Composite Endpoint Of Mortality Research Articles

Sex differences outcomes in conduction system pacing for patients with typical left bundle branch block

BackgroundBiventricular pacing (BVP) appears to confer more pronounced advantages in women, yet the impact of conduction system pacing (CSP) remains insufficiently characterized. This investigation seeks to elucidate sex-specific disparities in clinical outcomes among patients with typical left bundle branch block (LBBB) undergoing CSP, with a particular focus on assessing contributory factors. MethodsConsecutive patients diagnosed with nonischemic cardiomyopathy, exhibiting left ventricular ejection fraction (LVEF) ≤ 40%, and manifesting typical LBBB as Strauss criteria, underwent CSP. Subsequent longitudinal monitoring assessed improvements in LVEF and the composite endpoint of mortality or heart failure hospitalization (HFH). ResultsAmong the included 176 patients, women (n = 84, mean age: 69.5 ± 8.8 years) displayed smaller heart size (LVEDd, 62.0 ± 8.3 mm vs. 64.8 ± 7.9 mm, P = 0.023) and shorter baseline QRSd (163.5 ± 17.7 ms vs. 169.7 ± 15.1 ms; P = 0.013) than men. Of the 171 patients who completed the follow-up, super-response was observed in 120 (70%), with a higher occurrence in women than men (78.3% vs. 62.5%, P = 0.024). The incidence of death or HFH was numerically lower in women (7.1% Vs 13%, Log-rank P = 0.216). Notably, the super-response showed a significant difference in women compared to men at the same electrocardiography and/or echocardiographic parameters value. Mediation analysis between sex and super-response revealed that LVEDd and pQRSd play an intermediary role, with the mediation proportion of 26.07% and 27.98%, respectively. ConclusionsWomen may derive more benefits from CSP, and pQRSd and LVEDd partly drive this difference.

Systemic Atrioventricular Valve Surgery in Patients With Congenitally Corrected Transposition of the Great Vessels.

Limited data exist regarding the long-term outcomes of systemic atrioventricular valve (SAVV) intervention (morphologic tricuspid valve) in congenitally corrected transposition (ccTGA). The goal of this study was to evaluate the mid- and long-term outcomes of SAVV surgery in ccTGA. We performed a retrospective review of 108 ccTGA patients undergoing SAVV surgery from 1979 to 2022. The primary outcome was a composite endpoint of mortality, cardiac transplantation, or ventricular assist device implantation. The secondary outcome was long-term systemic right ventricular ejection fraction (SVEF). Cox proportional hazard and linear regression models were used to analyze survival and late SVEF data. The median age at surgery was 39.5 years (Q1-Q3: 28.8-51.0 years), and the median preoperative SVEF was 39% (Q1-Q3: 33.2%-45.0%). Intrinsic valve abnormality was the most common mechanism of SAVV regurgitation (76.9%). There was 1 early postoperative mortality (0.9%). Postoperative complete heart block occurred in 20 patients (18.5%). The actuarial 5-, 10-, and 20-year freedom from death or transplantation was 92.4%, 79.1%, and 62.9%. The 10- and 20-year freedom from valve reoperation was 100% and 93% for mechanical prosthesis compared with 56.6% and 15.7% for bioprosthesis (P< 0.0001). Predictors of postoperative mortality were age at operation (P=0.01) and preoperative SVEF (P=0.04). Preoperative SVEF (P< 0.001), complex ccTGA (P=0.02), severe SAVV regurgitation (P=0.04), and preoperative creatinine (P=0.003) were predictors of late postoperative SVEF. SAVV surgery remains a valuable option for the treatment of patients with ccTGA, with low early mortality and satisfactory long-term outcomes, particularly in those with SVEF≥40%. Timely referral and accurate patient selection are the keys to better long-term outcomes.

962. Impact of Care Bundle Element Compliance on Clinical Outcomes for Pediatric Patients with Staphylococcus aureus Bacteremia

