Higher Risk Of Mortality Research Articles

Trajectories of depressive symptoms in Korean adults with diabetes: Individual differences and associations with life satisfaction and mortality.

We examined trajectories of depressive symptoms and their predictors in adults with diabetes. We assessed whether these trajectories were related to life satisfaction and mortality. Longitudinal, prospective observational study. We analysed data from 1217 adults with diabetes (aged ≥45 years) in the Korean Longitudinal Study of Aging (2006-2018). Three trajectories of depressive symptomology were identified in growth mixture models: low/stable (i.e., low and stable levels of symptoms; 85.56%), high/decreasing (i.e., high levels of symptoms with a decreasing trajectory; 7.47%), and moderate/increasing (i.e., moderate levels of symptoms with an increasing trajectory; 6.98%). Participants with poor perceived health status at baseline were more likely to be in the moderate/increasing or high/decreasing classes than in the low/stable class. The moderate/increasing class had the lowest satisfaction with quality of life, followed by the high/decreasing and low/stable classes. The moderate/increasing and the high/decreasing classes had lower satisfaction with relationships with spouse and children than the low/stable class. The high/decreasing class had a higher mortality risk than the low/stable class. Long-term monitoring of depressive symptoms in adults with diabetes is warranted given their potential adverse impact on life satisfaction and mortality.

Left atrial reservoir strain and global longitudinal strain associates with re-hospitalization and mortality in patients admitted for acute heart failure

Abstract Background Left atrial reservoir strain (LAr) and global longitudinal strain (GLS) have emerged as useful parameters for the assessment of left ventricular diastolic function and the estimation of left ventricular filling pressures. Yet, there remains a gap of knowledge regarding the possible association of LAr and GLS with re-hospitalization and mortality in patients with acute heart failure (HF). Aims This study aims to investigate the association between LAr and GLS with re-hospitalization and mortality in patients admitted for acute HF. Methods Out of 526 enrolled patients admitted for acute HF, 142 (mean age 71, 25% women) were systematically evaluated for LAr and GLS using speckle tracking echocardiography. Multivariable Cox regression analyses, adjusting age, sex, current smoking prevalent atrial fibrillation, hypertension, kidney disease and plasma glucose, were used to assess the associations between continuous values of LAr and GLS with all-cause mortality and HF-related re-hospitalization. Results The median follow-up time to death of any cause and HF rehospitalization was 39 (interquartile range 14-66) and 22 (4-51) months, respectively. During follow up, 63 (44%) patients died, and 63 (44%) were re-hospitalized due to HF. Lower values of LAr were significantly associated with higher risk of mortality (HR 0.93; 95%CI 0.89-0.98, p=0.008). Similarly, lower GLS was associated with higher risk of mortality (HR 0.94; 95%CI 0.89-0.99, p=0.045). Only lower values of LAr were associated with higher risk of HF re-hospitalization in the multivariable model (HR 0.93; 95%CI 0.88-0.98, p=0.004). Conclusion In this prospective, long-term follow-up study of patients with acute heart failure, lower values of LAr and GLS showed prognostic significance, with lower values being indicative of poorer outcomes. Notably, LAr was associated with higher risk of both death and rehospitalization for heart failure, whereas GLS was solely associated with higher mortality risk. These echocardiographic parameters could be further investigated for risk assessment of patients with heart failure in order to identify those at higher risk of rehospitalization and death, thereby facilitating targeted interventions to improve their prognosis.KM-curves for or the Quartiles of LAr

Unveiling the heartbeat of hope: exploring cardiovascular morbidity, mortality, and socioeconomic threads in 65,173 Child, Adolescent, and Young Adult (caya) cancer patients

Abstract Background Despite significant progress in managing cancer in children, adolescents, and young adults (CAYAs), persistent complications impact their quality of life with some being severe or life-threatening.(1,2) Long-term outcomes depend on common risk factors for malignancy and cardiovascular diseases (CVD) that overlap, and treatments are known to increase the risk for CVD. (3,4) Healthcare inequality due to socioeconomic status is omnipresent and may significantly impact outcomes. Purpose This study aims to comprehensively cover morbidity, mortality, demographic, and socioeconomic factors among CAYAs and investigate their impact on cardiovascular outcomes. Methods This retrospective matched cohort study included the entire Swedish population under 25 with cancer from 1958 to 2021. The study population was identified from the National Board of Health and Welfare's Cancer Register, with controls paired 1:5 based on age, sex, and residence. Multiple registers provided data on morbidity, mortality, and demographics. Results Covering 63 years, identified 65,173 CAYAs (1.24 million patient-years) and matched with 312,935 controls (7.45 million person-years), a total of 378,108 individuals (74% females). The mean follow-up was 19.5 (SD16.9) years for CAYAs, and 23.8 (16.8) for controls, (p<0.001). At the end of the study, the median age of CAYAs was 33.4 (IQR 27.9) years and controls 39.2 (28.3) (p<0.0001), with an age span of <1-88 years in both groups. CVD was detected in 16.9 % of the CAYAs, representing a 1.21-time elevated risk (95% CI 1.18-1.23, p<0.0001) compared to controls. CAYAs had a higher mortality rate, and 5-years survivors lived a mean of 26.9 years shorter than controls. CV mortality was also increased in CAYAs, (1.9% compared to 0.7% in controls) but at a higher age, although at a mean of 22.8 years younger than their controls. The 5-year survivors were older at CV mortality and lived in mean 6.5 years shorter than controls (p<0.0001). After adjusting for socioeconomic factors, individuals born outside Europe and those with greater sick leave had a higher mortality risk, while education and marriage showed a beneficial association with mortality. (p<0.0001). Interpretation The Rebuc study, spanning six decades, revealed a significantly increased risk of serious complications among young cancer patients in Sweden. Not only do young cancer patient survivors face a significantly higher risk for cardiovascular disease, but the higher mortality risk before middle age also underscores the severity of the health challenges they confront. Furthermore, these young individuals are more susceptible to socioeconomic factors that may adversely affect their survival.

