Cardiovascular Readmission Research Articles

Frailty as an independent predictor for midterm adverse outcomes in the elderly undergoing primary percutaneous coronary intervention: A longitudinal cohort study.

Frailty is associated with poor health outcomes in elderly population. However, its effect on midterm outcomes in elderly patients undergoing primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) remains unknown. This study aimed to evaluate the association between frailty, as classified by the Clinical Frailty Scale (CFS), and midterm adverse outcomes in elderly STEMI patients after primary PCI. In this prospective, observational, multicenter cohort study, frailty status of 426 STEMI patients aged ≥60 years undergoing primary PCI was determined using the nine-point CFS 2 weeks before the occurrence of STEMI. Patients scoring at least four points on the CFS were considered frail. The primary outcome was a composite of cardiovascular death or readmission. Secondary outcomes included cardiovascular death, cardiovascular readmission, heart failure-related death or readmission, and myocardial reinfarction. Follow-up data were collected through medical record reviews and/or telephone interviews. Of 426 elderly patients, 116 were frail. The median follow-up period was 15 months (interquartile range 5-19 months). Primary outcome events occurred in 87 (75.0%) frail and 75 (24.2%) nonfrail patients. The adjusted hazard ratio was 3.278 after model selection using the Bayesian Model Averaging approach (95% confidence interval 2.372-4.531). Multivariate Cox proportional hazard survival analysis showed that frailty was significantly associated with a higher prevalence of all secondary outcome events after adjusting for TIMI, PAMI, and CADILLAC risk scores. Frailty, as defined by the CFS, was independently associated with midterm adverse outcomes in elderly patients undergoing primary PCI for STEMI.

Abstract 4127931: Chronic Steroid Use is Associated with Increased Readmission Rates in Patients Admitted with Acute Coronary Syndromes

Introduction: Acute coronary syndrome (ACS) is associated with significant morbidity and mortality. Management of ACS includes percutaneous coronary intervention (PCI) and requires the use of antithrombotic therapy, which increases bleeding risk. Chronic steroid use (CSU) is common for many diseases and is also associated with bleeding risk and impaired wound healing. However, data on outcomes of patients with CSU and AMI are sparse. Methods: Patients admitted for ACS and managed with PCI from 2014 to 2020 with and without CSU were identified using the National Readmissions Database (NRD). In-hospital outcomes include death, arterial thrombosis (composite of ischemic stroke and arterial thromboembolism), and major bleeding (composite of gastrointestinal, intracranial, or post-procedure bleeding or transfusion). Ninety-day readmission outcomes were cardiovascular (CV)-related, bleeding-related and all-cause. Multivariable logistic or Cox proportional hazards were utilized. Results: A total of 1,087,357 patients with ACS were included, of whom, 9,864 (0.9%) had CSU. After multivariable adjustment, there was no significant difference in in-hospital mortality (3.1% vs 3.2%; OR 1.09, 95% CI 0.93-1.26) or risk of arterial thrombosis (3.3% vs 2.8%; OR 0.91, 95% CI 0.81-1.02) between patients with and without CSU. CSU was associated with an increased risk of major bleeding events (8.3% vs 6.0%; OR 1.15, 95% CI 1.06-1.25). CSU was associated with a higher risk of CV-related (10.7% vs 7.5%; HR 1.10, 95% CI 1.02-1.18), bleeding-related (2.3% vs 1.2%; HR 1.28, 95% CI 1.09-1.51), and all-cause 90-day readmissions (23.9% vs 14.9%; HR 1.28, 95% CI, 1.22-1.34). Conclusion: Among patients admitted with ACS who underwent PCI, CSU was associated with increased risk of bleeding during index hospitalization and readmissions for bleeding. Furthermore, CSU was associated with increased risk of 90-day CV and all-cause readmission. Further studies are needed to better characterize this risk.

Cardiac rehabilitation attendance and outcomes 3 years after acute coronary syndrome (ACS): Linked national data of the SNAPSHOT ACS audit

Abstract Background In international guidelines, cardiac rehabilitation is recommended to reduce readmissions, mortality and improve disease management. However, evidence from a long-term follow-up in a representative cohort is scarce. Purpose To compare 3-year outcomes among acute coronary syndrome (ACS) survivors who attended cardiac rehabilitation programs and those who did not. Methods This was a follow-up of the SNAPSHOT ACS cohort in 1,920 Australians. Clinical data of those presenting with suspected ACS, hospitalised, discharged alive and followed for 18 months were linked to jurisdictional/national regulatory hospitalisation, mortality and pharmacotherapy records. Outcomes were all-cause and cardiovascular mortality, myocardial infarction (MI) and cardiovascular readmissions. Cox regression was used to analyse all-cause mortality, and Fine and Gray competing risk model for cardiovascular mortality, MI and cardiovascular readmissions, where non-cardiovascular mortality or all-cause mortality were competing events. The models were adjusted for age, sex, discharge diagnosis and coronary revascularisation. Results The cohort was aged 66±13.5 years; 60% were male, 31% had a discharge diagnosis of MI, and 490 (26%) attended cardiac rehabilitation. Cardiac rehabilitation attendees more frequently received coronary revascularisation and had a discharge diagnosis of MI during index admission. Attendees were more likely to be men (70% vs 57%, p<0.001) with a family history of coronary disease (43% vs 36%, p=0.008). The prescription of ≥3 guideline-indicated medications was higher in cardiac rehabilitation attendees. Compared to those who did not attend cardiac rehabilitation, the hazard of all-cause mortality was lower for the attendees (4.3% vs 8.6%, HR: 0.55, 95% CI: 0.34-0.91), but the hazard of MI and cardiovascular readmissions significantly greater in the attendees (17% vs 8.5%, HR: 1.99, 95% CI: 1.41-2.82; 42% vs 33%, HR: 1.34, 95% CI: 1.10-1.63; respectively) (Figure). There was insufficient cardiovascular mortality between groups to fit a statistical model (n=7 (1.4%) vs n=24 (1.7%), p=0.705). Conclusions Survivors of ACS attending cardiac rehabilitation were associated with reduced all-cause mortality and increased readmissions related to MI and cardiovascular disease at 3 years follow-up. These findings support secondary prevention strategies to mitigate mortality risk after ACS.

