Adverse Clinical Events In Patients Research Articles

Association between right ventricular global longitudinal strain and mortality in intermediate-risk pulmonary embolism.

Right ventricular (RV) systolic dysfunction has been identified as a prognostic marker for adverse clinical events in patients presenting with acute pulmonary embolism (PE). However, challenges exist in identifying RV dysfunction using conventional echocardiography techniques. Strain echocardiography is an evolving imaging modality which measures myocardial deformation and can be used as an objective index of RV systolic function. This study evaluated RV Global Longitudinal Strain (RVGLS) in patients with intermediate risk PE as a parameter of RV dysfunction, and compared to traditional echocardiographic and CT parameters evaluating short-term mortality. Retrospective single center cohort study of 251 patients with intermediate-risk PE between 2010 and 2018. The primary outcome was all-cause mortality at 30 days. Statistical analysis evaluated each parameter comparing survivors versus non-survivors at 30 days. Receiver operating characteristic (ROC) curves and Kaplan-Meier curves were used for comparison of the two cohorts. Altogether 251 patients were evaluated. Overall mortality rate was 12.4%. Utilizing an ROC curve, an absolute cutoff value of 17.7 for RVGLS demonstrated a sensitivity of 93% and specificity of 70% for observed 30-day mortality. Individuals with an RVGLS ≤17.7 had a 25 times higher mortality rate than those with RVGLS above 17.7 (HR 25.24, 95% CI=6.0-106.4, p<.001). Area under the curve was (.855), RVGLS outperformed traditional echocardiographic parameters, CT findings, and cardiac biomarkers on univariable and multivariable analysis. Reduced RVGLS values on initial echocardiographic assessment of patients with intermediate-risk PE identified patients at higher risk for mortality at 30 days.

Right ventricular dyssynchrony for the prediction of prognosis in patients with systemic lupus erythematosus-aaociated pulmonary arterial hypertension: a study with two-dimensional speckle tracking.

Pulmonary arterial hypertension (PAH) is a common complication of systemic lupus erythematosus (SLE), and PAH can cause right ventricle (RV) remodel and dyssynchrony. The aim of this study was to explore the value of RV dyssynchrony in predicting adverse clinical events in patients with systemic lupus erythematosus-aaociated pulmonary arterial hypertension (SLE-PAH) using two-dimensional speckle tracking echocardiography (2D-STE). A total of 53 patients with SLE-PAH were enrolled in this study. The dyssynchrony of the RV (RV-SD6) was evaluated by 2D-STE. The clinical data of all participants were collected, and routine cardiac function parameters were measured by two-dimensional echocardiography, and analyzed for their correlation with RV-SD6. The predictive value of RV-SD6 in clinical adverse event was evaluated. RV-SD6 was negatively correlated with RV-FLS, RV-FAC, and TAPSE (r = -0.788, r = -0.363 and r = -0.325, respectively, all P < 0.01), while the correlation with RV-FLS was the strongest. linear regression analysis showed that RV-FLS was an independent risk factor for RV-SD6 (β = -1.40, 95% CI -1.65 ~ -1.14, P < 0.001). Cox regression analysis showed that RV-SD6 was a predictor with clinical adverse events (HR = 1.03, 95% CI 1 ~ 1.06, P < 0.05). RV-SD6 was highly discriminative in predicting clinical adverse events (AUC = 0.764), at a cutoff of 51.10ms with a sensitivity of 83.3% and specificity of 68.3%. RV-FLS was negatively correlated with RV-SD6 and was an independent risk factor for it. RV-SD6 can serve as an indicator for predicting the occurrence of adverse clinical events in SLE-PAH patients, with high sensitivity and specificity.

Increased Left Ventricular End-Diastolic Volume Index Is Associated With Increased Adverse Events After MitraClip Implantation

This study investigated the association between the left ventricular end-diastolic volume index (LVEDVI) and the incidence of adverse clinical events in patients after MitraClip implantation. In this retrospective, observational study, 123 patients who underwent the MitraClip procedure were enrolled. Participants were divided into 2 groups according to the LVEDVI cut-off level, calculated using receiver operating characteristic curve analysis, to predict the primary end point and the occurrence of cardiovascular events was compared between the groups. The primary end point was all-cause mortality and hospitalization because of heart failure. The receiver operating characteristic curve analysis for the composite primary end point revealed an LVEDVI cut-off point of 118ml/m2. Based on this threshold, 61 patients (49.6%) were categorized into the LVEDVI <118 ml/m2 group, whereas 62 (50.4%) fell into the LVEDVI ≥118 ml/m2 group. Over a median follow-up period of 336days (interquartile range 80 to 667), the primary end points occurred in 15 and 26 patients in the LVEDVI <118 and LVEDVI ≥118 ml/m2 groups, corresponding to incidence rates of 24.6% and 41.9%, respectively. Patients in the LVEDVI ≥118ml/m2 group demonstrated a significantly higher risk of adverse clinical events than those in the LVEDVI <118ml/m2 group (hazard ratio 2.24, 95% confidence interval 1.17 to 4.28, p=0.01). This trend persisted even after adjusting for several confounders (p=0.02). In conclusion, increased LVEDVI values were associated with increased adverse clinical events after MitraClip implantation in patients with severe mitral valve regurgitation.