Determinants of changes in peak oxygen consumption in patients with new onset heart failure

Abstract Background Patients with heart failure (HF) with reduced ejection fraction (HFrEF) have a high risk of mortality. Cardio-Pulmonary Exercise Test (CPET) assesses peak oxygen consumption (pVO2) which is considered a key predictor of mortality and morbidity in patients with HFrEF. Factors responsible for the changes in pVO2 could consequently be of interest, as optimizing these factors may improve prognosis and overall quality of life in patients with HFrEF. Purpose To investigate factors contributing to changes in pVO2 within a contemporary cohort of new-onset patients with HFrEF. Methods From December 2022 to September 2023, patients with new-onset HFrEF (European Society of Cardiology (ESC) criteria) were included from a HF outpatient clinic, who after referral to the clinic underwent 12 weeks of HF management according to ESC guidelines. This included physical training and optimization of pharmacological management of HFrEF. Baseline characteristics, CPET, medication and echocardiography were collected at referral and after 12 weeks. Changes in pVO2 were investigated according to baseline characteristics, changes in medication, and changes in echocardiographic parameters in both uni- and multivariable linear regression models. Significant independent variables were identified using stepwise selection (p<0.1), adjusted for age and sex. A p-value of 0.05 was considered significant. Results We included 48 patients with new-onset HFrEF with a median age of 73 (interquartile range (IQR): 60-77) years, 10 (20.8%) women, a baseline median left ventricular ejection fraction (LVEF) of 30% (IQR: 25-35), and a baseline median pVO2 of 17.3 ml/min/kg (IQR: 14.1-21.9). After 12 weeks, pVO2 improved with a mean of +2.18 ml/min/kg (95% confidence interval (CI) 1.25 to 3.10, p<0.01) and LVEF improved with a mean of +11.7% (95% CI 7.9 to 15.6, p<0.01). In univariable analyses increasing age were negatively associated with pVO2 changes (p=0.04) and increasing minute ventilation (MV) and initiation of sodium-glucose cotransporter (SGLT2) inhibitors were all positively associated with pVO2 changes (p<0.01 and p=0.03, respectively). Other clinical variables included in the analysis were not significantly associated with a change in pVO2. In the multivariable analysis, body mass index emerged as an independent variable negatively associated with pVO2 changes, and MV and initiation of SGLT2 inhibitors remained significantly positively associated with pVO2 changes. Conclusion Optimal pharmacological management and physical training in patients with new-onset HFrEF, induce a significant recovery of cardiorespiratory performance and ejection fraction. Furthermore, our results suggest that the initiation of SGLT2 inhibitors in patients with new-onset HFrEF appears to improve their pVO2 already after 12 weeks of optimal HF management.Table 1:BaselineTable 2:Associations

Developing a multi-center registry of peripheral artery disease using natural language processing: unlocking the power of the electronic health record

Abstract Background Although peripheral artery disease (PAD) is common and associated with a high risk of mortality, contemporary PAD research remains limited due to poor accuracy of diagnosis codes in the electronic health record (EHR). We previously developed and validated a novel natural language processing (NLP) algorithm that can extract ankle brachial index (ABI) and toe-brachial index (TBI) values from clinical documents and identify patients with PAD with high accuracy (positive predictive value 92.4%). Purpose Scale the NLP system for developing a nationwide registry of PAD in the Veterans Health Administration (VHA), the largest integrated health system in the U.S. that provides care to ~9 million Veterans across 130 sites. Describe the baseline characteristics and mortality outcomes among participants and identify predictors of long-term mortality. Methods A total of 1,182,025 documents from vascular and radiology procedures during 2013-2020 were processed by the NLP system. After excluding non-ABI vascular studies, patients with a known diagnosis of PAD prior to 2015, patients younger than 40 years of age, and those who do not regularly follow-up in the VHA, we identified 107,711 patients with newly diagnosed PAD during 2015-2020. Patients were followed longitudinally using the VA’s electronic health record data. The primary outcome was all-cause mortality. We used Cox proportional hazards regression to examine predictors of long-term mortality. Results The mean age was 70.5 years; 97.3% were males, and 18.5% were of Black race. The mean ABI value was 0.78 (SD: 0.26) and the mean TBI value was 0.51 (SD: 0.19). There was a high prevalence of hypertension (83.6%), heart failure (20.8%), diabetes (53.6%), renal failure (22.1%) and chronic obstructive pulmonary disease (32.4%, Table 1). At 1-year, 9.6% of patients had died and this proportion increased to 25.4% at 3 years. Although nearly all patient variables were significantly associated with mortality, older age, severe PAD at diagnosis, diabetes, heart failure, renal failure and COPD were the strongest predictors of long-term mortality. Black race was associated with lower hazard of long-term mortality. Conclusions Using a previously validated novel NLP algorithm that extracts ABI and TBI values from clinical documents, we have successfully developed a registry of newly diagnosed PAD in the VHA. Ongoing studies from our cohort will yield important insights into the association between clinical management of PAD and clinical outcomes, with the goal of identifying opportunities for improving care.

