Adverse Clinical Outcomes In Patients Research Articles

Impact on clinical outcome of ventricular arrhythmias in patients undergoing transcatheter aortic valve implantation (TAVI)

Abstract Background Transcatheter aortic valve implantation (TAVI) in the treatment of severe aortic stenosis has considerably grown in the latest years. There are limited data, however, about predictors of long-term prognosis in this population. Particularly, whether ventricular arrhythmic burden is associated with clinical outcome has poorly been investigated. Purpose The aim of our study was to investigate the association between ventricular arrhythmias and adverse clinical outcomes in patients undergoing TAVI. Methods We performed a 24-hour 3-channel ECG Holter monitoring (HM) in 267 consecutive patients who underwent TAVI for severe aortic stenosis at our Centre within 30 days from a successful procedure (average 10.2 days, range 2-30). For each patient we obtained the number of premature ventricular complexes (PVCs) and the presence of non-sustained ventricular tachycardia (NSVT, >3 PVCs with a rate >100 bpm). Frequent PVCs were defined as the presence of at least 30 PVCs per hour. We also collected clinical and echocardiographic findings for each patient. Assessment of clinical events at follow-up was performed by clinical visits or telephone interviews of patients or relatives (in case of fatal events). The primary endpoint of the study was the occurrence of cardiovascular events (CVE), a composite of cardiovascular death and resuscitation from cardiac arrest. All-cause-mortality was assessed as secondary endpoint. Survival Cox regression was applied to assess the univariate and multivariate association of clinical, echocardiographic and HM variables with endpoints. Results Clinical outcome could be obtained for 228 patients (85%), for an average follow-up of 3.5 years (range 1.0-8.6). Among these patients, frequent PVCs (≥30/hour) and episodes of NSVT at HM were found in 47 (20.6%) and 52 (22.4%) patients, respectively. CVE occurred in 26 patients (11.4%) and 63 patients died (27.6%). Frequent PVCs at HM were detected in 12 patients with (46.2%) and 35 patients without (17.3%) CVE (HR 2.29; 95% CI 1.03-5.09; p=0.04). One or more episodes of NSVT were detected in 9 patients with (34.6%) and 43 patients without (21.3%) CVE (HR 2.29; 95% CI 1.03-5.09; p=0.04), although it was not predictive of all-cause mortality (HR 1.18; 95% CI 0.48-2.77; p=0.52). Both the presence of PVCs>30/hour (HR 1.19; 95% CI 0.69-2.08; p=0.53) and NSVT (HR 0.93; 95% CI 0.52-1.65; p=0.22) were not significantly associated with all-cause mortality. Moreover, no clinical (age, gender, cardiovascular risk factors) and echocardiographic (aortic valve area, trans-aortic mean gradient, left ventricle mass and ejection fraction) variable showed significant association with both the primary and secondary outcome in our patients. Conclusions In our study the detection of frequent PVCs at HM after TAVI was a major predictor of CVE (cardiovascular death/cardiac arrest), suggesting that a 24-hour HM after TAVI can be helpful for risk stratification of these patients.

The prognostic value of aortic stenosis and aortic sclerosis in patients with heart failure with reduced ejection fraction

Abstract Background Aortic stenosis (AS) and aortic valve sclerosis (AVS) as assessed by Doppler echocardiography have been associated with adverse clinical outcomes in patients with heart failure with reduced ejection fraction (HFrEF). However, further clarification of the role of AV and AVS in the HFrEF population is warranted. Methods A total of 873 patients with stable HFrEF were included in this retrospective cohort study. At referral, the patients had a left ventricular ejection fraction (LVEF) of 45% or lower Baseline clinical and echocardiographic data were retrieved from the heart failure outpatient clinic's database, and the patients were followed through a nationwide register for the outcome of all-cause mortality. The presence of AS and AVS was assessed using Doppler-derived pressure gradients of the aortic valve (AV) from the echocardiogram. Cox-regression models were used to determine the association between AV peak gradient and mortality. Multivariable models were adjusted for demographic, clinical, and echocardiographic parameters (age, sex, diabetes (DM), ischemic heart disease (IHD), BMI, heart rate, mean arterial pressure, total cholesterol and atrial fibrillation (AF), LVEF, left atrial volume index (LAVi), left ventricular mass index (LVMi), E/e’). Results Seventy-four percent of patients were male, and mean age was 66.8 ± 11.4 years. In total, 13% had DM, 57% had IHD, 38% had NYHA III-IV, 8% had implantable cardiac device (including pacemaker, ICD, and CRT), and 15.9% had AF. Mean LVEF was 27.3 ± 9.4% with a mean LVMi of 120.2 g/m2 ± 38.2. Mean AV peak velocity was 1.4 m/s ± 0.5 and median AV peak gradient was 6.3 mmHg (IQR 4.7; 8.9). During a median follow-up of 3.3 years (IQR 1.9 – 4.7 years), 143 patients (16.4 %) reached the outcome. In univariable analysis, AV peak gradient was associated with all-cause mortality (HR 1.23 per 10 mmHg increase, 95% CI 1.05-1.44, p = 0.012). LVEF modified the prognostic value of AV peak gradient (p = 0.026 for interaction). After stratifying the population by the median value of LVEF (cut-off = 28%), AV peak gradient remained prognostic only in patients with LVEF above the median (HR 1.58 per 10 mmHg increase, 95% CI 1.30-1.91, p < 0.001), whereas AV peak gradient was not significantly associated with mortality amongst the patients with LVEF below the median level (HR 1.03 per 10 mmHg increase, 95% CI 0.83-1.37, p = 0.827). After multivariable adjustment, AV peak gradient remained an independent predictor of the outcome in patients in the higher median of LVEF (HR 1.32 per 10 mmHg increase, 95% CI 1.02-1.70, p = 0.035) (Figure 1). Conclusion Presence of AS and AVS (derived by AV peak gradient Doppler echocardiography) is an independent predictor of all-cause mortality amongst HFrEF patients. However, presence of AS and AVS only entails prognostic information amongst the HFrEF patients without severely reduced LVEF.Incidence rates of all-cause mortality