Abstract Background Staphylococcus aureus bacteremia (SAB) is a major cause of morbidity and mortality in children. The Infectious Disease Society of America (IDSA) outlines standards of care for patients with SAB known to positively impact morbidity and mortality, which have been validated in numerous studies within the adult population. However, there is limited data evaluating the clinical impact of compliance with these standards in pediatric patients. The primary objective of this study was to evaluate the impact of compliance with seven key bundle elements for the treatment of SAB in children. Methods This was a retrospective, single-center, cohort study of pediatric patients aged 18 years or younger with SAB admitted to Michigan Medicine from 2019–2022. The seven bundle elements evaluated included timely initiation of antibiotics, appropriate targeted antibiotic therapy, ID consultation, documented culture clearance, an echocardiogram for high-risk patients, source control, and appropriate duration of therapy. To be considered fully compliant, patients had to meet all seven elements. The primary endpoint was a composite endpoint of mortality and 30-day infection-related readmission rates. Results A total of 73 patients were included; 40 (54.8%) met the fully compliant bundle definition, and 33 (45.2%) were partially compliant. Fully compliant patients had a significantly lower incidence of combined mortality and readmission (7.5% vs. 24.2%; p = 0.0466). Lack of appropriate targeted therapy and lack of source control in patients with a removable source were the most common reasons for not meeting full bundle compliance (Table 1). Appropriate duration of therapy was met in 78.8% of patients in the partially compliant group (26/33, p = 0.0026).Table 1.Bundle Element Compliance.Bundle element compliance between the two cohorts (fully bundle compliant vs partially bundle compliant)Table 2.Primary OutcomeCombine primary outcome of 30-day mortality and 30-day infection-related readmission (fully bundle compliant vs partially bundle compliant) Conclusion Adherence to all bundle elements was associated with lower incidences of mortality and readmission. The results of this study will assist in quality improvement interventions at Michigan Medicine. Disclosures All Authors: No reported disclosures

Abstract 14660: The Effect of Sacubitril/Valsartan Therapy on Hospitalization and Mortality in Patients Non-Respondent to Cardiac Resynchronization Therapy

Background: Non-responders to Cardiac Resynchronization Therapy (CRT-NR) have poor prognosis. Sacubitril/valsartan (SV) treatment improved the outcomes of heart failure patients with reduced left ventricular (LV) ejection fraction (HFrEF) in randomized trials; however, limited data are available on the specific cohort of CRT-NRs. Aim of the study: We have compared heart failure hospitalization (HFH) and mortality rates in three patient cohorts: CRT-NR patients on S/V versus on ACEi/ARB and general HFrEF patients on S/V. Methods: 275 HF patients, including 70 CRT-NRs receiving S/V at least for 6 months (Group I); 70 CRT-NRs on ACEi/ARB treatment (Group II); and 135 HFrEF patients without CRT indication on S/V therapy at least for 6 months (Group III) were included. CRT-NR was defined as a less than 10% improvement in left ventricular ejection fraction (LVEF) 6 months after device implantation. Rates of HFH and the composite of all-cause mortality/heart transplantation/LVAD therapy were compared with a mean follow-up of 21.5 months. A subgroup analysis was also performed in patients on S/V (Groups I and III) who demonstrated a more versus less than 10% increase in LVEF after 6 months of S/V treatment (S/V super-responders versus S/V moderate responders, respectively). Results: HFH rates were similar in Groups I and III (28.5% vs. 28.1%, respectively; p&gt;0.05), while significantly higher (54.2%) in Group II (p=0.02). No significant difference in the composite mortality endpoint was demonstrated between the three groups (22.8% vs. 24.2% vs. 22.2%, p=0.08). On S/V treatment, 13 out of the 70 (18.5%) CRT-NR patients (Group I) and 24 out of the 135 (17.8%) HFrEF patients (Group III) were found to be SV super-responders. Comparing these 37 patients with the 168 S/V moderate responders, neither the HFH (24.3% vs 30.9%, p=0.07), nor the composite mortality rates (24.3% vs 23.2%, p=0.53) demonstrated significant differences. Conclusion: S/V treatment in CRT-NRs improved hospitalization rates similarly to what was observed in a general HFrEF population. No benefit in mortality rates was demonstrated in this cohort. The extent of change in LVEF on S/V was not predictive of a better response on HFH or mortality.

CT attenuation correction improves quantitative risk prediction by cardiac SPECT in obese patients.

This study aimed to compare the predictive value of CT attenuation-corrected stress total perfusion deficit (AC-sTPD) and non-corrected stress TPD (NC-sTPD) for major adverse cardiac events (MACE) in obese patients undergoing cadmium zinc telluride (CZT) SPECT myocardial perfusion imaging (MPI). The study included 4,585 patients who underwent CZT SPECT/CT MPI for clinical indications (chest pain: 56%, shortness of breath: 13%, other: 32%) at Yale New Haven Hospital (age: 64 ± 12years, 45% female, body mass index [BMI]: 30.0 ± 6.3kg/m2, prior coronary artery disease: 18%). The association between AC-sTPD or NC-sTPD and MACE defined as the composite end point of mortality, nonfatal myocardial infarction or late coronary revascularization (> 90days after SPECT) was evaluated with survival analysis. During a median follow-up of 25months, 453 patients (10%) experienced MACE. In patients with BMI ≥ 35kg/m2 (n = 931), those with AC-sTPD ≥ 3% had worse MACE-free survival than those with AC-sTPD < 3% (HR: 2.23, 95% CI: 1.40 - 3.55, p = 0.002) with no difference in MACE-free survival between patients with NC-sTPD ≥ 3% and NC-sTPD < 3% (HR:1.06, 95% CI:0.67 - 1.68, p = 0.78). AC-sTPD had higher AUC than NC-sTPD for the detection of 2-year MACE in patients with BMI ≥ 35kg/m2 (0.631 versus 0.541, p = 0.01). In the overall cohort AC-sTPD had a higher ROC area under the curve (AUC, 0.641) than NC-sTPD (0.608; P = 0.01) for detection of 2-yearMACE. In patients with BMI ≥ 35kg/m2 AC sTPD provided significant incremental prognostic value beyond NC sTPD (net reclassification index: 0.14 [95% CI: 0.20 - 0.28]). AC sTPD outperformed NC sTPD in predicting MACE in patients undergoing SPECT MPI with BMI ≥ 35kg/m2. These findings highlight the superior prognostic value of AC-sTPD in this patient population and underscore the importance of CT attenuation correction.