Temporal trends in mortality and hospitalisation risk in patients with heart failure according to frailty status

Abstract Background Heart failure (HF) and frailty often coexist, and patients with both conditions have a higher risk of mortality and hospitalisation compared with those who are not frail. Over the past two decades, advances in medication targeting HF have been introduced, prolonging the life of patients with HF, but also resulting in increased comorbidity accumulation and susceptibility to frailty. It remains unknown how the interplay between HF and frailty at HF onset impacts patient prognosis and how this has changed over time. Purpose We investigated the temporal trends in the risk of all-cause mortality and HF hospitalisation in patients with HF from 1999 to 2017 according to their frailty status. Methods From Danish nationwide registers, we included patients with new-onset HF. Patients were categorised into four groups according to the year of HF onset: 1999-2002, 2003-2007, 2008-2012, and 2013-2017. The Hospital Frailty Risk Score was used to classify patients into frailty severity categories: 1) non-frail, 2) moderately frail, and 3) severely frail. The primary outcome was the 5-year cumulative incidence of all-cause mortality, assessed using the Kaplan-Meier estimator. The secondary outcome was the 5-year risk of HF hospitalisation, assessed using the Aalen-Johansen estimator, accounting for the competing risk of death. Moreover, a sensitivity analysis was conducted using a multivariable Cox proportional hazard model, investigating the interaction between year group and frailty status for all-cause mortality, comparing frail patients with non-frail patients. Results Among 131,235 patients with HF (median age 74 years; 39.7% female), 102,635 (78%) were categorised as non-frail, 26,054 (20%) as moderately frail, and 2609 (2%) as severely frail. The proportion of moderately frail patients increased the most, from 13% in 1999 to 25% in 2017. From 1999-2002 to 2003-2017, the 5-year cumulative incidence of all-cause mortality declined from 56.4% (95% CI, 55.8-57.0%) to 33.3% (32.6-34.1%), 79.8% (78.5-81.0%) to 58.6% (57.2-60.1%), and 90.8% (85.6-96.0%) to 79.8% (76.4-83.2%) in the non-frail, moderately frail, and severely frail patient group, respectively (Fig 1). The largest relative improvement was observed in the non-frail patient group. The 5-year cumulative incidence of HF hospitalisation remained fairly constant across the frailty groups (Fig 2). Conclusions From 1999 to 2017, we observed an increase in moderately and severely frail patients. Overall, the mortality risk decreased across all frailty groups. These findings underscore the importance of implementing guidelines directed at frail patients with HF.5-year risk of all-cause mortality5-year risk of HF hospitalisation

Pretreatment with dual antiplatelet therapy in acute myocardial infarction

Abstract Background Combined antithrombotic therapy prevents thrombus progression and its components embolization, and thus, it has an essential role in coronary microcirculation (re)perfusion in acute myocardial infarction (AMI). Pretreatment with P2Y12 inhibitors, on top of aspirin, before primary angioplasty has not been satisfactorily studied in STEMI. Purpose To investigate the impact of combined antiplatelet therapy on-treatment on the outcome of patients with STEMI. Methods Patients who suffered STEMI during the 7 years (1/2016-12/2022) were included. The analysis is based on population data from the National Health Information System (NHIS). Information on AMIs from the Intervention Module of the Registry of Cardiovascular Operations and Interventions was combined with prescription data from the Registry of Reimbursed Health Services 6 months before MI and identification of deceased patients from the Registry of Death Records. Data from the NHIS covers almost 100% of all cases in the population. Standard descriptive statistics and test were applied in the analysis. Multivariate logistic regression adjusted for clinical and procedural characteristics was adopted to analyze the influence of pretreatment on the risk of 1) out-of-hospital cardiac arrest (OHCA), 2) clinical condition at admission – need of mechanical ventilation and circulatory instability (Killip III,IV), 3) initial TIMI flow through the infarct-related coronary artery (IRA ), and 4) short term mortality. Results The study sample consisted of data from 40,383 STEMIs of which 1,601 patients were on dual antiplatelet therapy (DAPT) with aspirin plus iP2Y12 lasting 1 to 6 months before the event occurred. Patients on chronic oral anticoagulation (N 2101) were excluded. Patients on DAPT versus those without antiplatelet therapy or on aspirin at a daily dose of 100 mg were older, had higher comorbidity rates, and were at higher risk of mortality (Table). The multivariate logistic regression analysis showed that patients on DAPT at the time of MI onset and lasting for at least one month had a higher likelihood of preserved perfusion through the IRA (Odds ratio and 95% Confidence interval, OR (95% CI) 1. 193 (1.074; 1.326), p=0.001). However, the DAPT pretreatment did not reduce the risk of OHCA, the need for mechanical ventilation, or initial circulatory destabilization. It did not positively affect the prognosis of the patients (Figure ). Conclusion The significant benefit of the DAPT pretreatment on the preservation of infarct-related coronary artery flow did not translate into a positive effect on the prognosis of STEMI patients.

Sex differences in outcomes of patients with cardiogenic shock due to acute myocardial infarction: a systematic review and epidemiological meta-analysis