Sex differences in patients with acute myocardial infarction under 65 years of age: a Spanish cohort

Abstract Background Myocardial infarction (MI) clinical presentation and prognosis usually vary between men and women. Studying different age groups may be of interest. Aim Compare clinical characteristics and prognosis between men and women under 65 years old (y/o) with MI. Methods observational prospective study, including all patients admitted for MI between 2016 and 2023. Median follow-up was 43months[20-71]. Results Out of a total of 1064 patients, 436 were younger than 65 y/o (98 were women and 338 were men). The median age was similar in both sexes: 53.4[41-65] vs 54.2[43-65], p=0.24. A higher percentage of men were married (76.6 vs 59.2%, p<0.01), while a greater proportion of women were widowed (7.9 vs 1.3%, p<0.01). Men showed higher rates of permanent employment (71.4vs54.9%, p=0.01) and night shifts (58vs26.1%, p<0.01), whereas women had a higher unemployment rate (26.8vs15.2%, p=0.03) and reported higher levels of stress (70.3 vs 42.4%, p<0.01). The percentage of smokers was similar in both sexes (84.6% in men vs 75.8% in women, p=0.06), but there were more cocaine users in the male group (10.8vs1.4%, p=0.01). Women had a higher prevalence of autoimmune diseases (20.4 vs 6.2%, p<0.01), allergies (17.3 vs 5.6%, p<0.01), psychiatric illnesses (25.8 vs 9.9%, p<0.01), and migraines (15.6 vs 1.8%, p<0.01). Men had more history of previous coronary angioplasty (9.5 vs 3.1%, p=0.05). At admission, men presented with higher levels of creatine kinase (1175.2±1490.1 vs 766.5±1084.5 U/L, p=0.02), haemoglobin (15.2±1.6 vs 14±1.4 g/dl, p<0.01) and serum creatinine (1.2±1.4 vs 0.8±0.5 mg/dl, p<0.01), while women exhibited higher cholesterol levels (186.5±51.6 vs 174.9±44.5 mg/dl, p=0.03). Coronary dissection and myocardial infarction with non-obstructive coronary arteries were more frequent in women (14.3 vs 2.1%, p<0.01 and 27.6 vs 11.5%, p<0.01, respectively). Women also underwent additional tests at a higher rate, such as cardiac magnetic resonance (14.3 vs 4%, p<0.01) and vasospasm test (7.6vs1.9%, p=0.02). During hospitalization, men underwent drug-eluting stent implantation more frequently (66.7vs23.8%, p<0.01). At discharge, they were more likely to receive antiplateles (93.7vs84.5%, p<0.01), beta-blockers (81.7vs.71.1%, p=0.03), angiotensin-converting enzyme inhibitors (63.2vs49.5%, p=0.02) and statins (96.4vs84.5%, p<0.01). The rest of variables, which showed no significant differences, are in Table 1. Prognosis was similar in both sexes: death from any cause (HR 0.7, 95%CI[0.1-3.4]), cardiovascular readmission (HR 1.2, 95%CI[0.5-2.7]), reinfarction (HR 1.9, 95%CI[0.3-10.3]), stroke (HR 1, 95%CI[0.1-11.9]). Conclusion The clinical profile of men and women with MI is clearly different. The investigation into the underlying mechanisms of MI occasionally necessitates more extensive testing in women. Additionally, the treatment plans at discharge diverge between the two genders. Nevertheless, the prognosis appears to be similar for both sexes.

Dynamic changes of excessive trabeculation in dilated cardiomyopathy: a longitudinal cardiovascular magnetic resonance study