Risk factors and early outcomes of repeat sternotomy in 1960 adults with congenital heart disease: A 30-year, single-center study

ObjectivePatients with congenital heart disease (CHD) increasingly live into adulthood, often requiring cardiac reoperation. We aimed to assess the outcomes of adults with CHD (ACHD) undergoing repeat sternotomy at our institution. MethodsReview of our institution's cardiac surgery database identified 1960 ACHD patients undergoing repeat median sternotomy from 1993 to 2023. The primary outcome was early mortality, and the secondary outcome was a composite end point of mortality and significant morbidity. Univariable and multivariable logistic regression models were used to determine factors independently associated with outcomes. ResultsOf the 1960 ACHDs patient undergoing repeat sternotomy, 1183 (60.3%) underwent a second, third (n = 506, 25.8%), fourth (n = 168, 8.5%), fifth (n = 70, 3.5%), and sixth sternotomy or greater (n = 33, 1.6%). CHD diagnoses were minor complexity (n = 145, 7.4%), moderate complexity (n = 1380, 70.4%), and major complexity (n = 435, 22.1%). Distribution of procedures included valve (n = 549, 28%), congenital (n = 625, 32%), aortic (n = 104, 5.3%), and major procedural combinations (n = 682, 34.7%). Overall early mortality was 3.1%. Factors independently associated with early mortality were older age at surgery, CHD of major complexity, preoperative renal failure, preoperative ejection fraction, urgent operation, and postoperative blood transfusion. In addition, sternotomy number and bypass time were independently associated with the composite outcome. ConclusionsDespite the increase in early mortality with sternotomy number, sternotomy number was not independently associated with early mortality but with increased morbidity. Improvement strategies should target factors leading to urgent operations, early referral, along with operative efficiency including bypass time and blood conservation.

Predicting 1-Year Mortality in Outpatients With Heart Failure With Reduced Left Ventricular Ejection Fraction: Do Empiric Models Outperform Physician Intuitive Estimates? A Multicenter Cohort Study.

Many studies have demonstrated that physicians often err in estimating patient prognosis. No studies have directly compared physician to model predictive performance in heart failure (HF). We aimed to compare the accuracy of physician versus model predictions of 1-year mortality. This multicenter prospective cohort study on 11 HF clinics in 5 provinces in Canada included consecutive consented outpatients with HF with reduced left ventricular ejection fraction (<40%). By collecting clinical data, we calculated predicted 1-year mortality using the Seattle HF Model (SHFM), the Meta-Analysis Global Group in Chronic HF score, and the HF Meta-Score. HF cardiologists and family doctors, blinded to model predictions, estimated patient 1-year mortality. During 1-year follow-up, we recorded the composite end point of mortality, urgent ventricular assist device implant, or heart transplant. We compared physicians and model discrimination (C statistic), calibration (observed versus predicted event rate), and risk reclassification. The study included 1643 patients with ambulatory HF with a mean age of 65 years, 24% female, and mean left ventricular ejection fraction of 28%. Over 1-year follow-up, 9% had an event. The SHFM had the best discrimination (SHFM C statistic 0.76; HF Meta-Score 0.73; Meta-Analysis Global Group in Chronic Heart Failure 0.70) and calibration. Physicians' discrimination differed little (0.75 for HF cardiologists and 0.73 for family doctors) but both physician groups substantially overestimated risk by >10% in both low- and high-risk patients (poor calibration). In risk reclassification analysis, among patients without events, the SHFM better classified 51% in comparison to HF cardiologists and 43% in comparison to family doctors. In patients with events, the SHFM erroneously assigned lower risk to 44% in comparison to HF cardiologists and 34% in comparison to family doctors. Family doctors and HF cardiologists showed adequate risk discrimination, with however substantial overestimation of absolute risk. Predictive models showed higher accuracy. Incorporating models in family and HF cardiology practices may improve patient care and resource use in HF with reduced left ventricular ejection fraction. URL: https://www. gov; Unique identifier: NCT04009798.

Target versus sub-target dose of renin-angiotensin system inhibitors on survival in elderly patients with heart failure with reduced ejection fraction: a systematic review and meta-analysis.