Abstract Background Women are at higher risk of mortality from ST-elevation myocardial infarction (1) when compared to men. There is a lack of consensus among studies examining the effect of sex on outcomes from cardiogenic shock due to acute myocardial infarction (AMI-CS) (2-5). In this systematic review and meta-analysis, we sought to assess the relationship between outcomes of AMI-CS and sex. Purpose To examine sex-related differences in mortality in patients with cardiogenic shock secondary to acute myocardial infarction (AMI-CS). Methods Cochrane Central, PubMed, MEDLINE and EMBASE were searched in February 2023 for studies reporting in-hospital or 30-day sex-specific mortality in patients with cardiogenic shock. Inclusion criteria consisted of observational or randomised controlled trials of adult patients with cardiogenic shock that reported unadjusted or adjusted (by odds or risk ratio) mortality rates by sex. In-hospital or 30-day mortality were treated as equivalent. Data were extracted for study size, number of men and women, unadjusted and adjusted mortality rates, and factors used in multivariable analysis. Studies were assessed for risk of bias and publication bias. Meta-analysis was performed using DerSimonian-Laird random effects model with inverse variant weighting, due to predicted high heterogeneity of included studies. Data are reported as odds ratios (ORs) with 95% confidence interval (CI). P values were adjusted for multiple comparison using Holm-Bonferonni correction. The primary outcomes were unadjusted and adjusted sex-specific mortality rates due to AMI-cardiogenic shock. Results 4,286 studies were identified and 37 met inclusion criteria, pooling a total of 630,890 patients. Raw 30-day/in-hospital mortality of females with AMI-cardiogenic shock was 41.2% compared to 32.3% in males. Unadjusted OR for mortality in females was 1.42 (95% CI 1.31–1.55, p <0.001, t2 = 0.02, I2 = 70.3%), and the adjusted OR was 1.11 (95% CI 1.04–1.20, p <0.001, t2 = 0.01, I2 = 76.8%). Eight studies included data on use of mechanical circulatory support (MCS), which was used in 31.2% of females compared to 39.9% of males. OR for use of MCS in females compared to males was 0.71 (95% CI 0.66–0.77, p < 0.001, t2 = 0.003, I2 = 35.2%). Conclusions Women with AMI-related cardiogenic shock are at greater risk of death compared to male patients and are less often treated with MCS. Potential explanations include residual confounding factors, differences in AMI-cardiogenic shock pathophysiology between men and women, and sex-related differences in healthcare behaviours, but we cannot exclude the effect of systemic bias on outcomes. Further research is required to address the causes of sex disparities in outcomes and ensure equitable management of AMI-cardiogenic shock in women.Unadjusted sex outcomes from AMI-CSAdjusted sex outcomes from AMI-CS

Investigating the influence of possible liver fibrosis on mortality in patients with coronary artery disease - a post-hoc ISCHEMIA trial analysis

Abstract Background There is a plethora of studies demonstrating that comorbidities (e.g., diabetes and renal dysfunction) directly influence outcomes in patients undergoing PCI or CABG for coronary artery disease (CAD). Yet, liver dysfunction is not really included in current risk assessment beyond the presence of liver cirrhosis. Retrospective single center evidence now suggests that the presence of liver fibrosis may be an indicator of elevated risk. Using the FIB-4 score, where increasing values correlate with increaseing degrees of histological liver fibrosis, liver fibrosis could already be detected with all required laboratory values (AST, ALT, platelets) within normal range. In addition, the study suggests a beneficial effect of off-pump CABG when FIB-4 is elevated. This finding contradicts current randomized evidence, negating any difference between off and on-pump CABG. Since randomized trials always suffer from strong selection of low risk patients, it is conceivable that trial patients may primarily have low FIB-4 scores. Purpose To address the distribution of FIB-4 scores in a selected trial population with CAD (from the ISCHEMIA trial) and relate the degree of liver fibrosis reflected by the score to mortality. Methods The FIB-4 score was calculated for all patients. According to the standard classification, a value of greater than 1.2 reflects a 90% chance of the presence of histological liver fibrosis. The imapct of FIB-4 on late all-cause mortality was assessed as a continuous and categorical variable using maximally selected rank statistics determined FIB-4 cutoff. Cox regression model was peformed including the adjustment for the main CAD risk factors. Results Among 3735 included patients, 58.8% had a FIB-4 value above 1.2. Patients with higher FIB-4 score (cutoff= 1.64) were slighly older, presented higher prevalence of male sex, prior PCI and CABG, and prior history of atrial fibrillation and cerebrovascular disease. FIB-4 score was directly associated with higher risk of mortality when addressed as a continouos variable and as a categorical variable (Fig. 1). This relationship was evident in the overall population and in all subsets (PCI, CABG and no revascularization; Fig. 2). Conclusions The use of Fib-4 to determine the degree of liver fibrosis may be powerful to predict mortality in CAD populations which may not show any evident clinical signs of liver dysfunction. The Fib-4 distribution in this trial population, considered as selected and low risk, warrants investigating randomized trial populations having compared on- and off-pump CABG.Figure 1.Mortality: overall population.Figure 2.Mortality: by therapy subsets.

Effect of triglycerides on cardiovascular risk in patients with a first vs. recurrent acute coronary syndrome

Abstract Background Triglyceride (TG) levels have gained increasing interest in the prevention of cardiovascular disease although there is divergent evidence that might be explained by confounding factors. Methods We performed a multicenter and retrospective study using the ongoing registries of acute coronary syndrome (ACS) patients of 7 hospitals from Spain. TG were measured during the hospitalization, and mortality and major adverse cardiovascular events (MACE) were analyzed through follow-up. Results We included 14,483 patients discharged after an ACS, mean age 67.5 (13.3), 28.1% women, and 30.4% with an ST-elevation ACS; 2,378 (16.4%) patients had a previous ACS and were classified as recurrent ACS. Median triglyceride level was 120.5 (interquartile range [IQRS] 90-197) mg/dL and was slightly higher in patients with recurrent ACS (135 IQR 98-186 vs. 129 IQR 95-175; p<0.01). Patients with first vs. recurrent ACS received ticagrelor or prasugrel more frequently at discharge (14.8% vs. 7.4%; p<0.01), but no other differences in medical treatments were observed. Median follow-up was 1223 (interquartile range 570-2040) days. All-cause mortality was 15.0% (n= 2,166), and 34.71% (n=5,019) of the patients experienced a first MACE during follow-up. Patients with recurrent ACS had higher mortality (32.9% vs. 11.4%; p<0.01) and MACE (46.5% vs. 32.4%; p<0.01) rates. Multivariate analysis, adjusted for age, sex, diabetes, previous heart failure, and medical treatments at discharge showed that TG levels were not associated with higher risk of mortality (p=0.29) but with higher risk of MACE (p=0.04). A significant interaction (p=0.01) was observed for TG and previous ACS for both endpoints and, therefore, analyses were performed separately (Figure 1). As shown in Figure 2, TG were associated with higher risk of death in patients with first ACS (p=0.02) but not in patients with recurrent ACS (p=0.48); in contrast, TG were associated with higher risk of MACE (p=0.024) in patients with a recurrent ACS but not in patients with a first ACS (p=0.25). Conclusions Previous ACS modifies the risk of TG on mortality and MACE in patients discharged after an ACS. TG might be considered a target for treatment in patients after a first or recurrent ACS, although the exact impact on outcomes might be different.