Stress hyperglycemia ratio and long-term clinical outcome in patients with acute coronary syndrome

Abstract Background Stress hyperglycemia is strongly associated with adverse prognosis in patients with acute coronary syndrome (ACS). Recently, the stress hyperglycemia ratio (SHR- relationship between acute/chronic glycemic values) has been proposed as a better measurement of stress hyperglycemia. Studies on SHR and long-term clinical outcome in ACS are limited. This study aimed to clarify the association between SHR and 3-year adverse clinical events in patients with ACS. Methods We analyzed data of 795 patients admitted to our center for ACS who were enrolled in the PRATO-ACS Registry (ClinicalTrials.gov ID: NCT04087200) and underwent laboratory analyses 1 month after the index event. All patients had undergone early invasive strategy and received high intensity statins during hospitalization and at discharge. Patients were stratified in baseline SHR tertiles: &amp;lt; 0.95, ≥ 0.95 to &amp;lt; 1.17 and ≥ 1.17. The primary end point was 3-year all cause death; secondary end points were major adverse clinical events (MACE) including all-cause death, myocardial infarction or congestive heart failure. The association between SHR and outcome measures was evaluated with Cox proportional analysis expressed by hazard ratio (HR) and 95% confidence intervals (CI). Results With increasing SHR, there was a significant progressive increase in mortality (4.2, 8.3, and 11.7% in the 1st, 2nd, and 3rd tertile, respectively, p= 0.006) and MACE (10.6, 14, and 20.8% in the 1st, 2nd, and 3rd tertile, respectively, p=0.004). Multivariable analysis shows that SHR was an independent predictor of 3-year all-cause death (HR 1.65, 95% CI 1.12-2.4; p= 0.012). Subgroup analysis evidenced that the relationship between SHR and mortality was statistically significant only for patients with poor glycemic control at 1 month follow up (HR 3.4, 95% CI 1.14-10.9, p= 0.02 in the 2nd tertile and HR 3.9, 95% CI 1.3-11.8, p= 0.015 in the 3rd tertile). Conclusion Baseline SHR is significantly associated with 3-year all-cause death and MACE in patients with ACS. However, its prognostic impact is much stronger in patients who do not achieve desired glycemic targets at 1 month after the index event. Therefore, insistent attention to glycemic values is mandatory in ACS patients even after discharge.

Abstract 11965: Impact of Atherothrombotic Risk Stratification in Patients With Heavily Calcified Lesions Following Rotational Atherectomy

Background: Patients who undergo percutaneous coronary intervention (PCI) with rotational atherectomy (RA) are at high risk of adverse clinical outcomes, and there are few clinical risk stratification tools for these patients. The Thrombolysis in Myocardial Infarction Risk Score for Secondary Prevention (TRS 2°P) is a simple 9-point risk stratification tool. A previous study reported that TRS 2°P was useful in predicting adverse clinical events in patients with acute coronary syndrome. However, it is unclear whether TRS 2°P predicts adverse clinical events in patients with heavily calcified lesions, requiring RA. Hypothesis: This study aimed to investigate whether TRS 2°P is useful for the prediction of adverse clinical events in patients undergoing PCI with RA from the Japanese multicenter PCI registry. Methods: We conducted a study with 196 patients who underwent PCI with RA out of 7,391 patients who underwent PCI in a multicenter, prospective cohort registry. Patients were divided into 3 groups according to the tertiles of the TRS 2°P: 65 patients in the T1 group (TRS 2°P&lt;3), 66 patients in the T2 group (TRS 2°P=3), and 65 patients in the T3 group (TRS 2°P&gt;3). The primary endpoint was the cumulative 2-year incidence of major adverse cardiovascular and cerebrovascular events (MACCE), defined as a composite of cardiac death, acute coronary syndrome, and ischemic stroke. Results: A cumulative 2-year MACCE occurred in 41 (24%) patients during the follow-up period. The cumulative incidence of MACCE was significantly higher in the T3 group than in T1 group (log-rank p=0.02). Multivariate Cox analyses revealed that the T3 group was associated with an increased risk of MACCE compared to T1 group (adjusted hazard ratio, 2.66; 95% confidence interval, 1.04–6.77; p=0.04). The addition of TRS 2°P to conventional risk factors, including male sex, number of diseased vessels, and low-density lipoprotein cholesterol levels, improved the net reclassification improvement (NRI) and integrated discrimination improvement (IDI) (NRI 0.39, p=0.027; IDI 0.072, p&lt;0.001). Conclusions: Atherothrombotic risk stratification using TRS 2°P is useful for identifying high-risk patients with heavily calcified lesions following RA.