Glycated Albumin and Adverse Clinical Outcomes in Patients with CKD

Glycated Albumin and Adverse Clinical Outcomes in Patients with CKD

Atrial fibrillation in patients with dilated cardiomyopathy: prevalence, risk factors and prognostic significance

Aim. To study the epidemiological profile and long-term prognostic significance of atrial fibrillation (AF) as a risk factor for adverse clinical outcomes in patients with dilated cardiomyopathy (DCM).Material and methods. The study included 270 patients with DCM (206/76,3% men, age 47 [37; 56] years, left ventricular (LV) ejection fraction 29 [21; 35]%). The observation period was 6 years (Me 76 [57; 119] months). To assess the effect of AF on DCM prognosis, Kaplan-Meier curves and Cox regression of clinical outcomes, including cardiovascular death, heart transplantation, and ventricular assist device implantation, were analyzed.Results. Of 270 patients with DCM, paroxysmal AF was detected in 10 (3,7%) patients (initial, 5/1,85%; during the first follow-up year, 5/1,85%). After 5 years, another 65 (24,1%) individuals had AF (paroxysmal, persistent or permanent). Ventricular tachyarrhythmias were registered in 163 (60,4%) patients. Compared with patients maintaining sinus rhythm, patients with AF were older (51,4±10 vs 43,6±13 years, p=0,001) and had lower exercise tolerance (6-minute walk test: 379±45 vs 445±43 meters; p=0,0002) and a higher heart failure functional class (NYHA class III-IV: 38/50,7% vs 52/26,7%; χ2=13,6; p=0 ,0003). In patients with AF, initially more pronounced manifestations of right ventricular contractile dysfunction (TAPSE: 13,1±3,4 vs 15,5±4,6 mm; p=0,0001) and LV diastolic dysfunction (E/A: 2,9±1,5 vs 2,1±1,3; p=0,006; E/e' 15,6±6,9 vs 11,8±7,2; p=0,019), more dilated left atrium (left atrial volume index: 63,3±19 vs 50±18,7 ml/m2; p=0,006). During the 6-year median follow-up, AF was observed in 75 patients (0,46 new cases/100 patients/year). As a result of Cox regression analysis, AF as a time-dependent factor was identified as an independent predictor of cardiovascular death (hazard ratio 3,99; 95% confidence interval, 1,67-8,59; p=0,0001).Conclusion. AF, as one of the most common sustained atrial tachyarrhythmias in the population, demonstrated a lower prevalence (27,8%) in the DCM cohort compared to ventricular tachyarrhythmias (60,4%), but a high prognostic significance of the negative impact on the risk of fatal outcomes. The development of AF in patients with DCM is associated with a 4-fold increase in cardiovascular death risk over a 6-year period.

Left ventricular underfilling in PAH: A potential indicator for adaptive-to-maladaptive transition.