The efficiency of the target versus sub-target dose of renin-angiotensin system inhibitors (RASIs) in elderly patients with heart failure (HF) with reduced ejection fraction (HErEF) remains unclear. PubMed, Embase, and the Cochrane Central Register of Controlled Trials were searched from database inception through March 2022 for randomized controlled trials (RCTs) and observational studies considering the effect of the target versus sub-target dose of RASIs on survival in elderly patients (≥ 60 years) with HErEF. The primary outcome was all-cause mortality. The secondary outcomes were cardiac mortality, HF hospitalization, and the composite endpoint of mortality or HF hospitalization. A meta-analysis was conducted to generate combined hazard ratio (HR) and 95% CI. Seven studies (two RCTs and five observational studies) enrolling 16,634 patients were included. A pooled analysis suggested that the target versus sub-target dose of RASIs led to lower rates of all-cause mortality (HR = 0.92, 95% CI: 0.87-0.98, I2 = 21%) and cardiac mortality (HR = 0.93, 95% CI: 0.85-1.00, I2 = 15%) but not reduced rates of HF hospitalization (HR = 0.94, 95% CI: 0.88-1.01, I2 = 0) and the composite endpoint (HR = 1.03, 95% CI: 0.91-1.15, I2 = 51%). However, the target dose of RASIs was associated with a similar primary outcome (HR = 0.85, 95% CI: 0.64-1.14, I2 = 0) in a subgroup of very elderly patients > 75 years of age. Our analysis suggests that the target dose of RASIs has a better survival benefit in elderly patients with HFrEF compared to the sub-target dose of RASIs. However, the sub-target dose of RASIs is associated with a similar mortality rate in very elderly patients > 75 years of age. Future high-quality and adequately powered RCTs are warranted.

Management of Severe Cerebral Venous Sinus Thrombosis Using Mechanical Balloon Assisted Thrombectomy

Background Cerebral venous thrombosis is a devastating condition with, despite optimal medical management, a significant proportion deteriorating due to involvement of the deep venous system, worsening intracranial pressures, and hemorrhage. In this study, we report the characteristics, immediate and long‐term outcomes of mechanical thrombectomy (MT) using a Forgarty balloon catheter among patients with cerebral venous thrombosis. Methods A prospective study conducted at the Christian Medical College, Vellore over 5 years (February 2017–February 2022), wherein patients with cerebral venous thrombosis who had clinical deterioration despite best medical management and requiring MT were included. MT was performed through retrograde venous access through internal jugular veins using a Fogarty balloon. The primary outcome was composite end point of mortality and proportion of patients with favorable clinical response at last follow‐up, defined as a disability score in modified Rankin scale 0–2. Results Among 546 patients treated in our center during the study period, 57(10%), patients required MT. The median age of the study population was 33 years (interquartile range: 17–70 years) with equal gender predilection. Hemorrhagic venous infarction was seen in 28/57 (50%) patients. The mean duration between starting medical treatment and to MT was 43 hours (interquartile range: 5–260 hours) with the most common indication being clinical deterioration (70%). Five patients (9%) required decompressive hemicraniectomy. The mortality at discharge was 5% (n=3), and at last follow‐up visit was 7% (n=4). Younger patients without hemorrhagic venous infarction and non‐involvement of the frontoparietal lobes seem to benefit the most. Favorable functional outcome at discharge (modified Rankin scale 0–2) was seen in 65% which further improved to 77% at 1‐year follow‐up. Conclusion Balloon‐assisted MT is safe and effective in a subset of patients with severe cerebral venous thrombosis, with clinical deterioration despite optimal medical management.

Fecal microbiota transplantation may reduce the mortality of patients with severe and fulminant Clostridioides difficile infection compared to standard-of-care antibiotics in a community hospital.

Clostridioides difficile infection (CDI) is known for significant morbidity and mortality. Fecal microbiota transplantation (FMT) is an effective therapy for recurrent and resistant CDI. However, its impact on the mortality rate of patients with severe and fulminant CDI has not been rigorously studied yet. We aimed to evaluate the effectiveness of FMT on the mortality rate of patients with severe or fulminant CDI in a community hospital system. Our study included 106 inpatients with severe or fulminant CDI. Both standard-of-care (SOC) and FMT were provided to 14 (13.2%) patients (the FMT group). SOC antibiotics alone were provided to 92 (86.8%) patients, out of whom 28 patients were included via propensity score matching in a 2:1 ratio (the SOC group). The primary outcome was defined as the composite end-point of mortality during admission, within 30 and 90 days after discharge, and discharge with comfort measures only. Each component was a secondary end-point. The primary outcome rate in the FMT group was 7.1% (1/14) compared to 25.0% (7/28) in the SOC group. Univariate analysis demonstrated that FMT decreases mortality (odds ratio[OR] 0.08, 95% confidence interval [CI] 0.01-0.58, P=0.01). However, multivariate regression did not show statistical significance (OR 0.15, 95% CI 0.01-2.53, P=0.19), possibly due to the small sample size. FMT may decrease the mortality of patients with severe and fulminant CDI. Large studies are needed to validate these findings.