Abstract 11419: Combination of Right Ventricular Global Longitudinal Strain and Conventional Echocardiographic Parameter Carries Improved Prognostic Value in Submassive Pulmonary Embolism

Introduction and Hypothesis: Right ventricular (RV) dysfunction has been identified as a prognostic marker for adverse clinical events in patients with submassive pulmonary embolism (PE). We hypothesized that combination of right-sided strain analysis and conventional parameters can further risk stratify patients at high risk for mortality. Methods: Retrospective cohort study of patients with submassive PE between 2010 and 2018. The primary outcome was all-cause mortality at 30 days. Echocardiographic parameters including right to left ventricular end-diastolic diameter ratio (RV/LV ratio), RV global longitudinal strain (RVGLS), RV free wall strain and right atrium strain were compared between survivors and non-survivors. Multivariable analysis and receiver operator characteristic (ROC) curves analysis were used to demonstrate the predictive value of baseline measurements. Results: 251 patients were analyzed. Overall mortality rate at 30 days was 12.4 %. Multivariable analysis revealed RV/LV ratio was an independent predictor of 30-day mortality in conventional parameters, and RVGLS was also an independent predictor among the three strain parameters. ROC curves indicated that the best cutoff values for RVGLS and RV/LV ratio to predict mortality were 17.7 % and 1.03. When the 230 patients with measurable RVGLS and RV/LV ratio were divided into four groups using both cutoff values, patients with both high RVGLS and low RV/LV ratio had the lowest mortality (1.0 % at 30 days; n = 99) while patients with both low RVGLS and high RV/LV ratio had the highest mortality (46.2 % at 30 days; n = 39). Kaplan-Meier curves depicted the significantly different prognosis among the four groups (p &lt; 0.001. Figure). Conclusions: The combination of RVGLS and RV/LV ratio can help further risk stratify patients with submassive PE. This may identify patients at highest risk of mortality and ultimately alter treatment pathways.

Abstract 13106: Two-Year Clinical Outcomes of Staged Transcatheter Mitral Edge-to-Edge Repair After Transcatheter Aortic Valve Replacement

Introduction: Residual significant MR has been linked to an increased risk of adverse clinical events in patients undergoing TAVR. However, the effectiveness of staged TEER after TAVR has been poorly assessed. Hypothesis: To investigate clinical outcomes of staged transcatheter edge-to-edge repair (TEER) for residual significant mitral regurgitation (MR) after transcatheter aortic valve replacement (TAVR). Methods: This observational study included consecutive patients with residual grade 3+ or 4+ MR after TAVR performed at our institution between April 2016 and November 2020. The primary composite outcomes were all-cause mortality and heart failure (HF) hospitalization at 2 years, with HF hospitalization assessed as a secondary outcome for all-cause mortality. Additional analyses, including changes in MR grade and New York Heart Association (NYHA) functional classification, were performed. Results: Among 314 patients, 104 (33.1%) treated with staged TEER and 210 (66.9%) treated with medical therapy alone were enrolled. Patients who underwent staged TEER had a lower rate of primary composite outcomes than those who received medical therapy alone (33.7% vs. 48.1%, p=0.027) (Figure1). However, there was no significant difference in all-cause mortality (11.5% vs. 13.8%, p=0.46) or HF hospitalization (31.7% vs. 42.9%, p=0.061). Staged TEER was associated with a marked improvement in the MR grade and NYHA class from baseline to 2 years. Conclusions: Staged TEER following TAVR was associated with improved clinical outcomes and a reduced MR grade. The findings suggest that TEER should be considered a potential treatment option for significant residual MR in patients who have previously undergone TAVR.

Discordance Between Neutrophil to Lymphocyte Ratio and High Sensitivity C-Reactive Protein to Predict Clinical Events in Patients with Stable Coronary Artery Disease: A Large-Scale Cohort Study.