Mortality and patient stratification 30 days after Staphylococcus aureus bacteraemia in patients with cardiac implantable electronic devices - a Danish nationwide cohort study

Abstract Background Staphylococcus aureus bacteraemia (SAB) is a high-risk condition with a reported 30-day mortality of up to 25% even with timely and correct treatment. Patients with cardiac implantable electronic devices (CIEDs) are at increased risk of a complicated course of disease due to the risk of device infection. Purpose We aimed to estimate the 30-day mortality rate following SAB among adult Danish patients with a de novo CIED. Furthermore, we aimed to identify patients with low, intermediate, and high mortality risk following SAB. Methods Using The National Danish Staphylococcus Aureus Bacteriemia Database and The Danish Pacemaker and ICD Register, we identified all Danish patients aged 18 to 99 years with a de novo CIED implantation between 2000 and 2020, and subsequently positive Staphylococcus aureus blood culture. The primary outcome was 30-day all-cause mortality from date of SAB. Clinical variables significantly associated with increased 30-day mortality following SAB were identified (p<0.05 and 95% CI not including 1) using adjusted multivariable Cox regression modelling. We tested variables related to age, sex, calendar year of SAB, device type, timing of infection, previous SAB, concomitant medication, and clinically relevant pre-existing co-morbidities including valvular replacement, recent surgery, and renal dialysis. Patients were awarded 1 point for each of the significant variables present, and the sum was used to stratify into low-, intermediate-, and high-risk groups. The cut-offs between the groups were set at 0 and 2 points (0 points = low risk, 1-2 points = intermediate risk, ≥3 = high risk). Results We identified 1,393 patients with de novo CIED (pacemaker: n=983, implantable cardioverter defibrillator: n=230, cardiac resynchronization therapy w/wo defibrillator capacity: n=180) and subsequent SAB (median time to SAB from CIED implantation: 679 days [IQR 168-1,525]). Median age at the time of SAB diagnosis was 77 years [IQR 68-84] with 72.4% being males. In total, 469 patients died within the first 30 days from SAB, equivalent to an overall 30-day mortality rate of 33.7% (95% CI 31.2-36.2). We identified high age, left sided valvular disease, use of systemic corticosteroids, and SAB occurring >6 months from CIED implantation to be associated with an increased hazard of 30-day mortality following the SAB diagnosis (Fig. 1). The median total sum obtained from the stratification model was 2 points [IQR 1-2]. 30-day all-cause mortality was estimated to 16.2%, 31.6% and 54.9% for the low-, intermediate- and high-risk groups, respectively (Fig. 2). Conclusions In patients with a de novo cardiac implantable electronic device and subsequent Staphylococcus aureus bacteraemia the overall 30-day mortality from date of SAB was 33.7%. Patients with high age, recent surgery, left sided valvular disease, and use of systemic corticosteroids were particularly at risk.Fig. 1.Simplified stratification modelFig. 2.30-day mortality following SAB

Non-surgical management of methicillin-sensitive Staphylococcus aureus bacteremia-related mediastinitis

Background: Acute mediastinitis is rarely caused by haematogenous spread of a remote infection. In this respect, since the only medical therapy is usually unsuccessful, treating acute mediastinitis with no source of infection detected is very challenging and management not standardized. In this case report, we describe non-surgical management experience of acute mediastinitis caused by methicillin-sensitive Staphylococcus aureus. Case presentation: In a 79-year-old man judged not eligible for cardiac surgery, we attempted the infection source control through vacuum-assisted closure therapy, together with antimicrobial therapy. We observed gradual clinical, laboratory and radiologic improvements: reduced swelling and normalization of the white blood cell count and C-reactive protein level were associated with reduction in size of a periaortic abscess. Conclusion: We managed a clinical condition with high mortality risk with chronic antimicrobial therapy alone, a strategy that is rarely considered. With this medical strategy we achieved an optimal response to a clinical picture that does not allow any other approach.

Dual guided heparin monitoring with anti-Xa and APTT during micro-axial flow pump support for cardiogenic shock