Abstract Background A portion of dilated cardiomyopathy (DCM) patients present with left ventricular (LV) excessive trabeculation at diagnosis. It remains unknown if the extent of trabeculation would be reduced after guideline-directed medical therapy (GDMT). Purpose To investigate the dynamic change of excessive trabeculation after GDMT in patients with DCM, and its relationship with that in LV structure and function. Methods A group of DCM patients with baseline and follow-up cardiovascular magnetic resonance (CMR) examination after 1-2 years of GDMT were enrolled. Trabeculation was assessed by Petersen method as measuring the thickness of the most prominent non-compacted (NC) layer and the corresponding compacted (C) segment at the apical long-axis view at end-diastole. Excessive trabeculation was defined as the NC/C ratio > 2.3, and a regression was reached if it decreased to ≤ 2.3. Major adverse cardiovascular events (MACE) consisted of cardiovascular death, heart transplantation, and heart failure readmission. Results Among 218 DCM patients (45 ± 14 years, 67.4% male), 58 (26.6%) met the excessive trabeculation criteria at baseline. Despite a similar LV ejection fraction (LVEF), patients with excessive trabeculation had a higher LV end-diastolic dimension (73.3 ± 9.0 vs. 70.5 ± 8.0mm) and native T1 (1325.3 ± 71.2 vs. 1305.5 ± 65.9mm) (both p<0.05) with a trend of more late gadolinium enhancement (51.7% vs. 39.4% of patients). After 15 months of GDMT, patients with excessive trabeculation (n=58) showed a decreased NC layer (12.7 ± 3.4 vs. 11.3 ± 3.0 mm) and NC/C ratio (3.1 ± 0.9 vs. 2.7 ± 0.9) (both p < 0.05), 25.9% of whom showed a regression of trabeculation. Patients with the regression had a lower NC/C ratio (1.8 ± 0.4 vs. 3.0 ± 0.8, p < 0.001) and LV end-diastolic volume index (LVEDVi) (121.5 ± 40.5 ml/m2 vs. 165.9 ± 67.8ml/m2, p=0.004) compared with those without. The change of (△) NC/C ratio was associated with that of LVEDVi (r = 0.323), and LVEF as well (r = -0.254) (both p < 0.001). Excessive trabeculation at baseline did not differentiate patients with a higher risk of MACE by Kaplan-Meier survival curve (p= 0.208), but its persistent presence at follow-up did (p= 0.004). However, when put △NC/C ratio, △LVEDVi, △LVEF and In NT-proBNP into multivariate cox regression model, only the △LVEDVi (HR, 0.963; 95% CI: 0.942, 0.985; P = 0.001) and In NT-proBNP (HR, 2.016; 95% CI: 1.288, 3.157; P = 0.002) were independent predictors of MACE. Conclusions Regression of excessive trabeculation occurred after GDMT in DCM patients that was related somewhat to LV reverse remodeling and not an independent predictor of MACE. It may also indicate the interconnection between LV remodeling and trabeculation.

Association between trajectory of systolic blood pressure and outcomes in heart failure patients with preserved ejection fraction (HFpEF)

BackgroundThe optimal systolic blood pressure (SBP) in heart failure patients with preserved ejection fraction (HFpEF) remains controversial. We aim to assess the SBP trajectory and prognosis in HFpEF. Methods and ResultsPatients from Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist Trial (TOPCAT) were classified into three SBP trajectory groups according to the follow-up blood pressure using a latent category trajectory model. The primary outcome was composite of cardiovascular death, cardiac arrest, and hospital readmission for heart failure. A total of 3388 patients (mean age 68.6 years, 48.5 % men) were included. Mean SBP maintained 128 mmHg in the stable SBP trajectory group, declined from 129 to 125 mmHg in the decreasing SBP trajectory group and rose from 132 to 143 mmHg in the increasing SBP trajectory group within 6 years. During a mean follow-up of 3.4 years, 654 individuals had a primary outcome. Incidence for both primary and secondary outcomes were higher in increasing SBP trajectory group and decreasing SBP trajectory group compared with stable SBP trajectory group. After adjustments, the decreasing SBP trajectory group was associated with increased risk of all outcomes (hazard ratio ≥1.32), the increasing SBP trajectory group was associated with all-cause hospitalization and stroke (hazard ratio ≥ 1.28). ConclusionThe decreasing or increasing SBP trajectory is associated with a high risk of cardiovascular events in HFpEF, suggesting a stable SBP trajectory group (≈130 mmHg) have lower incidence of cardiovascular events and mortality. Trials are necessary to determine the optimal SBP in HFpEF.

Transitions of Care Pharmacist Impact Following Hospitalization for Acute Myocardial Infarction.

Background: Patients admitted with acute myocardial infarction (AMI) are at high risk for morbidity and rehospitalizations. Pharmacists can play a vital role in secondary prevention by providing services such as medication reconciliation and patient education upon discharge. Objective: The purpose of this study was to evaluate the impact of a pharmacist-led transitions of care (TOC) service on readmissions in patients hospitalized with AMI. Methods: This single center, pre-post observational cohort study evaluated adults with AMI who received pharmacist TOC services compared with a historical cohort who did not. Patients were excluded if they underwent cardiac surgery during admission. The primary outcome was the difference in 90-day cardiovascular (CV)-related readmissions. Secondary outcomes included 30- and 90-day all-cause readmissions, 30-day CV-related readmissions, and patients discharged on defect-free guideline-directed medical therapy (GDMT) for AMI. Results: There were 252 patients in each cohort included. No difference was found in 90-day CV readmissions, with a rate of 10.7% in the pre-TOC group versus 9.9% in the post-TOC group (OR 0.937, 95% CI [0.493, 1.769]; P = 0.842). Patients discharged on defect-free GDMT significantly increased from 61.5% pre-TOC to 87.7% post-TOC (OR 5.424, 95% CI [3.204, 9.468]; P < 0.001). There were no significant differences found in other key secondary outcomes. Conclusion and relevance: This study did not find a significant difference in hospital readmissions after implementation of a pharmacist-led TOC service. However, the service was associated with a significant increase in patients discharged on defect-free GDMT. Further studies are needed to confirm the impact of increased GDMT on clinical outcomes.

Clinical phenotypes of heart failure patients with supranormal ejection fraction.