Neutrophil to lymphocyte ratio (NLR), a novel inflammatory biomarker, has been shown to positively predict prognosis independent of high-sensitivity C-reactive protein (hsCRP) in patients with coronary artery disease (CAD). This study aimed to use discordance analysis to evaluate the effectiveness of NLR and hsCRP to predict adverse events in patients with stable CAD. This observational cohort study included 7827 consecutive CAD patients at Fuwai Hospital from March 2011 to April 2017. Discordant NLR with hsCRP was defined by the highest quartiles and medians. The primary endpoint was major adverse cardiovascular and cerebrovascular events (MACCEs), including cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, and unplanned revascularization. During a median 36-month follow-up, 624 (8.0%) MACCEs occurred. Compared with the lowest NLR quartile,a significantly higher risk of MACCEs was observed in the highest NLR quartile after adjusting for confounding factors (hazard ratio [HR], 1.36; 95% confidence interval [CI], 1.09-1.71). High NLR and low hsCRP discordance were also associated with an increased risk of MACCEs in the fully adjusted model (HR, 1.39; 95% CI, 1.05-1.84). This study demonstrated that discordantly elevated NLR levels were associated with a greater risk of adverse clinical events in patients with stable CAD, suggesting the potential clinical significance of NLR as a goal of inflammatory risk management.

Baseline High-Sensitivity C-Reactive Protein as a Predictor of Adverse Clinical Events in Patients with Coronary Artery Disease Undergoing Percutaneous Coronary Intervention: A Meta-Analysis.

Inflammation in patients with coronary artery disease (CAD) has been linked to adverse clinical outcomes. A useful biomarker for measuring inflammation levels, high-sensitivity C-reactive protein (hs-CRP) in the blood can be used to detect the presence of low-grade inflammation. This study sought to assess the predictive value of baseline hs-CRP levels for adverse clinical events in CAD patients undergoing percutaneous coronary intervention (PCI). To investigate this topic, a meta-analysis was performed. We conducted a systematic search of PubMed, Embase, and the Cochrane Library for original articles reporting the correlation between hs-CRP levels and adverse clinical events in CAD patients undergoing PCI. We followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines and conducted a meta-analysis by extracting relevant data. Our pooled calculations yielded hazard ratios or odds ratios with 95% confidence intervals. A total of 28 studies comprising 60544 patients were included in this analysis. High baseline hs-CRP levels predicted increased risk for major adverse cardiac events (P = 0.037), major adverse cardiac and cerebrovascular events (P = 0.020), all-cause mortality (P = 0.001), cardiovascular mortality (P < 0.001), death and/or myocardial infarction (P = 0.017) in patients, as well as restenosis (P < 0.001). However, there was no association between elevated baseline hs-CRP levels and thrombosis. In conclusion, in CAD patients undergoing PCI, baseline hs-CRP levels are reliable predictors of major adverse cardiac events, major adverse cardiac and cerebrovascular events, all-cause mortality, cardiovascular mortality, death and/or myocardial infarction, and restenosis. Therefore, hs-CRP can effectively assist in prognosis determination for CAD patients undergoing PCI.

Fibrinogen is Associated with Clinical Adverse Events in Patients with Psoriasis and Coronary Artery Disease.

The presence of elevated fibrinogen levels is associated with cardiovascular disease. However, whether fibrinogen level is associated with adverse clinical events in patients with psoriasis and coronary artery disease (CAD) is unknown. This study aimed to investigate the relationship between fibrinogen levels and cardiovascular adverse events in these patients. This retrospective cohort study collected consecutive patients with psoriasis and CAD between January 2017 and May 2022 in our hospital. The clinical records were collected, and comparisons were made between groups. The Cox regression analysis and Kaplan-Meier survival analysis were used to evaluate the association between variables. Of the 267 participants, one hundred and forty-seven patients (55.1%) had elevated fibrinogen levels. Compared with patients in low fibrinogen group, white blood cell and platelet counts and high-sensitivity C-reactive protein levels were higher, whereas the left ventricular ejection fraction was lower in patients in high fibrinogen group. After a median follow-up of 35.5 months, the incidence of major adverse cardiovascular events (MACEs) was higher in patients in high fibrinogen group compared with patients in low fibrinogen group (31.4% vs 16.4%, p = 0.013). The Kaplan-Meier survival curves showed the same trend (log rank p = 0.020). Subgroup analysis revealed a positive association between elevated fibrinogen levels and MACEs in patients aged <60 years (log-rank p = 0.013), those with diabetes (log-rank p = 0.027), and those who were not admitted for acute cardiovascular syndrome (log-rank p = 0.015). Elevated fibrinogen levels were associated with adverse clinical events in patients with psoriasis and CAD, especially among patients aged <60 years, those with diabetes, and those not admitted for acute cardiovascular syndrome.