Abstract Background Precise management of unfractionated heparin (UFH) is key to avoid coagulopathic complications in patients on percutaneous mechanical circulatory support (pMCS) for cardiogenic shock (CS). While the activated partial thromboplastin time (APTT) is commonly used for this purpose, it can be affected by various laboratory factors during critical illness. Alternatively, the anti-Xa test directly measures UFH activity. We proposed a parallel anti-Xa/APTT-based protocol for UFH titration during pMCS. (1) Purpose We aimed to investigate the correlation between parallel anti-Xa/APTT measurements in a CS population on pMCS. We also evaluated mortality correlation in samples exhibiting prolonged APTT and in-range anti-Xa levels, based on fibrinogen levels and INR. Methods We assessed all CS patients with isolated left-sided ImpellaTM-support (>24h) and UFH anticoagulation monitoring per protocol at two pMCS-institutions from April-2017 to June-2022. Overall correlation between parallel anti-Xa/APTT samples was assessed by Pearson correlation coefficient (with ≤0.7 considered to confer a weak correlation). Anti-Xa levels were defined as 0.20-0.30IU/mL or 0.31-0.50IU/mL, with corresponding APTT values of 40-55s and 55-80s, respectively. Samples with prolonged APTT as compared to the in-range anti-Xa were stratified based on fibrinogen (<1.5g/dL or ≥ 1.5g/dL) and INR (<1.5 or ≥1.5) on the same day as the index sample. Mortality of patients with normal fibrinogen ànd INR was then compared to those with abnormal fibrinogen and/or INR via a Chi² test. Results Ninety-three ImpellaTM-runs (77 men, 83%) with a median age of 56 years (IQR 46-66) were analyzed. Median support was 6 days (IQR 4-12). In 2447 parallel anti-Xa/APTT samples, the Pearson correlation coefficient was 0.50 (p<0.001). Among the 1914 in-range anti-Xa samples, APPT was shortened in 460 (24%), in-range in 986 (52%) and prolonged in 468 (24%) samples. In the 59 patients with samples with prolonged APTT, two patients (with 80 samples) were excluded due to absence of fibrinogen and/or INR measurements on the same day. The mortality in patients with prolonged APTT but normal fibrinogen levels and normal INR (N=29; APTT prolongation due to FXI/FXII-consumption) was significantly lower compared to the remaining 28 patients who showed samples with reduced fibrinogen levels and/or prolonged INR (suffering from concomitant conditions) (10% vs. 32%; p=0.043). Conclusion We highlight a weak correlation between anti-Xa and APTT in an anti-Xa guided UFH anticoagulated CS population during left-sided ImpellaTM support. Patients with APTT-prolongation due to concomitant conditions with INR prolongation and/or fibrinogen shortage are at highest mortality risk. The APTT/Anti-Xa coefficient can serve as an independent risk factor whilst managing critically CS patients.

Personality and cardiovascular mortality risk: a multi-cohort analysis in individuals with and without pre-existing cardiovascular disease

AbstractThis study investigated the associations between personality traits of the Five Factor Model and cardiovascular mortality, with a specific focus on whether pre-existing cardiovascular conditions modified these associations. We used data from 43,027 participants across five cohort studies: Health and Retirement Study (HRS); Wisconsin Longitudinal Study (WLS); National Social Life, Health, and Aging Project (NSHAP); Midlife in the United States (MIDUS); Household, Income, and Labour Dynamics in Australia (HILDA) with a mean age 55.9 years and 6493 individuals with pre-existing cardiovascular disease. We conducted meta-analyses examining conscientiousness, emotional stability, agreeableness, openness to experience, and extraversion in relation to mortality due to coronary heart disease and stroke. During a mean follow-up of 12.1 years, 1620 participants died from coronary heart disease and 454 from stroke. Lower conscientiousness was associated with higher mortality risk from both coronary heart disease (hazard ratio per 1SD = 0.82, 95%CI = 0.75–0.90) and stroke (HR = 0.84, CI = 0.72–0.99). Lower emotional stability predicted increased coronary heart disease mortality (HR = 0.91, CI = 0.85–0.97). The association between conscientiousness and cardiovascular mortality did not differ between individuals with or without baseline cardiovascular conditions. In addition, adjustments for health behaviors and other covariates only slightly attenuated this association. Other personality traits were not associated with cardiovascular disease mortality. Our findings highlight the role of low conscientiousness, and to a lesser extent low emotional stability, in the development and progression of fatal cardiovascular disease through pathways that may extend beyond established health behaviors.

Hand grip strength in older and very old people: Results of the study Gesundheit 65+

Abstract Background Functional capacity decreases with increasing age. Hand grip strength (HGS) is considered as an objective general measure of health and a parameter of muscle strength, a component of functional capacity and is part of the evaluation of frailty. HGS is important for many everyday functions, such as holding heavy objects or supporting oneself to prevent a fall. Low HGS is associated with a higher mortality risk. In our study we describe HGS in people aged 66 to 101 years in Germany and identify groups with low HGS. Methods Gesundheit 65+ is a longitudinal epidemiologic study of the health status of persons 65 years and older in Germany by the Robert Koch Institute. In 2022/23, one year after baseline, isometric HGS was measured during the examination part of the study using a hand-held dynamometer (Smedley, Scandidact, Denmark, 100 kg). Two values were recorded for each hand. Maximum HGS from all attempts was used for analyses. Weighted prevalence estimates and 95% confidence interval (CI) for grip strength are reported by sex, age-group, height, self-rated health, chronic conditions, and difficulties in activities of daily living (ADL). Results HGS was measured in 1,457 persons aged 66 to 101 (48% women). Mean maximum HGS was 28.8 kg (CI 28.4-29.3). HGS was significantly related to sex (men: 35.4 kg, CI 34.8-36.0, women 21.8 kg, CI 21.4-22.2) and age (66-79: 31.0 kg, CI 30.1-31.9, 80+: 23.9 kg, CI 23.0-24.7). In both sexes, shorter persons and persons with bad self-rated health, chronic conditions or difficulties in ADL showed lower HGS than their reference group. Conclusions HGS was reduced in very old people, people with support needs, and people with poor health or chronic diseases, identifying these people as important risk groups for preventive measures. These should aim to improve not only endurance but also strength in older and very old people. In the long term, this could also maintain independence and reduce serious injuries from falls. Key messages • We found sex and age-related differences in hand grip strength in older people in Germany. • Based on the results, planning of prevention and intervention could be enhanced.