125-OR: Association between Preventive Podiatric Care and Outcomes of New Diabetic Foot Ulceration among Patients with End Stage Renal Disease

Objective: To assess the association between foot care by podiatric surgeons and outcomes of new diabetic foot ulceration (DFU) among patients with end-stage renal disease (ESRD) . Methods: We used the 2015 and 2016 claim data from the United States Renal Data System to identify patients (≥ 40 years and on dialysis for ≥ 12 months) with a new diagnosis of DFU. The patients were stratified into intervention or control cohort based on whether they received any foot care by a podiatric surgeon within 12 months before the diagnosis of a new DFU. Patients were followed from the index DFU date until December 31, 2018. The study outcome was amputation-free survival (composite endpoint of mortality and major amputation) . Adjusted comparisons between preventive foot care and its association with outcomes were performed by Cox-regression analysis after propensity score matching for age, gender, race, hospitalizations, and Charlson Comorbidity Index (CCI) . Results: Among the 51,362 ESRD patients included, 16,156 (31.5%) received podiatric care within 12 months before their index DFU. Compared to the control cohort, the intervention cohort was older, likely to be female (44% vs. 39%) , and more likely to have peripheral artery disease (64.2% vs. 49.5%) . The overall major amputation rate was 9.6% during study follow-up (intervention: 9.3% vs. control: 9.8%) . A Kaplan-Meier estimate indicated that foot care before index DFU was associated with increased amputation-free survival based on the Log Rank test (p&amp;lt;0.0001) . In addition, the multivariable analysis demonstrated that foot care prior to index DFU was associated with a lower risk of death or major amputation in both the unmatched (Hazard ratio [HR] 0.92, 95% Confidence Interval [CI] 0.90, 0.93, p&amp;lt;0.0001) and matched cohorts (HR 0.82, 95% CI 0.79, 0.85, p&amp;lt;0.0001) . Conclusion: Among patients with end stage renal disease, preventive podiatric care appears to improve amputation-free survival for DFU. Disclosure T.Tan: None. D.G.Armstrong: None. C.Chong: None. N.J.Hamilton-cotter: None. O.S.Kshirsagar: None. D.G.Marrero: None. D.J.Cotter: None. Funding National Institutes of Health (K23DK122126)

Clinical Utility and Cost Effectiveness of Long-Acting Lipoglycopeptides Used in Deep-Seated Infections among Patients with Social and Economic Barriers to Care.

The use of long-acting lipoglycopeptides (LaLGPs) in serious, deep-seated infections is of increasing interest. The purpose of this study is to evaluate the economic and clinical utility of LaLGPs in patients requiring protracted antibiotic courses who are not ideal candidates for oral transition or outpatient parenteral antibiotic therapy (OPAT). This is a retrospective, observational, matched cohort study of adult patients who received a LaLGP. Patients were matched 1:1 to those who received standard of care (SOC). Cost effectiveness was evaluated as total healthcare-related costs between groups. Clinical failure was a composite endpoint of mortality, recurrence, or need for extended antibiotics beyond planned course within 90 days of initial infection. There was no difference in clinical failure between the two cohorts (22% vs. 30%; p = 0.491). Six patients in the SOC cohort left against medical advice (AMA) prior to completing therapy. Among those who did not leave AMA, receipt of LaLGPs resulted in a decreased hospital length of stay by an average of 13.6 days. The average total healthcare-related cost of care was USD 295,589 in the LaLGP cohort compared to USD 326,089 in the SOC cohort (p = 0.282). Receipt of LaLGPs may be a beneficial treatment option for patients with deep-seated infections and socioeconomic factors who are not candidates for oral transition or OPAT.

44. Cost Effectiveness and Clinical Outcomes of Long Acting Lipoglycopeptides Used in Transitions of Care for Deep-Seated Infections