Direct Oral Anticoagulants Affect Activated Clotting Time During and Bleeding Events After Percutaneous Coronary Intervention

Inappropriately high activated clotting time (ACT) during percutaneous coronary intervention (PCI) is associated with an increased risk of bleeding events. However, whether the prescription of direct oral anticoagulants (DOACs) affects ACT kinetics during heparin use and adverse clinical events in patients who underwent PCI remains unclear. We aimed to evaluate the relations between ACT changes during and adverse clinical events after PCI in patients who were prescribed DOAC. This observational study included 246 patients who underwent PCI at the 2 cardiovascular centers who were not receiving warfarin and whose ACT was recorded immediately before and 30minutes after injection of unfractionated heparin. Patients were divided into 2 groups according to DOAC prescription at the time of the index PCI: DOAC users (n=31) and nonusers (n=215). Any bleeding and systemic thromboembolic events were investigated until 30days after PCI. The average age of this population was 70.5years, and 66.3% were male. Average ACT was significantly higher in DOAC users than nonusers both before and 30minutes after unfractionated heparin induction (157.2±30.1 vs 131.8±25.1seconds, p<0.001; 371.1±122.2 vs 308.3±82.2seconds, p<0.001; respectively). The incidence of systemic thromboembolism after PCI was low and comparable between the 2 groups (0% vs 3.7%, p=0.60). However, the rate of any bleeding event was significantly higher in DOAC users than in nonusers (16.1% vs 4.7%, p=0.028). Patients receiving DOAC have higher ACT during PCI and higher incidence of bleeding events than those not receiving DOAC.

Rates of adverse clinical events in patients with chronic kidney disease: analysis of electronic health records from the UK clinical practice research datalink linked to hospital data

BackgroundFurther understanding of adverse clinical event rates in patients with chronic kidney disease (CKD) is required for improved quality of care. This study described baseline characteristics, adverse clinical event rates, and mortality risk in patients with CKD, accounting for CKD stage and dialysis status.MethodsThis retrospective, noninterventional cohort study included data from adults (aged ≥ 18 years) with two consecutive estimated glomerular filtration rates of < 60 ml/min/1.73 m2, recorded ≥ 3 months apart, from the UK Clinical Practice Research Datalink of electronic health records obtained between January 1, 2004, and December 31, 2017. Select adverse clinical events, associated with CKD and difficult to quantify in randomized trials, were assessed; defined by Read codes and International Classification of Diseases, Tenth Revision codes. Clinical event rates were assessed by dialysis status (dialysis-dependent [DD], incident dialysis-dependent [IDD], or non–dialysis-dependent [NDD]), dialysis modality (hemodialysis [HD] or peritoneal dialysis [PD]), baseline NDD-CKD stage (3a–5), and observation period.ResultsOverall, 310,953 patients with CKD were included. Comorbidities were more common in patients receiving dialysis than in NDD-CKD, and increased with advancing CKD stage. Rates of adverse clinical events, particularly hyperkalemia and infection/sepsis, also increased with advancing CKD stage and were higher in patients on HD versus PD. Mortality risk during follow-up (1–5-year range) was lowest in patients with stage 3a NDD-CKD (2.0–18.5%) and highest in patients with IDD-CKD (26.3–58.4%).ConclusionsThese findings highlight the need to monitor patients with CKD for comorbidities and complications, as well as signs or symptoms of clinical adverse events.

Relationship between Exercise Test Parameters, Device-Delivered Electric Shock and Adverse Clinical Events in Patients with an Implantable Cardioverter Defibrillator for Primary Prevention.

(1) Background: Receiving the first internal electric shock is a turning point for patients with an implantable cardioverter defibrillator (ICD) for primary prevention. However, no study has investigated whether patients who receive a first device-delivered electric shock have a poor prognosis even at the time of ICD implantation. (2) Methods: We retrospectively identified 55 patients with ischemic (n = 31) or dilated (n = 24) cardiomyopathy who underwent ICD implantation for primary prevention with exercise test at the time of implantation. We recorded baseline characteristics, exercise test parameters, and clinical events. (3) Results: After a median follow-up of 5 years, we observed an association between an appropriate device-delivered electric shock, the occurrence of death or heart transplant, and the occurrence of the composite endpoint. There was also a significant relation between a VE/VCO2 slope >35 and the occurrence of the composite endpoint. Conversely, there was no significant association between negative outcomes on the exercise test and the occurrence of a device-delivered electric shock. (4) Conclusions: The exercise test performed at the time of ICD implantation do not predict the occurrence of device-delivered electric shock. The exercise test and the first electric shock are two independent markers of poor prognosis.

