5 independently predicted 2-year cardiac mortality (hazard ratio 1.917 [95% confidence interval [1.082 to 3.397], p=0.026). In conclusion, being underweight contributed to poorer cardiac outcomes in established ACS population. Smaller minimum lumen diameter after PCI and further progressed atherosclerosis at the culprit lesions despite their lower prevalence of comorbid metabolic risk factors may be related partly to poorer cardiac outcomes.

Prevalence, clinical characteristics, and impact of active cancer in patients with acute myocardial infarction: data from an all-comer registry

BackgroundAlthough a history of cancer is a poor prognostic factor in patients with acute myocardial infarction (AMI), the clinical importance of coexisting active cancer remains unclear. MethodsIn this single-center retrospective study, we reviewed an AMI registry and assessed the prevalence and predictors of active cancer, 1-year incidence of cardiac death or major bleeding events (defined as a Bleeding Academy Research Consortium type 3 or 5), and the impact of coexisting active cancer on clinical outcomes. Active cancer was defined as either an already-diagnosed or undiagnosed occult cancer. ResultsBetween January 2012 and December 2017, 1140 AMI patients (median age, 69 years; male, 76.0%) were enrolled. Active and historical cancers were diagnosed in 63 patients (5.5%) and 50 patients (4.4%), respectively. The most common location was the urinary tract (n=21). In the Kaplan-Meier analysis, the active cancer group had a higher incidence of 1-year cardiac death (17.5% vs. 5.3%, p < 0.001) and major bleeding events (19.0% vs. 5.6%, p < 0.001) than the non-cancer group. In the multivariate Cox proportional hazards regression models, active cancer was an independent predictor of both cardiac death and major bleeding at 1 year. Specifically, gastrointestinal tract and advanced-stage cancers had the poorest outcomes. Compared to the non-cancer group, the 1-year major bleeding rate was higher for all cancer types and stages. In contrast, early-stage cancers had a weaker impact on the 1-year cardiac mortality compared to advanced-stage cancers. Similarly, cardiac death during 1-year also occurred less frequently in occult cancers than in already-known cancers. ConclusionsIn patients with AMI, coexisting active cancer was rare, but it significantly impacted cardiac death and major bleeding events.

Weight impacts 1-year congenital heart surgery outcomes independent of race/ethnicity and payer.

Body mass index, race/ethnicity, and payer status are associated with operative mortality in congenital heart disease (CHD). Interactions between these predictors and impacts on longer term outcomes are less well understood. We studied the effect of body mass index, race/ethnicity, and payer on 1-year outcomes following elective CHD surgery and tested the degree to which race/ethnicity and payer explained the effects of body mass index. Patients aged 2-25 years who underwent elective CHD surgery at our centre from 2010 to 2017 were included. We assessed 1-year unplanned cardiac re-admissions, re-interventions, and mortality. Step-wise, multivariable logistic regression was performed.Of the 929 patients, 10.4% were underweight, 14.9% overweight, and 8.5% obese. Non-white race/ethnicity comprised 40.4% and public insurance 29.8%. Only 0.5% died prior to hospital discharge with one additional death in the first post-operative year. Amongst patients with continuous follow-up, unplanned re-admission and re-intervention rates were 14.7% and 12.3%, respectively. In multivariable analyses adjusting for surgical complexity and surgeon, obese, overweight, and underweight patients had higher odds of re-admission than normal-weight patients (OR 1.40, p = 0.026; OR 1.77, p < 0.001; OR 1.44, p = 0.008). Underweight patients had more than twice the odds of re-intervention compared with normal weight (OR 2.12, p < 0.001). These associations persisted after adjusting for race/ethnicity, payer, and surgeon.Pre-operative obese, overweight, and underweight body mass index were associated with unplanned re-admission and/or re-intervention 1-year following elective CHD surgery, even after accounting for race/ethnicity and payer status. Body mass index may be an important modifiable risk factor prior to CHD surgery.

Abstract 13677: Usefulness of 2-year Iodine-123 Metaiodobenzylguanidine-based Risk Model for the Post-discharge Risk Stratification in Acute Decompensated Heart Failure Patients With Preserved Left Ventricular Ejection Fraction

Background: A four-parameter risk model including cardiac iodine-123 metaiodobenzylguanidine (MIBG) imaging and readily available clinical parameters has been recently developed for the prediction of 2-year cardiac mortality risk in patients with chronic heart failure (CHF) using a Japanese CHF database consisting of 1322 patients. However, there is no information available on the usefulness of 2-year MIBG-based cardiac mortality risk score for the prediction of post-discharge prognosis in patients with heart failure with preserved LVEF (HFpEF) who are admitted with acute decompensated heart failure (ADHF). Methods and Results: Patients' data were extracted from The Prospective mUlticenteR obServational stUdy of patIenTs with Heart Failure with Preserved Ejection Fraction (PURSUIT-HFpEF) study, which is a prospective multicenter observational registry for ADHF patients with LVEF ≥50% in Osaka. We studied 239 patients who survived to discharge. Cardiac MIBG imaging was performed just before discharge. The 2-year cardiac mortality risk score was calculated using four parameters, including age, LVEF, NYHA functional class, and the cardiac MIBG heart-to-mediastinum ratio on delayed image. The patients were stratified into three groups based on the 2-year cardiac mortality risk score: low- (&lt;4%), intermediate- (4-12%), and high-risk (&gt;12%) groups. The endpoint was all-cause death. During a follow-up period of 1.6±0.8 years, 33 patients had all-cause death. Multivariate Cox analysis showed that 2-year MIBG-based cardiac mortality risk score was an independent predictor of all-cause death (p=0.0009). There was significant difference in the rate of all-cause death among the three groups stratified by 2-year cardiac mortality risk score (Figure). Conclusions: In this multicenter study, the 2-year MIBG-based cardiac mortality risk score was shown to be useful for the prediction of post-discharge clinical outcome in HFpEF patients admitted for ADHF.