Prognostic impact of left ventricular myocardial work in patients undergoing surgery for primary mitral regurgitation

Abstract Background Although left ventricular ejection fraction (LVEF) is widely used as a parameter for the assessment of LV systolic function, LVEF can overestimate LV systolic function in patients with severe mitral regurgitation (MR) due to its high load-dependency. Echocardiography-based, left ventricular myocardial work (LVMW) can assess LV function by incorporating LV afterload. Purpose This study aims to evaluate the prognostic value of LVMW indices in patients with primary MR undergoing mitral valve surgery. Methods Individuals who underwent mitral valve surgery for severe primary MR were included. All patients underwent transthoracic echocardiography before surgery. LVMW was derived from a vendor-specific package which integrates LV global longitudinal strain with sphygmomanometric blood pressure to construct pressure-strain loops during the cardiac cycle. (Figure 1) For the LVMW indices, previously-established normal values were used as thresholds. The primary endpoint was all-cause mortality after mitral valve surgery. Results A total of 309 patients (mean age 63 ± 12 years, 68% male) with severe, primary MR who underwent surgery, were included. The mean LV global work index (LVGWI) was 1977 ± 537 mmHg% and 132 (43%) patients had impaired LVGWI (≤ 1900 mmHg%). During a median follow-up of 5.0 years (interquartile range, 2.5-8.9), 27 (8.7%) patients died after mitral valve surgery. Patients with impaired LVGWI or LV GLS (≤ 20%) had lower survival rates compared to the group with preserved LVGWI (p <0.01) or LVGLS (p = 0.02), whereas there was no significant difference in the survival rate between patients with LVEF ≤ 60% and > 60%. (Figure 2) Furthermore, LVGWI ≤ 1900 mmHg% demonstrated incremental prognostic value over LVGLS (p = 0.049) for all-cause mortality. Conclusions In patients with severe, primary MR who underwent surgery, impaired pre-operative LVGWI was associated with a higher mortality risk. In addition, impaired LVGWI had incremental prognostic value over LVGLS. Based on these findings, LVMW is a promising parameter for predicting postoperative outcome and determining the optimal timing of valve surgery in patients with severe, primary MR.Fig1.Echo-derived Myocardial workFig2.Kaplan-Meier curves

Comparison of long-term prognosis between coronary artery disease and peripheral artery disease in haemodialysis and non-dialysis patients

Abstract Background Patients on hemodialysis (HD) have been consistently recognized as a population with a high risk for cardiovascular diseases. However, it has not been clear which vascular disease had more impact on clinical prognosis. The aim of this study was to compare coronary artery disease (CAD) and peripheral artery disease (PAD) among HD and non-HD patients undergoing coronary artery bypass graft (CABG) and lower extremity bypass (LEB) surgery. Methods A total of consecutive 1,867 patients who initially and successfully underwent cardiovascular bypass surgery (242 CABG and 620 LEB in HD patients, 604 CABG and 401 LEB in non-HD patients) were enrolled in this study. They were followed up for up to 10-year. The primary endpoint was all-cause mortality. Results Cumulative mortality rates for 10-year were 15.6%, 21.8%, 38.7% and 58.9% after CABG in non-HD patients, LEB in non-HD patients, CABG in HD patients and LEB in HD patients, respectively (Figure). HD patients consistently had higher risk of mortality after cardiovascular bypass surgery compared to non-HD patients [adjusted hazard ratio (aHR) 3.04, 95% confidence interval (CI) 2.21-4.36, p<0.0001]. Similar results were observed after CABG and LEB in both, respectively (aHR 2.50, 95%CI 1.75-3.61, p<0.0001 for CABG and aHR 3.07, 95%CI 3.07, 95%CI 2.21-4.36, p<0.0001). Also, patients with LED tended to have higher risk of mortality compared to those with CABG (aHR 1.25, 95%CI 1.0.99-1.57, p=0.057) in entire cohort. However, the risk of mortality was significantly higher after LED than CABG in HD patients (aHR 1.34, 95%CI 1.02-1.81, p=0.042) but not in non-HD patients (aHR 1.00, 95%CI 0.67-1.49), p=0.98). In addition, HD patients with LEB had markedly higher risk of mortality compared to non-HD patients with CABG (aHR 3.50, 95%CI 2.62-4.74, p<0.0001). Conclusion Long-term prognosis was consistently poorer after cardiovascular surgery regardless of CABG or LEB in HD patients than in non-HD patients. The risk of mortality was also significantly higher after LEB than CABG in HD patients but not non-HD patients, and HD patients with LEB was considered to have the highest mortality risk in the study. Thus, PAD might be at more advanced atherosclerotic status than CAD in this high-risk population.

Psychiatric comorbidity and hospitalization outcomes for AMI in portuguese public hospitals

Abstract Background Severe mental health disorders directly affect quality of life but may also indirectly relate to physical diseases and their prognosis. We test this hypothesis for the specific case of acute myocardial infarction (AMI), postulating a longer in-patient stay and an excess in-hospital mortality among patients suffering psychiatric comorbidities (PC). Methods A retrospective observational study was conducted using secondary data from public Portuguese hospitals, for all patients with a primary diagnosis of AMI (12,213 patients aged 18-80, for the years 2017-18). We used linear and logistic regression to model length of stay (LoS) and in-hospital mortality, respectively. Having at least one psychiatric comorbidity was the explanatory variable, and models were adjusted for age, sex, and the Charlson Comorbidity Index. Results The prevalence of PC was 12.95%. The in-hospital mortality rate was significantly higher in the group with PC (4.43%, OR = 1.372, 95%CI=1.041-1.784), than in the group without PC (3,38%). Stays were significantly longer among those with PC (mean=7.69 days), compared to those without PC (mean=6.87 days; adjusted β-coefficient=0.098, 95%CI=0.056-0.141). Conclusions Patients with AMI and comorbid mental disorders have poorer hospitalization outcomes than those without PC. This emphasizes the importance of promoting effective management strategies for comorbid psychiatric disorder, for instance, by improving the integration of mental health care in general hospitals, and empowering healthcare professionals to recognize and manage patients with PC. Key messages • Psychiatric comorbidity is related to longer inpatient stays and higher mortality risk among patients with AMI. • Efforts to integrate mental health care in general hospitals should be maintained.