Anticoagulation Control and Major Adverse Clinical Events in Patients with Operated Valvular Heart Disease with and without Atrial Fibrillation Receiving Vitamin K Antagonists.

Good quality anticoagulation among patients with operated valvular heart disease is needed to reduce ischaemic and thromboembolic complications. There is limited evidence regarding factors that affect anticoagulation control in patients implanted with mechanical or tissue prosthetic valve(s). To examine the quality of and factors that affect anticoagulation control, major adverse clinical events and all-cause death in operated valvular heart disease patients with and without atrial fibrillation who are receiving a vitamin K antagonist. Quality of anticoagulation were retrospectively assessed among 456 operated valvular heart disease patients [164 (36%) with AF and 290 (64%) without AF] via time in therapeutic range (TTR) (Rosendaal method) and percentage of INRs in range (PINRR) over a median of 6.2 (3.3-8.5) years. VHD was defined by the presence of a mechanical or tissue prosthetic valve at the mitral, aortic, or both sites. Mean age 51 (14.7), 64.5% men. Most (96.1%) had a mechanical prosthesis and 64% had aortic valve replacement. Overall, mean TTR was 58.5% (14.6) and PINRR was 50.1% (13.8). Operated valvular heart disease patients with AF had significantly lower mean TTR and PINRR (TTR: 55.7% (14.2) vs. 60.1% (14.6); p = 0.002, respectively, PINRR: 47.4% (13.5) vs. 51.6% (13.7); p = 0.002, respectively), and a lower proportion of TTR ≥ 70%, despite a similar number of INR tests compared to those without AF. Predictors of TTR < 70% were female sex, AF and anaemia/bleeding history. Significantly higher proportions of operated valvular heart disease patients with AF died (20.7% vs. 5.8%; p < 0.001), but ≥1 MACE rates were similar between the two groups. Operated valvular heart disease patients with AF at baseline have poorer anticoagulation control compared to those without AF. The presence of concomitant AF, anaemia/bleeding history and female sex independently predicted poor TTR. Stringent INR monitoring is needed to improve anticoagulation control and prevent major adverse clinical events in patients with operated valvular heart disease.

Predictive value of left atrial strain analysis in adverse clinical events in patients with hypertrophic cardiomyopathy: a CMR study

BackgroundA subset of patients with hypertrophic cardiomyopathy (HCM) will experience adverse clinical events such as heart failure (HF), cardiovascular death, and new-onset atrial fibrillation (AF). Current risk stratification methods are imperfect and limit the identification of patients at high risk for HCM. This study aimed to evaluate the role of cardiac magnetic resonance (CMR)-derived left atrial strain parameters in the occurrence of adverse clinical events in patients with HCM.MethodsLeft atrial (LA) structural, functional, and strain parameters were evaluated in 99 patients with HCM and compared with 89 age-, sex-, and BMI-matched control subjects. LA strain parameters were derived from CMR two- and four-chamber cine images by a semiautomatic method. LA strain parameters include global longitudinal strain (GLS) and global circumferential strain (GCS). The LA GLS includes reservoir strain (GLS reservoir), conduit strain (GLS conduit), and booster strain (GLS booster). Three LA GLS strain rate (SR) parameters were derived: SR reservoir, SR conduit, and SR booster. The primary endpoint was set as a composite of adverse clinical events, including SCD, new-onset or worsening to hospitalized HF, new-onset AF, thromboembolic events, and fatal ventricular arrhythmias.ResultsLA GLS, GLS SR and GCS were impaired in HCM patients compared to control subjects (all p < 0.001). After a mean follow-up of 37.94 ± 23.69 months, 18 HCM patients reached the primary endpoint. LA GLS, GLS SR, and GCS were significantly lower in HCM patients with adverse clinical events than in those without adverse clinical events (all p < 0.05). In stepwise multiple Cox regression analysis, LV SV, LA diameter, pre-contraction LAV (LAV pre-ac), passive LA ejection fraction (EF), and LA GLS booster were all independent determinants of adverse clinical events. LA GLS booster ≤ 8.9% was the strongest determinant (HR = 8.9 [95%CI (1.951, 40.933)], p = 0.005). Finally, LA GLS booster provided predictive adverse clinical events value (AUC = 0.86 [95%CI 0.77–0.98]) that exceeded traditional outcome predictors.ConclusionLA strain assessment, a measure of LA function, provides additional predictive information for established predictors of HCM patients. LA GLS booster was independently associated with adverse clinical events in patients with HCM.