BackgroundDalbavancin and oritavancin are long-acting lipoglycopeptides (LaLGPs) FDA-approved for one-time only dosing for skin and skin structure infections. The use of these agents in serious, deep-seated infections requiring protracted antibiotic courses is of increasing interest. The purpose of this study is to evaluate the economic and clinical utility of LaLGPs in patients requiring protracted antibiotic courses who are not ideal candidates for oral transition or outpatient parenteral antibiotic therapy (OPAT).MethodsThis is a retrospective, observational, matched cohort study of adult patients who received a LaLGP. Patients who received a LaLGP were matched 1:1 to those who received standard of care (SOC) therapy by age (+/- 10 years), infection type, microorganism, and socioeconomic factor (e.g. persons who inject drugs, homelessness). Cost effectiveness was evaluated as total healthcare-related costs between groups. Clinical failure was a composite endpoint of mortality, recurrence, or need for extended antibiotics beyond planned course within 90 days of initial infection. Secondary outcomes included hospital length of stay and proportion of patients who left against medical advice (AMA).ResultsA total of 46 patients were included (23 per group). The most frequent indication was endovascular infection and the most common organism methicillin-resistant Staphylococcus aureus. The average length of stay was 22.9 days vs. 31.9 days in the LaLGP and SOC cohorts, respectively (p=0.153). The average total healthcare-related cost of care was USD &295,589 in the LaLGP cohort compared to &326,089 in the SOC cohort (p=0.282). LaLGPs were associated with a mean savings of &30,500 - &55,831 per patient (cumulative cost savings of &701,510). There was no difference in clinical failure between the two cohorts (22% vs. 30%; p=0.491). Nearly 26% of patients in the SOC cohort left AMA compared to 0% in the LaLGP cohort (p=0.022). ConclusionReceipt of LaLGPs may be a beneficial treatment option for patients with socioeconomic factors and deep-seated infections who are not candidates for oral transition or OPAT.Disclosures Julie Ann Justo, PharmD, MS, BCPS-AQ ID, bioMerieux (Speaker’s Bureau)Merck & Co. (Advisor or Review Panel member)Therapeutic Research Center (Speaker’s Bureau)Vaxart (Shareholder) P. Brandon Bookstaver, Pharm D, ALK Abello, Inc. (Grant/Research Support, Advisor or Review Panel member)Biomerieux (Speaker’s Bureau)Kedrion Biopharma (Grant/Research Support, Advisor or Review Panel member)

Prevalence and Prognosis of HFimpEF Developed From Patients With Heart Failure With Reduced Ejection Fraction: Systematic Review and Meta-Analysis

Background: Heart failure with improved ejection fraction (HFimpEF) is classified as a new type of heart failure, and its prevalence and prognosis are not consistent in previous studies. There is no systematic review and meta-analysis regarding the prevalence and prognosis of the HFimpEF.Method: A systematic search was performed in MEDLINE, EMBASE, and Cochrane Library from inception to May 22, 2021 (PROSPERO registration: CRD42021260422). Studies were included for analysis if the prognosis of mortality or hospitalization were reported in HFimpEF or in patients with heart failure with recovered ejection fraction (HFrecEF). The primary outcome was all-cause mortality. Cardiac hospitalization, all-cause hospitalization, and composite events of mortality and hospitalization were considered as secondary outcomes.Result: Nine studies consisting of 9,491 heart failure patients were eventually included. During an average follow-up of 3.8 years, the pooled prevalence of HFimpEF was 22.64%. HFimpEF had a lower risk of mortality compared with heart failure patients with reduced ejection fraction (HFrEF) (adjusted HR: 0.44, 95% CI: 0.33–0.60). HFimpEF was also associated with a lower risk of cardiac hospitalization (HR: 0.40, 95% CI: 0.20–0.82) and the composite endpoint of mortality and hospitalization (HR: 0.56, 95% CI: 0.44–0.73). Compared with patients with preserved ejection fraction (HFpEF), HFimpEF was associated with a moderately lower risk of mortality (HR: 0.42, 95% CI: 0.32–0.55) and hospitalization (HR: 0.73, 95% CI: 0.58–0.92).Conclusion: Around 22.64% of patients with HFrEF would be treated to become HFimpEF, who would then obtain a 56% decrease in mortality risk. Meanwhile, HFimpEF is associated with lower heart failure hospitalization. Further studies are required to explore how to promote left ventricular ejection fraction improvement and improve the prognosis of persistent HFrEF in patients.Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021260422, identifier: CRD42021260422.

In-hospital COVID-19 infection echocardiographic analysis: a Brazilian, tertiary single-centre experience

BackgroundInformation is lacking concerning in-hospital echocardiography analysis of COVID-19 infection in Brazil. We evaluated echocardiographic parameters to predict a composite endpoint of mortality, pulmonary thromboembolism or acute renal failure.MethodsA prospective full echocardiographic study of consecutive patients hospitalized with COVID-19, single tertiary centre in Brazil. We correlated echocardiographic findings to biomarkers, clinical information, thoracic tomography, and in-hospital composite endpoint of mortality, pulmonary thromboembolism or renal failure.ResultsOne hundred eleven patients from March to October 2020, 67 ± 17 years, 65 (58.5%) men, death was observed in 21/111 (18.9%) patients, 48 (43%) required mechanical ventilation, myocardial infarction occurred in 10 (9%), pulmonary thromboembolism in 7 (6.3%) patients, haemodialysis was required for 9 (9.8%). Echocardiography was normal in 51 (46%) patients, 20 (18%) presented with decreased left ventricle ejection, 18 (16.2%) had abnormal left ventricle global longitudinal strain, 35 (31%) had diastolic dysfunction, 6 (5.4%) had an E/e’ratio > 14, 19 (17.1%) presented with right ventricle dilated/dysfunction, 31 (28%) had pericardial effusion. The echocardiographic parameters did not correlate with mortality, biomarkers, clinical events. Tricuspid velocity was related to the composite endpoint of mortality, pulmonary thromboembolism or acute renal failure (p: 00.3; value: 2.65 m/s; AUC ROC curve: 0.739; sensitivity: 73.3; specificity: 66.7; CI: 0.95, inferior: 0.613; superior: 0,866).ConclusionsAmong hospitalized patients with COVID-19, echocardiography was normal in 51(46%) patients, and 20 (18%) patients presented with a decreased left ventricle ejection fraction. Tricuspid velocity was related to the composite endpoint of mortality, pulmonary thromboembolism or acute renal failure.