Heart failure (HF) with supranormal ejection fraction (HFsnEF) represents a distinct clinical entity characterized by limited treatment options and an unfavourable prognosis. Revealing its phenotypic diversity is crucial for understanding disease mechanism and optimizing patient management. We aim to identify phenotypic subgroups in HFsnEF using unsupervised clustering analysis. Consecutive hospitalized patients with a diagnosis of HF and a left ventricular ejection fraction ≥65% at baseline echocardiographic evaluations were included for analysis. We conducted unsupervised hierarchical clustering analysis on principal components (HCPC) to identify HFsnEF phenogroups using mixed data variables including demographics, HF duration, vital signs, anthropometrics, smoking/drinking status, HF aetiology, comorbid diseases, laboratory tests and echocardiographic parameters. We then employed decision tree modelling to identify parameters capable of distinguishing distinct clusters. Clinical outcomes, including all-cause death, cardiovascular (CV) death and CV readmission for different clusters, were examined. Three mutually exclusive clusters were identified from the cohort of 221 HFsnEF patients. Cluster 1 (52.5%) predominantly consisted of patients with valvular heart disease, who had larger cardiac chambers and a higher prevalence of atrial fibrillation/atrial flutter. Cluster 2 (26.2%) primarily comprised older ischaemic patients with a higher prevalence of metabolic comorbidities. Cluster 3 (21.3%) were mainly hypertrophic cardiomyopathy patients. Two clinical variables were identified that could be used to group all HFsnEF patients into one of the clusters; they were HF aetiology and comorbid diabetes. During the median follow-up of 53.4months, 46 (20.8%) all-cause deaths occurred, among them 39 of CV causes. Seventy (31.7%) patients experienced CV readmissions. Three clusters showed distinct differences in mortality outcomes, with Cluster 1 exhibiting the highest risk of all-cause mortality [Cluster 1 vs. Cluster 2: adjusted hazard ratio (aHR)=3.32, P=0.022; Cluster 1 vs. Cluster 3: aHR=3.81, P=0.036; Cluster 2 vs. Cluster 3: aHR=1.15, P=0.865] and CV mortality (Cluster 1 vs. Cluster 2: aHR=3.73, P=0.022; Cluster 1 vs. Cluster 3: aHR=4.27, P=0.020; Cluster 2 vs. Cluster 3: aHR=1.15, P=0.870). CV readmission risk was comparable among the three clusters (Cluster 1 vs. Cluster 2: aHR=0.82, P=0.590; Cluster 1 vs. Cluster 3: aHR=1.04, P=0.900; Cluster 2 vs. Cluster 3: aHR=1.28, P=0.580). In a heterogeneous HFsnEF cohort, three clusters were identified by unsupervised HCPC with distinct clinical characteristics and outcomes.

Direct Bilirubin, but not Indirect Bilirubin, is Associated with Short-term Adverse Events in HFpEF.

Abnormal live function tests have been identified as independent risk factors for ominous prognosis in patients with heart failure. However, most of the previous studies have failed to determine the contribution of direct bilirubin (DBIL) and indirect bilirubin (IBIL) separately. Hence, we aimed to explore whether DBIL or IBIL is correlated with the prognosis of heart failure with preserved ejection fraction (HFpEF). A total of 19837 patients were hospitalized for HFpEF between January 2012 and January 2022 in Fuqing City Hospital affiliated with Fujian Medical University. The primary endpoint was in-hospital all-cause mortality. Secondary endpoints included in-hospital cardiovascular mortality and 30-day re-admission for heart failure. Univariable analysis indicated that patients with elevated DBIL or IBIL were exposed to a higher risk of mortality and re-admission. However, in multivariable models, both ln-transformed DBIL and TBIL, but not IBIL, were independent risk factors for in-hospital all-cause mortality (hazard ratio (HR)=1.796, 95% confidential interval (CI)=1.477-2.183, P<0.001; HR=1.854, 95% CI=1.461-2.352, P.0.001; HR=1.161, 95% CI=0.959-1.407, P=0.126) and in-hospital cardiovascular mortality (HR=1.831, 95% CI=1.345-2.492, P.0.001; HR=1.899, 95% CI=1.300-2.773, P=0.001; HR=1.145, 95% CI=0.841-1.561, P=0.389). Only DBIL remained independently associated with 30-day readmission for heart failure (HR=1.361, 95% CI=1.036-1.787, P=0.027). Adding ln-transformed DBIL to model 1 increased its discriminatory capacity (C-statistic: 0.851 to 0.869, respectively), whereas adding ln-transformed IBIL yielded little increment (C-statistic: 0.851 to 0.852, respectively). DBIL, but not IBIL, was associated with short-term ominous prognosis in patients with HFpEF. Hence, DBIL may be the superior predictor for prognosis in HFpEF.

Comparison of machine learning and conventional statistical modeling for predicting readmission following acute heart failure hospitalization

IntroductionDeveloping accurate models for predicting the risk of 30-day readmission is a major healthcare interest. Evidence suggests that models developed using machine learning (ML) may have better discrimination than conventional statistical models (CSM), but the calibration of such models is unclear. ObjectivesTo compare models developed using ML with those developed using CSM to predict 30-day readmission for cardiovascular and non-cardiovascular causes in HF patients. MethodsWe retrospectively enrolled 10,919 patients with HF (> 18 years) discharged alive from a hospital or emergency department (2004-2007) in Ontario, Canada. The study sample was randomly divided into training and validation sets in a 2:1 ratio. CSMs to predict 30-day readmission were developed using Fine-Gray subdistribution hazards regression (treating death as a competing risk), and the ML algorithm employed random survival forests for competing risks (RSF-CR). Models were evaluated in the validation set using both discrimination and calibration metrics. ResultsIn the validation sample of 3602 patients, RSF-CR (c-statistic=0.620) showed similar discrimination to the Fine-Gray competing risk model (c-statistic=0.621) for 30-day cardiovascular readmission. In contrast, for 30-day non-cardiovascular readmission, the Fine-Gray model (c-statistic=0.641) slightly outperformed the RSF-CR model (c-statistic=0.632). For both outcomes, The Fine-Gray model displayed better calibration than RSF-CR using calibration plots of observed vs. predicted risks across the deciles of predicted risk. ConclusionsFine-Gray models had similar discrimination but superior calibration to the RSF-CR model, highlighting the importance of reporting calibration metrics for ML-based prediction models. The discrimination was modest in all readmission prediction models regardless of the methods used.