Prognostic impact of heart rate during atrial fibrillation on clinical outcomes in elderly non-valvular atrial fibrillation patients: ANAFIE Registry sub-cohort study

BackgroundElderly patients with atrial fibrillation (AF) are at a higher risk for all-cause mortality and heart failure. Rate control is an essential component in AF management. This exploratory study assessed the relationship between resting heart rate during AF at baseline and clinical outcomes in Japanese elderly non-valvular AF (NVAF) patients, using the All Nippon AF In the Elderly Registry (ANAFIE) dataset. MethodsThis sub-cohort included patients who agreed to participate and presented with AF at enrollment in the ANAFIE study. They were categorized into six groups according to the resting heart rate during AF. Outcomes included 2-year cumulative incidences of stroke/systemic embolic events (SEE), ischemic stroke, major bleeding, cardiovascular (CV) events, CV death, all-cause death, and net clinical outcome, a composite of stroke/SEE, major bleeding, and all-cause death. ResultsOf the 8292 patients included in this sub-cohort (paroxysmal, 1496; non-paroxysmal, 6796), 90 % of patients were using anticoagulants. Higher heart rate was more frequently reported in women and in patients with paroxysmal AF and was associated with increased use of direct oral anticoagulants (DOACs) and antiarrhythmic drugs. Heart rate ≥110 beats per minute (bpm) was associated with a significantly higher incidence of cardiac events and numerically higher incidences of CV death and all-cause death compared with a heart rate of 60 to <80 bpm, all of which were driven by an increased risk in patients with non-paroxysmal AF. Hazard ratios by the type of anticoagulant for each clinical outcome were comparable across all heart rate categories, indicating no significant interactions. ConclusionsElderly Japanese patients with non-paroxysmal NVAF and a heart rate ≥110 bpm have an increased risk of cardiac events. There was no interaction between heart rate category and the relative risk of adverse clinical events in patients taking DOACs compared with those taking warfarin.

Abstract 10864: Reduction in Right Ventricular Strain is Associated With Increased Mortality in Acute Pulmonary Embolism

Introduction: Right ventricular (RV) systolic dysfunction has been identified as a prognostic marker for adverse clinical events in patients presenting with acute pulmonary embolism (PE). However, problems exist in identifying RV dysfunction using conventional echocardiography. Strain echocardiography is an evolving imaging modality which measures myocardial deformation and can be used as an objective index of RV systolic function. Hypothesis: We hypothesized that RV strain analysis is prognostic of mortality in patients with acute PE. Methods: Retrospective cohort study of 177 patients with acute PE between 2010 and 2017. Strain analysis was retroactively applied. All echocardiograms were completed within 48 hours of diagnosis. RV global longitudinal strain (RVGLS) was applied using TomTec®. The primary outcome was all-cause mortality at 30 days and in-hospital mortality. T-test statistical analysis was performed. Receiver operating characteristic (ROC) curves and Kaplan-Meier curves were used for evaluation. Results: Study quality was sufficient to perform RVGLS analysis in 157 patients (90.2%). Mortality at 30 days and in-hospital mortality occurred in 12.7% and 8.9% of patients respectively. Comparing 30-day mortality, there was a significant reduction in RVGLS compared to survivors (13.0% ± 3.0% vs 19.6% ± 3.5%, p &lt; 0.001). In-hospital mortality as well showed a significant difference (13.1% ± 3.3% vs 19.3% ± 3.7%, p &lt; 0.001). Using ROC curves, we chose a RVGLS value of 17.5% (sensitivity 90%, specificity 74%) to predict 30-day mortality. Patients with RVGLS worse than 17.5% had 18 times higher risk of 30-day mortality compared to patients with RVGLS better than 17.5% (HR 18.4, 95% CI= 4.2-79.7, p &lt; 0.001. Figure). Conclusions: RV strain have significant prognostic value in patients with acute PE, and identifying those at higher risk of death. Assessment of RV strain has promise for clinical applications.