Prognostic value of NT-proBNP and best cut-offs for risk prediction in obese patients with chronic systolic heart failure

Abstract Background N-terminal fraction of pro-B-type natriuretic peptide (NT-proBNP) is a strong predictor of outcome in chronic systolic heart failure (CHF). Although plasma NT-proBNP has been reported to display an inverse correlation with body-mass-index (BMI), its prognostic value in obese patients has been poorly investigated so far. Objectives To evaluate the prognostic value and the best cut-offs for risk prediction of NT-proBNP in obese individuals from a multinational cohort of patients with systolic CHF. Methods We analyzed data from the BIOS (Biomarkers In Heart Failure Outpatient Study) Consortium. Patients with left ventricular ejection fraction (LVEF) ≤50% were selected and classified as nonobese (BMI &amp;lt;30 kg/m2), mildly obese (BMI 30–35 kg/m2), moderately obese (BMI 35–40 kg/m2), or severely obese (BMI ≥40 kg/m2), according to standard nomenclature. Clinical and bio-humoral data, including NT-proBNP testing, were retrieved, and 5-year cardiac and all-cause mortality status were considered as primary and secondary outcome, respectively. The independent prognostic role of NT-proBNP was evaluated through Cox regression analysis, adjusting the model for age, gender, New York Heart Association class, ischaemic aetiology, LVEF, and estimated glomerular filtration rate (eGFR). Results The study population included 11,574 patients (age 65±12 years, LVEF 30±9%, males 78%). Most of patients were nonobese (n=8,937, 77%), while mildly, moderately, and severely obese patients were 1,887 (16%), 499 (4%), and 251 (3%), respectively. Median values of plasma NT-proBNP were progressively lower from nonobese to mildly, moderately, and severely obese patients (1455 ng/L, 903 ng/L, 767 ng/L, 660 ng/L, respectively) and BMI was predictive of NT-proBNP independently from age, LVEF, and eGFR (r=−0.152, p&amp;lt;0.001). The best NT-proBNP cut-offs to predict 5-year cardiac mortality were significantly lower in mildly [1044 ng/L; AUC 0.663 (Sen 66%; Spe 59%), p&amp;lt;0.001] moderately [736 ng/L; AUC 0.670 (Sen 76%; Spe 52%), p&amp;lt;0.001]), and severely [1060 ng/L; AUC 0.635 (Sen 57%; Spe 69%), p=0.021] obese patients compared to nonobese individuals [2034 ng/L; AUC 0.714 (Sens. 65%; Spec. 66%), p&amp;lt;0.001]. Further, NT-proBNP independently predicted 5-year cardiac death in nonobese, mildly and moderately obese patients (all p&amp;lt;0.001), but not in severely obese patients (p=0.457). Similar findings were observed for the secondary endpoint of 5-year all-cause mortality. Conclusions Compared to nonobese CHF patients, obese patients have lower circulating NT-proBNP levels, which retain independent prognostic significance for cardiac and all-cause mortality across most categories of obesity. BMI-adjusted NT-proBNP cut-offs might be considered for prognostic stratification in obese patients with CHF. Funding Acknowledgement Type of funding source: None

Aspartate aminotransferase and mortality in patients with ischemic heart disease

Background and aimsEvidence on the association between aspartate aminotransferase (AST) activity and mortality of patients with ischemic heart disease (IHD) is limited. We investigated whether there is an association between AST activity and mortality in IHD patients. Methods and resultsThe study included 6857 patients with coronary angiography-proven IHD and AST activity within the reference range. AST activity measurements were available in all patients. The primary outcome was 3-year cardiac mortality. Patients were categorized in groups according to the AST activity tertiles: a group with AST within the 1st tertile (AST < 17.0 U/L), a group with AST within the 2nd tertile (AST > 17–24.5 U/L) and a group with AST within the 3rd tertile (AST > 24.5 U/L). Cardiac death (n = 297) occurred in 109, 69 and 119 patients in the 1st to 3rd AST tertiles (Kaplan–Meier estimates of mortality: 5.3%, 3.6% and 5.9%; univariable hazard ratio [HR] = 1.75, 95% confidence interval [CI] 1.30–2.36, P < 0.001 for tertile 3 vs. 2; HR = 1.13 [0.87–1.46], P = 0.370 for tertile 3 vs. 1; and HR = 0.65 [0.48–0.87], P = 0.004 for tertile 2 vs. 1). The association between AST and cardiac mortality was U-shaped. AST values <15 U/L (HR = 1.118 [1.009–1.238]) and >23 U/L (HR = 1.029 [1.003–1.056]) were associated with higher cardiac mortality compared with the reference value (21 U/L). After adjustment, the association between AST and cardiac mortality was attenuated (P = 0.133) but remained non-linear (P = 0.047). ConclusionsIn patients with IHD, AST activity was associated with the risk of cardiac mortality with a U-shaped relationship. After adjustment, the association between AST and mortality was attenuated.