Long term outcomes of patients with chronic inflammatory diseases after percutaneous coronary intervention

Abstract Introduction Patients with chronic inflammatory diseases are at increased risk for coronary artery disease. Aim We aimed to assess the long-term outcomes of patients with chronic inflammatory diseases who underwent percutaneous coronary intervention. Methods A Retrospective cohort study of all adult (&amp;gt;18 years) patients who underwent PCI in a large [1000 bed] tertiary care centerfrom January 2002 to August 2020. Results A total of 12,951 patients underwent PCI during the study period and were included in the cohort. The population of chronic inflammatory diseases includes 247/12,951 [1.9%]; 70 with IBD and 173 with AIRD. The composite endpoint of mortality, ACS or CHF admission was more frequent in the inflammatory disease group (77.5% in AIRD group, 72.9% in the IBD group and 59.6% in the non-inflammatory group, p&amp;lt;0.001). The adjusted cox regression model found a statistically significant increased risk of the composite primary endpoints of around 40% for patients both with AIRD and IBD. The increased risk for ACS was 61% for AIRD patients and 37% for IBD patients. Patients with inflammatory diseases were found to have a significant increased risk CHF admission, while both IBD and AIED patients had a non-significant increased risk for mortality. Conclusion Patients with AIRD and IBD are at higher risk for cardiovascular events also in long term follow up once diagnosed with CAD and treated with PCI. Funding Acknowledgement Type of funding sources: None.

Multiple Cardiac Biomarker Testing Among Patients With Acute Dyspnea From the ICON-RELOADED Study

BackgroundAmong patients with acute dyspnea, concentrations of N-terminal pro-B-type natriuretic peptide (NT-proBNP), high-sensitivity cardiac troponin T, and insulin-like growth factor binding protein-7 predict cardiovascular outcomes and death. Understanding the optimal means to interpret these elevated biomarkers in patients presenting with acute dyspnea remains unknown. Methods and ResultsConcentrations of NT-proBNP, high-sensitivity cardiac troponin T, and insulin-like growth factor binding protein-7 were analyzed in 1448 patients presenting with acute dyspnea from the prospective, multicenter International Collaborative of NT-proBNP-Re-evaluation of Acute Diagnostic Cut-Offs in the Emergency Department (ICON-RELOADED) Study. Eight biogroups were derived based upon patterns in biomarker elevation at presentation and compared for differences in baseline characteristics. Of 441 patients with elevations in all 3 biomarkers, 218 (49.4%) were diagnosed with acute heart failure (HF). The frequency of acute HF diagnosis in this biogroup was higher than those with elevations in 2 biomarkers (18.8%, 44 of 234), 1 biomarker (3.8%, 10 of 260), or no elevated biomarkers (0.4%, 2 of 513). The absolute number of elevated biomarkers on admission was prognostic of the composite end point of mortality and HF rehospitalization. In adjusted models, patients with one, 2, and 3 elevated biomarkers had 3.74 (95% confidence interval [CI], 1.26–11.1, P = .017), 12.3 (95% CI, 4.60–32.9, P < .001), and 12.6 (95% CI, 4.54–35.0, P < .001) fold increased risk of 180-day mortality or HF rehospitalization. ConclusionsA multimarker panel of NT-proBNP, hsTnT, and IGBFP7 provides unique clinical, diagnostic, and prognostic information in patients presenting with acute dyspnea. Differences in the number of elevated biomarkers at presentation may allow for more efficient clinical risk stratification of short-term mortality and HF rehospitalization.

Tocilizumab administration for the treatment of hospitalized patients with COVID-19: A systematic review and meta-analysis.