Sex differences in acute myocardial infarction - Preliminary results from an umbrella review

Abstract Background Cardiovascular disease (CVD) is the leading cause of premature death among women, and the negative impact on public health is profound. Women have higher rates of comorbidities, complications such as stroke, in addition to higher mortality compared to men (1-6) and targeting sex-related differences regarding the treatment of CVD in women is of great importance to prevent the number of CVD events. The purpose of this study was to get an overview of the systematic reviews and meta-analyses investigating sex differences in patients with acute myocardial infarction (AMI) the past 10 years. Methods A systematic search was carried out in Epistemonikos, the largest database of systematic reviews that screens PubMed, Cochrane, Embase, CINAHL, PsycInfo and others (i.e., currently nine databases) (7, 8). The search was conducted 12 January 2024, with the general search strings: (1) sex differences OR gender differences AND myocardial infarction, (2) sex differences OR gender differences OR women OR female AND myocardial infarction. The search was restricted to systematic reviews conducted the last 10 years. Results Forty-nine (search 1: 19, search 2: 30) systematic reviews and meta-analyses were identified, and five studies investigating sex differences in relation to AMI were included. Two systematic reviews, Babioakis (2021) and Meer (2015), reported of longer door-to-balloon (D2B) time and/or symptom-to-balloon (S2B) time in female patients presenting with STEMI and referred for PCI, compared to male patients (9). Chaudhary (2022) investigated adverse event of MINOCA (more commonly in women/ younger age (51-59 years) and reported higher risk of MACE among women than men (10.1% vs. 9.1%, OR 1.15, 1.04-1.23), in addition to higher incidence of stroke (3.5% vs. 2.2%, OR 1.3, 1.01-1.68), however no significantly differences were observed for all-cause mortality, non-fatal AMI, and cardiovascular readmissions between the groups (10). Three systematic reviews reported of higher risk of mortality after STEMI among women, compared to men (11-13). Xi (2022) reported of higher risk of short-term mortality (RR, 1.73; 95% CI 1.53 to 1.96)) (adjusted RR, 1.24; 95% CI 1.11 to 1.38) (13), Pancholy (2014) reported of higher risk of in-hospital mortality (RR, 1.93; 95% CI, 1.75-2.14) (adjusted RR, 1.48; 95% CI, 1.07-2.05) (11), and van der Meer (2015) reported of higher crude short- and long-term mortality in women, in addition to less use of GP IIb/IIIa inhibitors in women, compared to men (women 51%, men 57%) (12). Conclusions Our umbrella review revealed that women had longer timeline for treatment in AMI, had less use of medication and higher risk of mortality and MACE compared to men. Clinical practice needs further improvements in management in female patients.

Management and outcomes of heart failure hospitalization among older adults in the United States and Japan.

Despite advances in therapies, the disease burden of heart failure (HF) has been rising globally. International comparisons of HF management and outcomes may reveal care patterns that improve outcomes. Accordingly, we examined clinical management and patient outcomes in older adults hospitalized for acute HF in the United States (US) and Japan. We identified patients aged >65 who were hospitalized for HF in 2013 using US Medicare data and the Japanese Registry of Acute Decompensated Heart Failure (JROADHF). We described patient characteristics, management, and healthcare utilization and compared outcomes using multivariable Cox regression during and after HF hospitalization. Among 11193 Japanese and 120289 US patients, age and sex distributions were similar, but US patients had higher comorbidity rates. The length of stay was longer in Japan (median 18 vs. 5days). While Medicare patients had higher use of implantable cardioverter defibrillator or cardiac resynchronization therapy during hospitalization (1.32% vs. 0.6%), Japanese patients were more likely to receive cardiovascular medications at discharge and to undergo cardiac rehabilitation within 3months of HF admission (31% vs. 1.6%). Physician follow-up within 30days was higher in Japan (77% vs. 57%). Cardiovascular readmission, cardiovascular mortality and all-cause mortality were 2.1-3.7 times higher in the US patients. The per-day cost of hospitalization was lower in Japan ($516 vs. $1323). We observed notable differences in the management, outcomes and costs of HF hospitalization between the USand Japan. Large differences in length of hospitalization, cardiac rehabilitation rate and outcomes warrant further research to determine the optimal length of stay and assess the benefits of inpatient cardiac rehabilitation to reduce rehospitalization and mortality.

Study on the management effect of chronic disease intelligent information management platform in post percutaneous coronary intervention patients.

In 2019, approximately 330 million individuals in China were affected by cardiovascular diseases, with 11.4 million cases specifically attributed to coronary artery disease (CAD). A national public health report indicated that the mortality rate for CAD ranged from 121.59 to 130.14 per 100,000 individuals in 2019. The treatments for CAD include lifestyle changes, medications, percutaneous coronary intervention (PCI) and coronary artery bypass grafting. To investigate the management effect of a digital health program in patients with coronary artery disease (CAD) after percutaneous coronary intervention (PCI). This retrospective study compares blood pressure, blood glucose, low-density lipoprotein cholesterol (LDL-C), medication adherence, lifestyle modification, and readmission rate between digital health users and traditional follow-up in post-PCI CAD patients. In this study of 698 CAD patients, the 6-month readmission rate of all patients was 27.4%, with digital health users showing lower rates than those in traditional follow-up (22.6% vs. 32.1%, p= 0.005). Digital health users had significantly higher target achievements rates in blood pressure (79.7% vs. 54.7%, p< 0.001), blood glucose (98.9% vs. 82.5%, p< 0.001) and LDL-C level (71.3% vs. 52.7%, p< 0.001) at 6-month post-PCI. The digital health group had more patients adopting lifestyle changes, including quitting smoking, maintaining a healthy diet, and exercising regularly. In risk factor analysis, digital health utilization (OR = 0.60, 95%CI: 0.40-0.90, p= 0.014) and multivessel disease (double: OR = 1.72, 95%CI: 1.09-2.72, p= 0.02; triple: OR = 2.59, 95%CI: 1.61-4.17, p< 0.001) were independent predictors of CAD-related cardiovascular readmissions. Post-PCI patients using digital health platforms exhibited improved blood pressure, glucose, and LDL-C control, greater treatment adherence, enhanced lifestyle changes, and reduced six-month readmission rates versus those with traditional follow-up.