Pulmonary arterial hypertension (PAH) still remains a life-threatening disorder with poor prognosis. The right ventricle (RV) adapts to the increased afterload by a series of prognostically significant morphological and functional changes, the adaptive nature should also be understood in the context of ventricular interdependence. We hypothesized that left ventricle (LV) underfilling could serve as an important imaging marker for identifying maladaptive changes and predicting clinical outcomes in PAH patients. We prospectively enrolled patients with PAH who underwent both cardiac magnetic resonance and right heart catheterization between October 2013 and December 2020. Patients were categorized into four groups based on their LV and RV mass/volume ratio (M/V). LV M/V was stratified using the normal value (0.7 g/mL for males and 0.6 g/mL for females) to identify patients with LV underfilling (M/V ≥ normal value), while RV M/V was stratified based on the median value. The primary endpoint was all-cause mortality, and the composite endpoints included all-cause mortality and heart failure-related readmissions. A total of 190 PAH patients (53 male, mean age 37 years) were included in this study. Patients with LV underfilling exhibited higher NT-proBNP levels, increased RV mass, larger RV but smaller LV, lower right ventricular ejection fraction, and shorter 6-min walking distance. Patients with LV underfilling had a 2.7-fold higher risk of mortality than those without and LV M/V (hazard ratio [per 0.1 g/mL increase]: 1.271, 95% confidence interval: 1.082-1.494, p = 0.004) was also independent predictors of all-cause mortality. Moreover, patients with low LV M/V had a better prognosis regardless of the level of RV M/V. Thus, LV underfilling is an independent predictor of adverse clinical outcomes in patients with PAH, and it could be an important imaging marker for identifying maladaptive changes in these patients.

Association between admission-blood-glucose-to-albumin ratio and clinical outcomes in patients with ST-elevation myocardial infarction undergoing percutaneous coronary intervention.

It is unclear whether admission-blood-glucose-to-albumin ratio (AAR) predicts adverse clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI) who are treated with percutaneous coronary intervention (PCI). Here, we performed a observational study to explore the predictive value of AAR on clinical outcomes. Patients diagnosed with STEMI who underwent PCI between January 2010 and February 2020 were enrolled in the study. The patients were classified into three groups according to AAR tertile. The primary outcome was in-hospital all-cause mortality, and the secondary outcomes were in-hospital major adverse cardiac events (MACEs), as well as all-cause mortality and MACEs during follow-up. Logistic regression, Kaplan-Meier analysis, and Cox proportional hazard regression were the primary analyses used to estimate outcomes. Among the 3,224 enrolled patients, there were 130 cases of in-hospital all-cause mortality (3.9%) and 181 patients (5.4%) experienced MACEs. After adjustment for covariates, multivariate analysis demonstrated that an increase in AAR was associated with an increased risk of in-hospital all-cause mortality [adjusted odds ratio (OR): 2.72, 95% CI: 1.47-5.03, P = 0.001] and MACEs (adjusted OR: 1.91, 95% CI: 1.18-3.10, P = 0.009), as well as long-term all-cause mortality [adjusted hazard ratio (HR): 1.64, 95% CI: 1.19-2.28, P = 0.003] and MACEs (adjusted HR: 1.58, 95% CI: 1.16-2.14, P = 0.003). Receiver operating characteristic (ROC) curve analysis indicated that AAR was an accurate predictor of in-hospital all-cause mortality (AUC = 0.718, 95% CI: 0.675-0.761) and MACEs (AUC = 0.672, 95% CI: 0.631-0.712). AAR is a novel and convenient independent predictor of all-cause mortality and MACEs, both in-hospital and long-term, for STEMI patients receiving PCI.

Prognostic value of three iron deficiency definitions in patients with advanced heart failure.

There is uncertainty about the definition of iron deficiency (ID) and the association between ID and prognosis in patients with advanced heart failure. We evaluated three definitions of ID in patients referred for heart transplantation. Consecutive patients assessed for heart transplantation at a single UK centre between January 2010 and May 2022 were included. ID was defined as (1) serum ferritin concentration of <100 ng/ml, or 100-299 ng/ml with transferrin saturation <20% (guideline definition), (2) serum iron concentration ≤13 μmol/L, or (3) transferrin saturation <20%. The primary outcome measure was a composite of all-cause mortality, urgent heart transplantation or need for mechanical circulatory support. Overall, 801 patients were included, and the prevalence of ID was 39-55% depending on the definition used. ID, defined by either serum iron or transferrin saturation, was an independent predictor of the primary outcome measure (hazard ratio [HR] 1.532, 95% confidence interval [CI] 1.264-1.944, and HR 1.595, 95% CI 1.323-2.033, respectively), but the same association was not seen with the guideline definition of ID (HR 1.085, 95% CI 0.8827-1.333). These findings were robust in multivariable Cox regression analysis. ID, by all definitions, was associated with lower 6-min walk distance, lower peak oxygen consumption, higher intra-cardiac filling pressures and lower cardiac output. Iron deficiency, when defined by serum iron concentration or transferrin saturation, was associated with increased frequency of adverse clinical outcomes in patients with advanced heart failure. The same association was not seen with guideline definition of ID.