Tocilizumab has been repurposed against the ‘cytokine storm’ in the setting of coronavirus disease 2019 (COVID‐19). Our aim was to evaluate the efficacy of tocilizumab in the management of hospitalized COVID‐19 patients. We searched MEDLINE, CENTRAL and medRxiv for studies of tocilizumab in hospitalized COVID‐19 patients. Primary objective was the effectiveness of tocilizumab on mortality. Secondary objectives included the need for invasive mechanical ventilation (IMV), composite endpoints of mortality or IMV and intensive care unit (ICU) admission or IMV, length of hospitalization and differences in mortality in subgroups (ICU and non‐ICU patients and patients receiving or not receiving concomitant corticosteroids). We included 52 studies (nine randomized controlled trials [RCTs] and 43 observational) with a total of 27,004 patients. In both RCTs and observational studies, the use of tocilizumab was associated with a reduction in mortality; 11% in RCTs (risk ratio [RR] 0.89, 95% CI 0.82 to 0.96) and 31% in observational studies (RR 0.69, 95% CI 0.58 to 0.83). The need for IMV was reduced by 19% in RCTs (RR 0.81, 95% CI 0.71 to 0.93), while no significant reduction was observed in observational studies. Both RCTs and observational studies showed a benefit from tocilizumab on the composite endpoint of mortality or IMV. Tocilizumab improved mortality both in ICU and non‐ICU patients. Reduction in mortality was evident in observational studies regardless of the use of systemic corticosteroids, while that was not the case in the RCTs. Tocilizumab was associated with lower mortality and other clinically relevant outcomes in hospitalized patients with moderate‐to‐critical COVID‐19.

Association Between Impaired Myocardial Flow Reserve on 82Rubidium Positron Emission Tomography Imaging and Adverse Events in Patients With Autoimmune Rheumatic Disease.

Coronary microvascular dysfunction has been described in patients with autoimmune rheumatic disease (ARD). However, it is unknown whether positron emission tomography (PET)-derived myocardial flow reserve (MFR) can predict adverse events in this population. Patients with ARD without coronary artery disease who underwent dynamic rest-stress 82Rubidium PET were retrospectively studied and compared with patients without ARD matched for age, sex, and comorbidities. The association between MFR and a composite end point of mortality or myocardial infarction or heart failure admission was evaluated with time to event and Cox-regression analyses. In 101 patients with ARD (88% female, age: 62±10 years), when compared with matched patients without ARD (n=101), global MFR was significantly reduced (median: 1.68 [interquartile range: 1.34-2.05] versus 1.86 [interquartile range: 1.58-2.28]) and reduced MFR (<1.5) was more frequent (40% versus 22%). MFR did not differ among subtypes of ARDs. In survival analysis, patients with ARD and low MFR (MFR<1.5) had decreased event-free survival for the combined end point, when compared with patients with and without ARD and normal MFR (MFR>1.5) and when compared with patients without ARD and low MFR, after adjustment for the nonlaboratory-based Framingham risk score, rest left ventricular ejection fraction, severe coronary calcification, and the presence of medium/large perfusion defects. In Cox-regression analysis, ARD diagnosis and reduced MFR were both independent predictors of adverse events along with congestive heart failure diagnosis and presence of medium/large stress perfusion defects on PET. Further analysis with inclusion of an interaction term between ARD and impaired MFR revealed no significant interaction effects between ARD and impaired MFR. In our retrospective cohort analysis, patients with ARD had significantly reduced PET MFR compared with age-, sex-, and comorbidity-matched patients without ARD. Reduced PET MFR and ARD diagnosis were both independent predictors of adverse outcomes.

Long-term outcomes of patients with chronic inflammatory diseases after percutaneous coronary intervention.

To assess the long-term outcomes of patients with chronic inflammatory diseases who underwent percutaneous coronary intervention (PCI). A Retrospective cohort study of all adult patients who underwent PCI in a large tertiary care center from January 2002 to August 2020. A total of 12,951 patients underwent PCI during the study period and were included in the cohort. The population of chronic inflammatory diseases includes 247 (1.9%) patients; 70 with inflammatory bowel disease (IBD) and 173 with autoimmune rheumatic diseases (AIRD). The composite endpoint of mortality, acute coronary syndrome (ACS) or admission due to acute heart failure was similar at 30 days and more frequent in the inflammatory disease group (42.8% in AIRD group, 35.7% in the IBD group and 29.6% in the noninflammatory group, p< 0.0001). The adjusted cox regression model found a statistically significant increased risk of the composite primary endpoints of around 40% for patients both with AIRD and IBD. Readmission due to ACS was also increases at 30 days in the AIRD group compared to the noninflammatory group (0.6% vs. 0.1%, p< 0.001) and 1year (37.6% for the AIRD group, 34.3% in the IBD group and 25.5% in the noninflammatory group (p< 0.0001). Patients with inflammatory diseases were found to have a significantly increased risk congestive heart failure admissions at 1year in a subgroup analysis of patients with myocardial infarction. Patients with AIRD and IBD are at higher risk for cardiovascular events in long-term follow up once diagnosed with CAD and treated with PCI.