Impact of preoperative haemoglobin A1c levels on postoperative outcomes in adults undergoing major noncardiac surgery: A systematic review.

Diabetes is known to increase morbidity and mortality after major surgery. However, literature is conflicting on whether elevated preoperative haemoglobin A1c (HbA1c) levels are associated with worse outcomes following major noncardiac surgery. We aimed to investigate the effect of incremental preoperative HbA1c levels on postoperative outcomes in adults who had undergone major noncardiac surgery. We systematically searched PubMed, EMBASE and the Cochrane Library databases for eligible studies published between January 2012 and July 2023. Randomised controlled trials and observational studies (cohort and case-control studies) which measured HbA1c within 6 months before surgery and compared outcomes between at least three incremental subgroups or analysed HbA1c as a continuous variable were included. The systematic review protocol was registered with PROSPERO (CRD42023391946). Twenty observational studies investigating outcomes across multiple surgical types were included. Higher preoperative HbA1c levels were associated with increased odds of overall postoperative complications, postoperative acute kidney injury, anastomotic leak, surgical site infections and increased length of stay. Each 1% increase in preoperative HbA1c was associated with increased odds of these complications. No association with reoperations and 30-day mortality was identified. The literature was highly variable with respect to composite major complications, perioperative cardiovascular events, hospital readmissions, postoperative pneumonia and systemic thromboembolism. Current evidence suggested that higher preoperative HbA1c levels were associated with increased odds of postoperative complications and extended length of stay in adults undergoing major noncardiac surgery. Further high-quality studies would be needed to quantify the risks posed and determine whether early intervention improves outcomes.

Colchicine in acute heart failure: Rationale and design of a randomized double-blind placebo-controlled trial (COLICA).

Heart failure (HF) elicits a pro-inflammatory state, which is associated with impaired clinical outcomes, but no anti-inflammatory therapies have demonstrated a clinical benefit yet. Inflammatory pathways related with the interleukin-1 axis are overactivated during episodes of acute HF. Colchicine, an anti-inflammatory drug with proven benefits in acute pericarditis and ischaemic heart disease, may target this inflammatory response. This study aims to assess the efficacy of colchicine in acute HF patients. COLICA is a multicentre, randomized, double-blind, placebo-controlled trial enrolling 278 patients across 12 sites. Patients presenting with acute HF, clinical evidence of congestion requiring ≥40 mg of intravenous furosemide and N-terminal pro-B-type natriuretic peptide (NT-proBNP) >900 pg/ml, are eligible for participation. Patients are enrolled irrespective of left ventricular ejection fraction, HF type (new-onset or not) and setting (hospital or outpatient clinic). Patients are randomized 1:1 within the first 24 h of presentation to either placebo or colchicine, with an initial loading dose of 2 mg followed by 0.5 mg every 12 h for 8 weeks (reduced dose if <70 kg, >75 years old, or glomerular filtration rate <50 ml/min/1.73 m2). The primary efficacy endpoint is the time-averaged proportional change in NT-proBNP concentrations from baseline to week 8. Key secondary and exploratory outcomes include symptoms, diuretic use, worsening HF episodes, related biomarkers of cardiac stress and inflammation, total and cardiovascular readmissions, mortality and safety events. COLICA will be the first randomized trial testing the efficacy and safety of colchicine for acute HF.

Hybrid therapy with ablation + subcutaneous ICD for secondary prevention of sudden cardiac death in ischemic heart disease