Targeting MS4A4A on tumour-associated macrophages restores CD8+ T-cell-mediated antitumour immunity

ObjectiveCheckpoint immunotherapy unleashes T-cell control of tumours but is suppressed by immunosuppressive myeloid cells. The transmembrane protein MS4A4A is selectively highly expressed in tumour-associated macrophages (TAMs). Here, we aimed to...

HS-CRP Modifies the Prognostic Value of Platelet Count for Clinical Outcomes After Ischemic Stroke.

Background We examined whether the relationship between baseline platelet count and clinical outcomes is modulated by HS-CRP (high-sensitivity C-reactive protein) in patients with ischemic stroke. Methods and Results A total of 3267 patients with ischemic stroke were included in the analysis. The primary outcome was a combination of death and major disability at 1 year after ischemic stroke. Secondary outcomes included major disability, death, vascular events, composite outcome of vascular events or death, and an ordered 7-level categorical score of the modified Rankin Scale at 1 year. Multivariate logistic regression and Cox proportional hazards regression models were used to assess the association between the baseline platelet count and clinical outcomes stratified by HS-CRP levels when appropriate. There was an interaction effect of platelet count and HS-CRP on the adverse clinical outcomes after ischemic stroke (all Pinteraction<0.05). The elevated platelet count was significantly associated with the primary outcome (odds ratio [OR], 3.14 [95% CI, 1.77-5.58]), major disability (OR, 2.07 [95% CI, 1.15-3.71]), death (hazard ratio [HR], 2.75 [95% CI, 1.31-5.79]), and composite outcome of vascular events or death (HR, 2.57 [95% CI, 1.38-4.87]) among patients with high HS-CRP levels (all Ptrend<0.05). Conclusions The HS-CRP levels had a modifying effect on the association between platelet count and clinical outcomes in patients with ischemic stroke. Elevated platelet count was significantly associated with adverse clinical outcomes in patients with ischemic stroke with high HS-CRP levels, but not in those with low HS-CRP levels. These findings suggest that strategies for anti-inflammatory and antiplatelet therapy should be developed according to the results of both platelet and HS-CRP testing.

Vascular endothelial profilin-1 drives a protumorigenic tumor microenvironment and tumor progression in renal cancer

Overexpression of actin-binding protein profilin-1 (Pfn1) correlates with advanced disease features and adverse clinical outcome of patients with clear cell renal carcinoma, the most prevalent form of renal cancer. We previously reported that Pfn1 is predominantly overexpressed in tumor-associated vascular endothelial cells in human clear cell renal carcinoma. In this study, we combined invivo strategies involving endothelial cell-specific depletion and overexpression of Pfn1 to demonstrate a role of vascular endothelial Pfn1 in promoting tumorigenicity and enabling progressive growth and metastasis of renal carcinoma cells in a syngeneic orthotopic mouse model of kidney cancer. We established an important role of endothelial Pfn1 in tumor angiogenesis and further identified endothelial Pfn1-dependent regulation of several pro- (VEGF, SERPINE1, CCL2) and anti-angiogenic factors (platelet factor 4) invivo. Endothelial Pfn1 overexpression increases tumor infiltration by macrophages and concomitantly diminishes tumor infiltration by T cells including CD8+ T cells invivo, correlating with the pattern of endothelial Pfn1-dependent changes in tumor abundance of several prominent immunomodulatory cytokines. These data were also corroborated by multiplexed quantitative immunohistochemistry and immune deconvolution analyses of RNA-seq data of clinical samples. Guided by Upstream Regulator Analysis of tumor transcriptome data, we further established endothelial Pfn1-induced Hif1α elevation and suppression of STAT1 activation. In conclusion, this study demonstrates for the first time a direct causal relationship between vascular endothelial Pfn1 dysregulation, immunosuppressive tumor microenvironment, and disease progression with mechanistic insights in kidney cancer. Our study also provides a conceptual basis for targeting Pfn1 for therapeutic benefit in kidney cancer.

Prognostic Significance of Activated Monocytes in Patients with ST-Elevation Myocardial Infarction.