The Potential Role of Fatigue in Identifying Patients With NASH and Advanced Fibrosis Who Experience Disease Progression

Fatigue is common in patients with advanced liver disease. We investigated fatigue and clinical outcomes among patients with advanced nonalcoholic steatohepatitis (NASH). In this study, patients with biopsy confirmed NASH and bridging fibrosis (F3) or compensated cirrhosis (F4) were followed for up to 2 years. The Chronic Liver Disease Questionnaire for Nonalcoholic Steatohepatitis (CLDQ-NASH) fatigue domain at baseline (range, 1-7; lower score indicating worse fatigue) quantified fatigue. The Cox proportional hazards model was used to study time to liver-related clinical events (progression to histologic cirrhosis or hepatic decompensation in F3, hepatic decompensation in F4). Of the 1679 NASH patients with fibrosis, 802 had F3 and 877 had F4 (58 ± 9 years of age, 40% male, 74% type 2 diabetes). During median follow-up of 16 months (interquartile range, 14-18), 15% (n= 123) of NASH F3 patients experienced liver-related events and 3.5% (n= 31) of NASH F4 patients experienced hepatic decompensation. Mean baseline CLDQ-NASH fatigue score in F3 patients was 4.77 ± 1.36; NASH F3 patients who experienced liver-related events had lower baseline scores: 4.47 ± 1.36 vs 4.83 ± 1.35 (P= .0091). The mean fatigue score in F4 was 4.56 ± 1.44; these scores were lower in patients who decompensated in follow-up: 3.74 ± 1.31 vs 4.59 ± 1.43 (P= .0011). The association of lower fatigue scores and risk of liver-related or decompensation events was significant after adjustment for confounders (adjusted hazard ratio per 1 point in fatigue score in F3, 0.85; 95% confidence interval, 0.74-0.97; P= .02; adjusted hazard ratio in F4, 0.62; 95% confidence interval, 0.48-0.81; P= .0004). Worse fatigue at baseline is associated with a higher risk of adverse clinical events in patients with NASH-related advanced fibrosis and cirrhosis.

Association of Proton Pump Inhibitor and Infection and Major Adverse Clinical Events in Patients With ST-Elevation Myocardial Infarction: A Propensity Score Matching Analysis.

BackgroundInfections are not common but important in patients with acute myocardial infarction, and are associated with worse outcomes. Infection was proved to be associated with the use of proton pump inhibitor (PPI) in several cohorts. It remains unclear whether PPI usage affects infection in patients with acute myocardial infarction.MethodsWe consecutively enrolled patients with ST-elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI) from January 2010 to June 2018. All patients were divided into the PPI group and non-PPI group according to whether the PPI was used. The primary endpoint was the development of infection during hospitalization.ResultsA total of 3027 patients were finally enrolled, with a mean age of 62.2 ± 12.6 years. 310 (10.2%) patients were developed infection during hospitalization. Baseline characteristics were similar between the PPI and non-PPI groups (n = 584 for each group) after propensity score analysis. PPI usage was significantly associated with infection based on the propensity score matching analysis (adjusted OR = 1.62, 95% CI = 1.02-2.57, P = 0.041). Comparing to patients with non-PPI usage, PPI administration was positively associated with higher risk of in-hospital all-cause mortality (adjusted OR = 3.25, 95% CI = 1.06-9.97, P = 0.039) and in-hospital major adverse clinical events (adjusted OR = 3.71, 95% CI = 1.61-8.56, P = 0.002). Subgroup analysis demonstrated that the impact of PPI on infection was not significantly different among patients with or without diabetes and patients with age ≥65 years or age <65 years.ConclusionPPI usage was related to a higher incidence of infection during hospitalization, in-hospital all-cause mortality, and in-hospital major adverse clinical events (MACE) in STEMI patients.

Randomized evaluation of vessel preparation with orbital atherectomy prior to drug-eluting stent implantation in severely calcified coronary artery lesions: Design and rationale of the ECLIPSE trial

Severe coronary artery calcification has been associated with stent underexpansion, procedural complications, and increased rates of early and late adverse clinical events in patients undergoing percutaneous coronary intervention. To date, no lesion preparation strategy has been shown to definitively improve outcomes of percutaneous coronary intervention for calcified coronary artery lesions. ECLIPSE (NCT03108456) is a prospective, randomized, multicenter trial designed to evaluate two different vessel preparation strategies in severely calcified coronary artery lesions. The routine use of the Diamondback 360 Coronary Orbital Atherectomy System is compared with conventional balloon angioplasty prior to drug-eluting stent implantation. The trial aims to enroll approximately 2000 subjects with a primary clinical endpoint of target vessel failure, defined as the composite of cardiac death, target vessel-related myocardial infarction, or ischemia-driven target vessel revascularization assessed at 1 year. The co-primary endpoint is the acute post-procedural in-stent minimal cross-sectional area as assessed by optical coherence tomography in a 500-subject cohort. Enrollment is anticipated to complete in 2022 with total clinical follow-up planned for 2 years. ECLIPSE is a large-scale, prospective randomized trial powered to demonstrate whether a vessel preparation strategy of routine orbital atherectomy system is superior to conventional balloon angioplasty prior to implantation of drug-eluting stents in severely calcified coronary artery lesions.