Utilizing unsupervised machine learning to uncover novel phenogroups within the broad QRS complex

Abstract Background Conduction disease can manifest as a broad QRS complex on the ECG. Broad QRS is conventionally categorised as left bundle branch block (LBBB) and right bundle branch block (RBBB) or non-specific intraventricular conduction delay (IVCD), based on QRS morphology. These subgroups were coined over a century ago and have been relevant for heart failure with reduced ejection fraction and cardiac resynchronization therapy (CRT). However, there may be more precise phenogroups underlying broad QRS complexes. Purpose Using unsupervised machine learning to define novel broad QRS phenogroups and characterise them using clinical variables and disease outcomes. Methods We extracted 51 relevant features using a Variational Autoencoder from 47,456 median-beat ECGs with broad QRS intervals (QRS ≥ 130ms) from a secondary care cohort. These were input into Discriminative Dimensionality Reduction via Learning a Tree (DDRTree), a clustering method that models the continuum of heterogeneity by projecting the underlying distribution as a tree structure in a low-dimensional space, while assigning distinct branch/cluster labels. Results Six distinct phenogroups were identified within broad QRS morphologies (Figure-1). Two branches were RBBB dominant (Branch 1: more males, high-comorbidity; Branch 6: low-comorbidity/healthy-RBBB). Two branches were LBBB dominant (Branch 4: mixed IVCD with CHB burden; Branch 5: more females, CRT responders). Two branches were IVCD/mixed-phenotype (Branch 2: IVCD-dominant, high risk of future cardiovascular events; Branch 3: average/core branch). Within LBBB, Branch 4 and 5 showed similar trends with improving echocardiography profiles and CRT response when adjusted for covariates, each compared against the core branch. Branch 5 was distinct due its high risk of future HF (HR 1.19 [1.07-1.33] p < 0.01), cardiovascular death (HR 1.35 [1.20-1.50] p < 0.0001), all-cause mortality (HR 1.08 [1.01-1.16] p < 0.05) and CHB (HR 1.35 [1.16-1.56] p < 0.0001) (Figure-2). Conversely within RBBB, Branch 1 and 6 showed stark differences across various traits. Branch 1 captured a high-risk profile associated to higher risk of cardiovascular death (HR 1.37 [1.24-1.52] p < 0.0001), all-cause mortality (HR 1.20 [1.12-1.29] p < 0.0001) and CHB (HR 1.15 [1.01-1.32] p < 0.05) (Figure-2), while Branch 6 retained a low-risk phenotype. The tree dimensions also revealed relevant trends in cardiac anatomy and valvular dysfunction; the top-left region in Figure-1 associated with higher left ventricular ejection fraction and lower left ventricular end-diastolic dimension, lower left ventricular end-systolic dimension and a greater CRT response. Conclusion Through unsupervised methods we have identified conduction disease phenogroups with additive value for disease prognosis and CRT response prediction beyond traditional LBBB and RBBB labels. These novel phenogroups may help guide precision care for patients with a broad QRS complex.Figure-1Figure-2

Factors influencing low-density-lipoprotein cholesterol after acute coronary syndrome and effectiveness of intensive teleconsultation monitoring, the teleobjectif cohort study

Abstract Context: Low-density lipoprotein cholesterol (LDL-c) plays a key role in the development and progression of atherosclerotic cardiovascular disease (ASCVD). Despite the availability of effective lipid-lowering treatments, patients who have experienced an acute coronary syndrome (ACS) continue to face a high risk of recurrent cardiovascular events and mortality. Achieving the recommended LDL-c target of <0.55 g/L in secondary cardiovascular prevention remains a significant challenge, with fewer than 30% of patients reaching this goal. Aim To investigate the factors influencing LDL-c control after ACS and the effectiveness of intensive teleconsultation monitoring to control LDL-c, even in sub-groups where control is poorest. Methods This bi-centric prospective cohort study conducted between december 2019 and december 2021 compared a group that received standard follow-up after an ACS with an interventional group that received regular follow-up by teleconsultation in addition of usual care to optimize lipid-lowering treatment. A subgroup analysis was carried out to examine the effect of teleconsultation in subpopulations known to be significantly associated with better or worse LDL-c control in the usual care group or described in the literature. Results 1602 patients met the inclusion criteria for our study (814 in the usual care group and 788 in the teleconsultation group). Baseline characteristics were similar between groups. In the usual care group, factors influencing lipid control included gender, diabetes, cardiology consultation, distance to the nearest cardiologist, social deprivation and initial LDL-C levels. Teleconsultation significantly improved LDL-C target attainment compared to usual care (74.7% vs. 26.6%, p<0.001 with multivariate analysis OR 5.06 [4.21 ; 6.07]), particularly benefiting geographically and socially disadvantaged patients. Conclusion Teleconsultation significantly improves lipid control in acute coronary syndrome patients compared to usual care. This universal intervention, particularly beneficial for geographically and socially disadvantaged patients, highlights the potential of telemedicine in enhancing cardiovascular management.analysis in usual care groupTeleconsultation effect in sub-groups