Circulating monocytes have different subsets, including classical (CD14++CD16-), intermediate (CD14++CD16+), and nonclassical (CD14+CD16++), which play different roles in cardiovascular physiology and disease progression. The predictive value of each subset for adverse clinical outcomes in patients with coronary artery disease is not fully understood. We sought to evaluate the prognostic efficacy of each monocyte subset in patients with ST-elevation myocardial infarction (STEMI). We recruited 100 patients with STEMI who underwent primary percutaneous coronary intervention (PCI). Blood samples were collected at the time of presentation to the hospital (within 6 h from onset of symptoms, baseline (BL)) and then at 3, 6, 12, and 24 h after presentation. Monocytes were defined as CD45+/HLA-DR+ and then subdivided based on the expression of CD14, CD16, CCR2, CD11b, and CD42. The primary endpoint was a composite of all-cause death, hospitalization for heart failure, stent thrombosis, in-stent restenosis, and recurrent myocardial infarction. Univariate and multivariate Cox proportional hazards models, including baseline comorbidities, were performed. The mean age of our cohort was 58.9 years and 25% of our patients were females. Patients with high levels (above the median) of CD14+CD16++ monocytes showed an increased risk for the primary endpoint in comparison to patients with low levels; adjusted hazard ratio (aHR) for CD14+/CD16++ cells was 4.3 (95% confidence interval (95% CI) 1.2-14.8, p = 0.02), for CD14+/CD16++/CCR2+ cells was 3.82 (95% CI 1.06-13.7, p = 0.04), for CD14+/CD16++/CD42b+ cells was 3.37 (95% CI 1.07-10.6, p = 0.03), for CD14+/CD16++/CD11b+ was 5.17 (95% CI 1.4-18.0, p = 0.009), and for CD14+ HLA-DR+ was 7.5 (95% CI 2.0-28.5, p = 0.002). CD14++CD16-, CD14++CD16+, and their CD11b+, CCR2+, and CD42b+ aggregates were not significantly predictive for our composite endpoint. Our study shows that CD14+ CD16++ monocytes and their subsets expressing CCR2, CD42, and CD11b could be important predictors of clinical outcomes in patients with STEMI. Further studies with a larger sample size and different coronary artery disease phenotypes are needed to verify the findings.

Geriatric Nutritional Risk Index and the Survival of Patients with Hepatocellular Carcinoma: A Meta-Analysis.

Malnutrition is a risk factor of adverse clinical outcome in patients with cancer. Recent studies suggest that geriatric nutritional risk index (GNRI) could reflect the nutritional status in patients with various clinical conditions. The aim of the systematic review and meta-analysis was to evaluate the association between GNRI and survival of patients with hepatocellular carcinoma (HCC). Observational studies evaluating the association between pretreatment GNRI and survival of patients with HCC were obtained by search of PubMed, Web of Science, Embase, Wanfang, and CNKI databases. A random-effects model was used to pool the results after incorporating the potential influence of heterogeneity. Seven cohort studies including 2636 patients with HCC contributed to the meta-analysis. Pooled results showed that HCC patients with low pretreatment GNRI were associated with poor overall survival [hazard ratio (HR): 1.77, 95% confidence interval (CI): 1.32 to 2.37, p<0.001; I2=66%) and progression-free survival (HR: 1.62, 95% CI: 1.39 to 1.89, p<0.001; I2=0%) as compared to those with normal GNRI. Sensitivity analyses by excluding one study at a time showed similar results (p all<0.05). Subgroup analyses showed that the association between low pretreatment GNRI and poor survival of patients with HCC was not significantly affected by age of the patients, main treatment, cutoff of GNRI, or the follow-up durations. In conclusion, malnutrition indicated by a low pretreatment GNRI may be a risk factor of poor survival of patients with HCC.

#6963 OBESITY, METABOLIC SYNDROME AND THE RISK OF ADVERSE CLINICAL OUTCOMES IN PATIENTS WITH CHRONIC KIDNEY DISEASE

Abstract Background and Aims Obesity and metabolic syndrome are prevalent disorder in patients with chronic kidney disease (CKD). However, it is unclear whether obesity without metabolic syndrome is associated with higher risk of adverse clinical outcomes in patients with CKD. Method We reviewed the National Health Insurance Service database of Korea for people who received ≥2 national health screenings between 2009 and 2011. A total of 68,464 chronic kidney disease patients were identified with consecutive estimated glomerular filtration rate &amp;lt;60 ml/min per 1.73 m2. Obesity was defined as body mass index ≥25 kg/m2 and metabolic syndrome status was considered as the presence of three or more of the following metabolic factors; waist circumference, blood pressure, fasting blood sugar, triglyceride level, high-density lipoprotein cholesterol level. The primary outcomes were cardiovascular events, end-stage renal disease progression (ESRD) and all-cause mortality. Results Compared to non-obese patients without metabolic syndrome, obesity without metabolic syndrome did not increase the risk of cardiovascular event (HR 1.02, 95% CI 0.95–1.11) and progression to ESRD (HR 0.86, 95% CI 0.73–1.02). Risk of all-cause mortality was significantly decreased in these patients (HR 0.88, 95% CI 0.81–0.96). These findings were consistently observed in overweight, obese, morbid obese patients without metabolic syndrome. In addition, while linear increase of HRs for each additional metabolic abnormality was observed, HRs increase for cardiovascular event was significantly slower in obese patients than in non-obese (P for interaction = 0.035). Conclusion Obesity without metabolic syndrome did not confer excess risk for cardiovascular complication or ESRD progression and decreased the risk of all-cause mortality. Healthy effect of obesity against mortality risk and metabolic hazard on cardiovascular event is better to be considered in CKD patients.