Abstract Background The aim of the prospective Ventricular Tachycardia Ablation- Subcutaneous ICD (VTAbl-SICD) Trial was to provide data on the efficacy and safety of a novel hybrid management strategy that combines VT ablation (VTAbl) with S-ICD implantation in patients who present with scar-related VT. The rate of appropriate therapy in patients with S-ICD may be a quite fairest surrogate of true residual sudden death (SD) risk compared to transvenous ICD (TV-ICD). More specific data on ischemic heart disease – the prominent cause of VT with the better results of VTAbl – may give arguments for questioning current practices in the future. Methods 32 patients with post ischemic scar-related sustained VT/VF were included. Patients underwent VTAbl with subsequent (or previous prophylactic n=8) S-ICD implant and were followed for 2-years. We evaluate the occurrence of appropriate and ICD therapies once ablated, as well as cardiovascular (CV) readmissions or death. We also compared to 64 propensity-score matched patients implanted with a secondary prevention TV-ICD (enrolled in the Ranolazine in High-Risk Patients With Implanted Cardioverter-Defibrillators (RAID) trial). Results Mean age was 57±12 years (28 males, 87%) (53% hypertension, 31% diabetes and 47% congestive heart failure with NYHA 1.6±1). Mean LVEF was 39±9%.There were no major complications associated with the ablation and implant procedures. Propensity-score matched patients implanted with a secondary prevention TV-ICD displayed similar clinical characteristics. At 16.5±8.6 months FU, appropriate ICD therapy occurred in 5 patients (15%) in the VTAbl-SICD group, significantly lower compared to the TV-ICD group (34 pts, 53%) (p&amp;lt;0.001). This corresponded to 2-year cumulative probability of 20% vs. 71% in the VTAbl-SICD vs. TV-ICD groups, respectively (log-rank p&amp;lt;0.001; Figure 1) and a significant 83% reduction in the risk of appropriate ICD therapy associated with VTAbl-SICD (HR= 0.17 [95% CI 0.07 - 0.39; p&amp;lt;0.001). Two of the patients who received appropriate ICD therapy in the VTAbl-SICD group may have had unrecognized transient causes of VT (torsades de pointes or unrecognized ischemia), letting 3 out of 32 (10%) with possible aborted SD caused by VT recurrences. There were no cases of untreated symptomatic VT. The rate of CV readmissions was similar in the VTAbl-SICD (41%) vs. TV-ICD group (44%) (p=0.7), whereas mortality was significantly lower in the VTAbl-SICD- vs.TV-ICD- group (0% vs. 17%, respectively; p&amp;lt;0.001) Conclusions Our findings suggest that VT ablation in ischemic heart disease patients allow reaching a low residual true risk for SD, which should now be evaluated in terms of cost-effectiveness compared to ablation + S-ICD implantation. Concommitant S-ICD implantation seems to be a safe alternative to TV-ICD without ablation.Appropriate ICD therapy-free KM

Bleeding risk stratification in patients admitted for acute coronary syndrome

Abstract Funding Acknowledgements None. Introduction The risk of hemorrhagic events should always be accounted for in patients admitted with acute coronary syndromes (ACS). With the increasing frailty of these patients, it is important to identify them and minimize the risk of such events. Purpose Identify high-risk patients admitted for ACS for hemorrhagic events during their hospital stay. Methods Multicenter retrospective study, data collected from 1/10/2010 and 31/12/2020 with ACS diagnosis. Patients were divided into 3 groups according to hemoglobin (Hb) and platelet (Plat) levels. Group 1 – Hb &amp;lt;8g/dl, Plat &amp;lt;150x109/L; Group 2 – Hb 8-12g/dl, Plat 150-450x109/L; Group 3 – Hb ≥12g/dl, Plat ≥450x109/L. We further divided these patients according to a composite endpoint. Group A without the composite endpoint; Group B with composite endpoint. This composite endpoint was defined as major hemorrhage, intracranial hemorrhage, need of blood transfusions and a Hb decrease of ≥ 2g/dl. Results 19409 patients were enrolled, of those 4707 (24.3%) had the composite endpoint. Group B was older (68±13 vs 66±12, p&amp;lt;0.001), had higher rates of arterial hypertension (72.5% vs 68.2%, p&amp;lt;0.001), diabetes mellitus (35.6% vs 30.7%, p&amp;lt; 0.001), stroke (9.0% vs 6.6%, p &amp;lt; 0.001) and previous haemorrhage (p= 0.004). No statistically significant differences regarding previous MI (p= 0.240). Hb levels &amp;lt;8g/dL (8.1% vs 0.6%, p&amp;lt;0.001) were associated with a higher risk of hemorrhagic events but not lower levels of Plat, instead higher levels (&amp;gt; 450x109/L) were event associated (1.8% vs 0.9%, p&amp;lt;0.001). The choice of femoral access was related to an increased risk of hemorrhagic events (p&amp;lt;0.001). Logistic regression confirmed that the Hb levels &amp;lt; 12g/dL when compared with normal levels were related to the composite endpoint proportionally to the degree of anemia, the lower the level of Hb the more likely these events occur, Hb &amp;lt;8g/dL p&amp;lt;0.001, OR 4.02, CI (95%) 2.50-6.47 and Hb 8-12g/dL, p&amp;lt;0.001, OR 0.761, CI (95%) 0.693-0.837. Survival analysis also showed that cardiovascular (CV) mortality and re-admission at 1 year were related to the degree of anemia. Conclusion Lower levels of Hb correlated well and proportionally to the occurrence of the composite endpoint as well as cardiovascular (CV) mortality and re-admission at 1 year. Contrarily to expected lower levels of Plat did not correlate with a higher risk of hemorrhagic events but instead thrombocytosis did, as a paradoxical risk of bleeding has been noted in patients with thrombocytosis, especially extreme thrombocytosis.