A transformer-based representation-learning model with unified processing of multimodal input for clinical diagnostics.

During the diagnostic process, clinicians leverage multimodal information, such as the chief complaint, medical images and laboratory test results. Deep-learning models for aiding diagnosis have yet to meet this requirement of leveraging multimodal information. Here we report a transformer-based representation-learning model as a clinical diagnostic aid that processes multimodal input in a unified manner. Rather than learning modality-specific features, the model leverages embedding layers to convert images and unstructured and structured text into visual tokens and text tokens, and uses bidirectional blocks with intramodal and intermodal attention to learn holistic representations of radiographs, the unstructured chief complaint and clinical history, and structured clinical information such as laboratory test results and patient demographic information. The unified model outperformed an image-only model and non-unified multimodal diagnosis models in the identification of pulmonary disease (by 12% and 9%, respectively) and in the prediction of adverse clinical outcomes in patients with COVID-19 (by 29% and 7%, respectively). Unified multimodal transformer-based models may help streamline the triaging of patients and facilitate the clinical decision-making process.

The impact of concomitant metabolic dysfunction-associated fatty liver disease on adverse outcomes in patients with hepatitis B cirrhosis: a propensity score matching study.

In cirrhotic patients, the clinical relevance of metabolic dysfunction-associated fatty liver disease (MAFLD) is unclear. We aimed to research the relationship between MAFLD and adverse clinical outcomes in patients with hepatitis B cirrhosis. A total of 439 patients with hepatitis B cirrhosis were enrolled. Abdominal MRI and computed tomography were used to calculate liver fat content in order to evaluate steatosis. The Kaplan-Meier method was implemented to generate survival curves. The independent risk factors for prognosis were identified by multiple Cox regression. Propensity score matching (PSM) was used to reduce the influence of confounding factors. This study explored the relevance between MAFLD and mortality, first decompensation and further decompensation. In our study, most patients were decompensated cirrhosis (n = 332, 75.6%) and the ratio of decompensated cirrhosis patients in non-MAFLD to MAFLD group was 199 : 133. Compared to the non-MAFLD group, patients with MAFLD had worse liver function which mainly reflected that there were more Child-Pugh C patients and higher model for end-stage liver disease score in the MAFLD group. A total of 207 adverse clinical events occurred in the total cohort during a median follow-up of 47 months, including 45 deaths, 28 hepatocellular carcinoma, 23 first decompensation and 111 further decompensation. Cox multivariate analysis showed that MAFLD was an independent risk factor for death [hazard ratio (HR) 1.931; 95% confidence interval (CI) 1.019-3.660; P = 0.044 HR 2.645; 95% CI, 1.145-6.115; P = 0.023] and further decompensation (HR 1.859; 95% CI, 1.261-2.741; P = 0.002 HR 1.953; 95% CI, 1.195-3.192; P = 0.008) before and after PSM. In decompensated group with MAFLD, diabetes had a more significant effect on adverse prognosis than overweight or obesity and other metabolic risk factors. In patients with hepatitis B cirrhosis, concomitant MAFLD can predict a higher risk of further decompensation and death among decompensated individuals. According to patients among MAFLD, diabetes may be a major factor in the occurrence of adverse clinical events.

The influence of gender on 30-day adverse clinical outcomes in patients undergoing carotid surgery.

We aimed to further evaluate sex differences of perioperative and 30-day complications after carotid surgery in patients with both asymptomatic and symptomatic carotid artery stenosis. This was a single-center prospective cohort study including 2013 consecutive patients, who were treated surgically due to extracranial carotid artery stenosis and prospectively followed. Patients who underwent carotid artery stenting and who were treated conservatively were excluded. The primary endpoints for this study were hospital stroke/transitory ischemic attack (TIA) and overall survival rates. Secondary outcomes included all other hospital adverse events, 30-day stroke/TIA, and 30-day mortality rates. Hospital mortality was higher in female patients with symptomatic carotid stenosis (3% vs. 0.5%, P=0.018). Bleeding requiring re-intervention occurred more often in female patients with both asymptomatic (1.5% vs. 0.4%, P=0.045) and symptomatic carotid stenosis (2.4% vs. 0.2%, P=0.022). 30-day stroke/TIA and mortality rates were higher in female patients with both asymptomatic (stroke/TIA 4.4% vs. 2.5%, P=0.041; mortality 3.3% vs. 1.6%, P=0.046) and symptomatic carotid stenosis (stroke/TIA 8.3% vs. 4.2%, P=0.040; mortality 4.1% vs. 0.7%, P=0.006). After adjusting for all confounding factors, female gender remained an important predicting factor for 30-day stroke/TIA in asymptomatic (OR=1.4, 95%CI 1.0-4.7, P=0.041) and symptomatic patients (OR=1.7, 95%CI 1.1-5.3, P=0.040), as well as for 30-day all-cause mortality in patients with asymptomatic (OR=1.5, 95%CI 1.1-4.1, P=0.030) and symptomatic carotid artery disease (OR=1.2, 95%CI 1.0-5.2, P=0.048). Female gender is important predicting factor for stroke/TIA and all-cause mortality, both perioperative and during the first 30 days after carotid surgery.

The ratio of QRS/RV6-V1: a new electrocardiographic predictor of short- and long-term adverse clinical outcomes in patients with acute myocardial infarction combined with new-onset right bundle branch block.

A few studies have focused on electrocardiography (ECG) parameters correlating with clinical prognosis in patients with acute myocardial infarction (AMI) combined with new-onset right bundle branch block (RBBB). To assess the prognostic value of a new ECG parameter, namely, the ratio of QRS duration/RV6-V1 interval (QRS/RV6-V1), in patients with AMI combined with new-onset RBBB. A total of 272 AMI patients combined with new-onset RBBB who received primary percutaneous coronary intervention (P-PCI) were retrospectively enrolled in the study. First, the patients were divided into survival group and non-survival group. Demographic, angiographic, and ECG characteristics were compared between the two groups. Receiver operating characteristic (ROC) curve was used to screen the best ECG parameter for predicting 1-year mortality. Second, the ratio of QRS/RV6-V1, a continuous variable, was converted to the high ratio group and low ratio group according to the optimal cutoff value point determined by the X-tile software. We compared the patient's demographic, angiographic, and ECG characteristics, in-hospital major adverse cardiovascular events (MACE), and 1-year mortality between the two groups. Multivariate logistic and Cox regressions were used to evaluate whether the ratio of QRS/RV6-V1 was an independent prognostic factor of in-hospital MACE and 1-year mortality. The ROC curve showed that the ratio of QRS/RV6-V1 had a higher value for predicting in-hospital MACE and 1-year mortality than the QRS duration, RV6-V1 interval, and RV1 interval. The patients in the high ratio group had significantly higher CK-MB peak and Killip class, lower ejection fraction (EF%), higher ratio of the left anterior (LAD) descending artery as infarct-related artery (IRA), and longer total ischemia time (TIT) than those in the low ratio group. The QRS duration was wider in the high ratio group than that in the low ratio group, whereas RV6-V1 was narrower in the high ratio group compared with that in the low ratio group. The in-hospital MACE rate (93.3% vs. 31.0%, p < 0.001) and 1-year mortality rate (86.7% vs. 13.2%, p < 0.001) in the high ratio group were higher than those in the low ratio group. The higher ratio of QRS/RV6-V1 was an independent predictor of in-hospital MACE (odds ratio, 8.55; 95% CI, 1.40-52.37; p = 0.02) after adjusting other confounders. Cox regression showed that the higher ratio of QRS/RV6-V1 predicted higher 1-year mortality of the patients with AMI combined with new-onset RBBB [hazard ratios (HR), 12.4; 95% CI, 7.26-21.22); p < 0.001] than the lower ratio of QRS/RV6-V1, and the HR still stayed at 2.21 even after a multivariable adjustment (HR, 2.21; 95% CI, 1.05-4.64); p = 0.037). According to the results of our study, the high ratio of QRS/RV6-V1 (>3.0) was a valuable predictor of short- and long-term adverse clinical outcomes in AMI patients combined with new-onset RBBB. The implications of the high ratio of QRS/RV6-V1 were severe ischemia and pseudo synchronization between bi-ventricle.

Clinical features and risk factors of adverse clinical outcomes in central pulmonary embolism using machine learning analysis

BackgroundIn prior studies, central pulmonary embolism (PE) was associated with high clot burden and was considered an independent predictor for thrombolysis. Further information about predictors of adverse outcomes in these patients is needed for better risk stratification. The objective is to describe independent predictors of adverse clinical outcomes in patients with central PE. MethodsLarge retrospective, observational, and single-center study of hospitalized patients with central PE. Data were gathered on demographics, comorbidities, clinical features on admission, imaging, treatments, and outcomes. Multivariable standard and Least Absolute Shrinkage and Selection Operator (LASSO) machine learning logistic regressions and sensitivity analyses were used to analyze factors associated with a composite of adverse clinical outcomes, including vasopressor use, mechanical ventilation, and inpatient mortality. ResultsA total of 654 patients had central PE. The mean age was 63.1 years, 59% were women, and 82% were African American. The composite adverse outcome was observed in 18% (n = 115) of patients. Serum creatinine elevation (odds ratio [OR] = 1.37, 95% CI = 1.20–1.57; p = 0.0001), white blood cell (WBC) count elevation (OR = 1.10, 95% CI = 1.05–1.15; p < 0.001), higher simplified pulmonary embolism severity index (sPESI) score (OR = 1.47, 95% CI = 1.18–1.84; p = 0.001), serum troponin elevation (OR = 1.26, 95% CI 1.02–1.56; p = 0.03), and respiratory rate increase (OR = 1.03, 95% CI = 1.0–1.05; p = 0.02) were independent predictors of adverse clinical outcomes. ConclusionAmong patients with central PE, higher sPESI score, WBC count elevation, serum creatinine elevation, serum troponin elevation, and respiratory rate increase were independent predictors of adverse clinical outcomes. Right ventricular dysfunction on imaging and saddle PE location did not predict adverse outcomes.