The role of cardiac rehabilitation in patients following acute coronary syndrome

Abstract Funding Acknowledgements None. Introduction The benefits of cardiac rehabilitation in patients with acute coronary syndrome (ACS) are well established. Although there are limited centres with cardiac rehabilitation and patients, especially from peripheral hospitals, wait a long time to enter the programme and many of them don’t even enter these programmes. Purpose Characterize the patient population that go to cardiac rehabilitation and evaluate short- and long-term outcomes. Methods Multicenter retrospective study, patients with the diagnosis of ACS and data collected from 1/01/2015 to 31/12/2021. Patients were divided into 2 groups (G). G1 – Patients with cardiac rehabilitation programmed and/or planned; G2 – Patients not referenced for cardiac rehabilitation. We further analyse patients according to MACE events, group A without MACE; group B with MACE. Results 11992 patients were enrolled, only 3162 (26.4%) patients were referenced for cardiac rehabilitation. G1 was younger 63.5 ± 12.4 (p&amp;lt;0.001), had more males 76.7% (p&amp;lt;0.001) and more smokers 38.0% vs 25.3% (p&amp;lt;0.001), but less patients with arterial hypertension (AH) 65.1% vs 70.9% (p&amp;lt;0.001), diabetes mellitus (DM) 29.5% vs 32.8% (p&amp;lt;0.001), dyslipidemia 57.0% vs 61.2% (p&amp;lt;0.001), previous heart failure 4.8% vs 7.9% (p&amp;lt;0.001) and chronic kidney disease (CKD) 3.8% vs 7.3% (p&amp;lt;0.001). G1 had although more patients with symptoms of angina 29.2% vs 23.3% (p&amp;lt;0.001) and previous MI 20.5% vs 17.6% (p&amp;lt;0.001). Regarding MACE events G1 had better outcomes 1.3% vs 6.1% (p&amp;lt;0.001). Considering MACE events, group B was older 74±12 years (p&amp;lt;0.001), male gender was predominant (62.5%) and had more patients with AH 76.9% vs 68.8% (p&amp;lt;0.001), DM 45.1% vs 31.1% (p&amp;lt;0.001), CKD 14.6% vs 5.6% (p&amp;lt;0.001) and pacemaker (PM) or ICD devices 3.8% vs 1.7% (p&amp;lt;0.001). Independent predictors of MACE achieved through logistic regression analysis are gender p&amp;lt;0.001, OR 0.325, CI (95%) 0.158-0.672; CKD p= 0.042, OR 4.027, CI 1.019-15.911; time from symptoms to 1st contact ≥ 120min p=0.032, OR 2.088, CI 1.067-4.087; usage of inotropic medications p&amp;lt;0.001, OR 6.383, CI 2.995-13.602; left ventricular ejection fraction &amp;lt;30% vs ≥30% p=0.002, OR 4.172, CI 1.722-10.108; need of invasive mechanical ventilation p&amp;lt;0.001, OR 6.593, CI 2.812-15.457 and need of temporary PM p&amp;lt;0.001, OR 12.372, CI 4.025-38.031. Conclusion In these study population, patients with less cardiovascular (CV) risk factors and comorbidities were more often assigned to cardiac rehabilitation programmes. Not unpredictable patients with more comorbidities suffered more from MACE events. Survival analysis also showed that CV mortality and re-admission at 1 year were higher in patients not assigned for cardiac rehabilitation.

Role of Vascular Function in the Prognosis of Heart Failure Patients.

Background: Blood vessels have the Windkessel effect and are involved in blood circulation. The breakdown of this mechanism is also involved in the pathogenesis of heart failure (HF); however, the relationship between vascular dysfunction and HF prognosis is not fully understood. Methods: We evaluated 214 patients hospitalized for HF at our institution who underwent a cardio-ankle vascular index (CAVI), which evaluates vascular function, between January 2012 and July 2018. To investigate factors (including CAVI) associated with major adverse cardiac events (MACE) during 1 year after patients with HF were discharged, we evaluated clinical profiles, blood tests, chest X-P, 12-lead electrocardiography, and transthoracic echocardiographic findings. MACE was defined as cardiovascular death or readmission for HF. Results: The severity of HF between the MACE and non-MACE was not significantly different. Previous HF and chronic kidney disease were significantly more common in the MACE group. CAVI and % mean atrial pressure in the MACE group were statistically higher than those in the non-MACE group. The cardiac shadow as shown by chest X-P and left ventricular size in the MACE group were significantly bigger, and HF preserved ejection fraction (EF) (EF > 50%) was significantly more common in the MACE group. In multivariate analysis, CAVI was an independent predictive factor for the occurrence of MACE (model 1; hazard ratio (HR): 1.33, 95% confidence interval (CI): 1.05-1.68, p = 0.018; model 2; HR: 1.31, 95% CI: 1.07-1.60, p = 0.009). Conclusions: Because high CAVI is associated with poor prognosis of HF, these patients require more careful treatment.

The prediction value of combined serum levels of TMAO and TML for poor prognosis in patients with heart failure

Objective: To evaluate the predictive value of combined serum levels of trimethylamine N-oxide (TMAO) and trimethyllysine (TML) for poor prognosis in patients with heart failure. Methods: This single-center prospective cohort study included hospitalized patients with heart failure and complete baseline data from the Department of Cardiology at Ruijin Hospital, Shanghai Jiao Tong University School of Medicine from June 2017 to December 2020. Patients were categorized into four groups based on median serum levels of TMAO and TML after admission: TMAO low level TML low level group (TMAO<9.7 μmol/L, TML<0.73 μmol/L), TMAO low level TML high level group (TMAO<9.7 μmol/L, TML≥0.73 μmol/L), TMAO high level TML low level group (TMAO≥9.7 μmol/L, TML<0.73 μmol/L) and TMAO high level TML high level group (TMAO≥9.7 μmol/L, TML≥0.73 μmol/L). The primary endpoint was a composite endpoint of cardiovascular death and readmission for heart failure. Multiple factor Cox regression analysis was conducted to evaluate the correlation between serum TMAO and TML levels and poor prognosis in patients with heart failure. Results: A total of 471 patients with heart failure were included, with an mean age of (62.5±12.0) years and a median follow-up time of 1.61 (1.06, 2.90) years. Multivariate Cox regression analysis showed that after adjusting for age, gender, and traditional risk factors, the TMAO high level TML high level group had a higher incidence of primary endpoint events compared to the TMAO low level TML low level group (HR=1.71, 95%CI 1.05-2.77, P=0.03). Conclusion: Elevated serum levels of both TMAO and TML can effectively predict the occurrence of long-term adverse events in patients with heart failure.