Lipoprotein(a) Does Not Predict Thrombotic Events and In-Hospital Outcomes in Patients with COVID-19.

The prothrombotic and proinflammatory properties of lipoprotein(a) (Lp(a)) have been hypothesized to play a role in the pathogenesis of severe COVID-19; however, the prognostic impact of Lp(a) on the clinical course of COVID-19 remains controversial. This study aimed to investigate whether Lp(a) may be associated with biomarkers of thrombo-inflammation and the occurrence of thrombotic events or adverse clinical outcomes in patients hospitalized for COVID-19. We consecutively enrolled a cohort of patients hospitalized for COVID-19 and collected blood samples for Lp(a) assessment at hospital admission. A prothrombotic state was evaluated through D-dimer levels, whereas a proinflammatory state was evaluated through C-reactive protein (CRP), procalcitonin, and white blood cell (WBC) levels. Thrombotic events were marked by the diagnosis of deep or superficial vein thrombosis (DVT or SVT), pulmonary embolism (PE), stroke, transient ischemic attack (TIA), acute coronary syndrome (ACS), and critical limb ischemia (CLI). The composite clinical end point of intensive care unit (ICU) admission/in-hospital death was used to evaluate adverse clinical outcomes. Among 564 patients (290 (51%) men, mean age of 74 ± 17 years) the median Lp(a) value at hospital admission was 13 (10-27) mg/dL. During hospitalization, 64 (11%) patients were diagnosed with at least one thrombotic event and 83 (15%) patients met the composite clinical end point. Lp(a), as either a continuous or categorical variable, was not associated with D-dimer, CRP, procalcitonin, and WBC levels (p > 0.05 for all correlation analyses). In addition, Lp(a) was not associated with a risk of thrombotic events (p > 0.05 for multi-adjusted odds ratios) nor with a risk of adverse clinical outcomes (p > 0.05 for multi-adjusted hazard ratios). In conclusion, Lp(a) does not influence biomarkers of plasma thrombotic activity and systemic inflammation nor has any impact on thrombotic events and adverse clinical outcomes in patients hospitalized for COVID-19.

Improved Outcomes After Pulmonary Valve Replacement in Repaired Tetralogy of Fallot

BackgroundThe impact of pulmonary valve replacement (PVR) on major adverse clinical outcomes in patients with repaired tetralogy of Fallot (rTOF) is unknown. ObjectivesThe purpose of this study was to determine whether PVR is associated with improved survival and freedom from sustained ventricular tachycardia (VT) in rTOF. MethodsA PVR propensity score was created to adjust for baseline differences between PVR and non-PVR patients enrolled in INDICATOR (International Multicenter TOF Registry). The primary outcome was time to the earliest occurrence of death or sustained VT. PVR and non-PVR patients were matched 1:1 on PVR propensity score (matched cohort) and in the full cohort, modeling was performed with propensity score as a covariate adjustment. ResultsAmong 1,143 patients with rTOF (age 27 ± 14 years, 47% PVR, follow-up 8.3 ± 5.2 years), the primary outcome occurred in 82. The adjusted HR for the primary outcome for PVR vs no-PVR (matched cohort n = 524) was 0.41 (95% CI: 0.21-0.81; multivariable model P = 0.010). Full cohort analysis revealed similar results. Subgroup analysis suggested beneficial effects in patients with advanced right ventricular (RV) dilatation (interaction P = 0.046; full cohort). In patients with RV end-systolic volume index >80 mL/m2, PVR was associated with a lower primary outcome risk (HR: 0.32; 95% CI: 0.16-0.62; P < 0.001). There was no association between PVR and the primary outcome in patients with RV end-systolic volume index ≤80 mL/m2 (HR: 0.86; 95% CI: 0.38-1.92; P = 0.70). ConclusionsCompared with rTOF patients who did not receive PVR, propensity score-matched individuals receiving PVR had lower risk of a composite endpoint of death or sustained VT.