Increase In Early Mortality Research Articles

Prognostic Factors Associated with Mortality in Cardiogenic Shock — A Systematic Review and Meta-Analysis

BackgroundCardiogenic shock remains highly associated with early mortality, with mortality often exceeding 50%. We sought to determine the association between prognostic factors and in-hospital and 30-day mortality in cardiogenic shock.MethodsWe performed a systematic review and meta-analysis of prognostic factors in cardiogenic shock, searching MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials for records up to June 5, 2023. English-language studies that investigated prognostic factors and in-hospital and/or 30-day mortality in cardiogenic shock were included. Studies were excluded if they evaluated the pediatric population, were postmortem studies, or included fewer than 100 patients. The primary aim was to identify modifiable and non-modifiable prognostic factors associated with in-hospital and 30-day mortality in cardiogenic shock.ResultsWe identified 160 studies, including 2,459,703 patients with a median in-hospital mortality of 41.4% (interquartile range, 33.6% to 49.2%). The majority were retrospective cohort studies. Patient factors potentially associated with an increase in early mortality included an age greater than or equal to 75 years of age, peripheral arterial disease, chronic kidney disease, and female sex. Procedural and presentation factors potentially associated with increased mortality included out-of-hospital cardiac arrest, left main culprit artery, left ventricular ejection fraction less than 30%, dialysis, and need for mechanical circulatory support. Revascularization in the form of coronary artery bypass graft and percutaneous coronary intervention were potentially associated with reduced in-hospital mortality.ConclusionsThis analysis quantifies the association between patient, presentation, and treatment-related factors and early mortality in cardiogenic shock. Increased certainty in the association of these prognostic factors with cardiogenic shock outcomes can aid in clinical risk assessment, development of risk tools, and analysis of clinical trials.

Emerging opportunities to target inflammation: myocardial infarction and type 2 diabetes.

After myocardial infarction (MI), patients with type 2 diabetes have an increased rate of adverse outcomes, compared to patients without. Diabetes confers a 1.5-2-fold increase in early mortality and, importantly, this discrepancy has been consistent over recent decades, despite advances in treatment and overall survival. Certain assumptions have emerged to explain this increased risk, such as differences in infarct size or coronary artery disease severity. Here, we re-evaluate that evidence and show how contemporary analyses using state-of-the-art characterization tools suggest that the received wisdom tells an incomplete story. Simultaneously, epidemiological and mechanistic biological data suggest additional factors relating to processes of diabetes-related inflammation might play a prominent role. Inflammatory processes after MI mediate injury and repair and are thus a potential therapeutic target. Recent studies have shown how diabetes affects immune cell numbers and drives changes in the bone marrow, leading to pro-inflammatory gene expression and functional suppression of healing and repair. Here, we review and re-evaluate the evidence around adverse prognosis in patients with diabetes after MI, with emphasis on how targeting processes of inflammation presents unexplored, yet valuable opportunities to improve cardiovascular outcomes in this vulnerable patient group.

Delayed Sternal Closure vs Emergency Sternal Reopening in Adults With Congenital Heart Disease

BackgroundLimited data exist regarding outcomes of delayed sternal closure (DSC) in adults with congenital heart disease (ACHD). MethodsWe reviewed 159 ACHD patients undergoing cardiac operation from 1993 to 2023 who required DSC (open sternum at the end of operation, n = 112) or sternum emergently reopened (n = 47). Regression models were performed to determine factors associated with outcomes. ResultsOf 112 patients undergoing DSC, 87 patients (77.6%) underwent DSC ≤4 days and 25 patients (22.3%) >4 days. The most common operations were valve (n = 35 [31.2%]), aortic (n = 33 [29.4%]), and right ventricular outflow tract procedures (n = 23 [20.5%]). Median time to chest closure was 2 days (interquartile range, 1-5 days). Apart from sex, baseline characteristics were similar between DSC groups. A stepwise increase in early mortality was observed from DSC ≤4 days to DSC >4 days (6.8% vs 32%), as well as the incidence of early complications, except sternal infection. Risk factors associated with early mortality were age (P = .02), DSC >4 days (P < .001), hemodynamic indication (P = .03), and single ventricle (P = .02). On multivariable analysis, lower ejection fraction (P = .04), hemodynamic indication (P = .02), single ventricle (P = .004), and diabetes mellitus (P = .03) were predictors of prolonged time to chest closure. Among hospital survivors, late survival was similar between patients undergoing DSC ≤4 days vs >4 days (P = .48). ConclusionsA brief duration of DSC in ACHD patients is associated with low morbidity and mortality. Higher early mortality and complications were observed among patients who did not achieve chest closure within 4 days.

Chronic dietary exposure to a glyphosate-based herbicide alters ovarian functions in young female broilers

Glyphosate (GLY)-based herbicide (GBH) formulations are widely used pesticides in agriculture. The European Union recently decided to extend the use of GLY in Europe until 2034. Previously, we showed that chronic dietary GBH exposure in adult hens resulted in a reversible increase in early mortality in chicken embryos. In this present study, we investigated the GBH effects on metabolism and ovarian functions by using a transcriptomic approach in vivo in young female broilers and in vitro in ovarian explant cultures. We exposed 11-day-old female broilers to 13 mg GLY equivalent/kg body weight/day (GBH13, n = 20), 34 mg GLY equivalent/kg body weight/day (GBH34, n = 20), or a standard diet (control [CT], n = 20) for 25 days. These two GBH concentrations correspond to approximatively one eighth and one third of the no observed adverse effect level (NOAEL) as defined by European Food Safety Authority in birds. During this period, we evaluated body weight, fattening, food intake, and the weight of organs (including the ovaries). Chronic dietary GBH exposure dose dependently reduced food intake, body weight, and fattening, but increased oxidative stress and relative ovary weight. We analyzed the ovarian gene expression profile in CT, GBH13, and GBH34 broilers with RNA sequencing and showed that differentially expressed genes are mainly enriched in pathways related to cholesterol metabolism, steroidogenesis, and RNA processing. With quantitative polymerase chain reaction and western blotting, we confirmed that GBH decreased ovarian STAR and CYP19A1 messenger RNA and protein expression, respectively. Furthermore, we confirmed that GBH altered steroid production in ovarian explants. We have identified potential regulatory networks associated with GBH. These data provide valuable support for understanding the ovarian transcriptional regulatory mechanism of GBH in growing broilers.

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.

Evolving trends in epidemiology and natural history of cardiac amyloidosis: 30-year experience from a tertiary referral center for cardiomyopathies.

Natural history of cardiac amyloidosis (CA) is poorly understood. We aimed to examine the changing mortality of different types of CA over a 30-year period. Consecutive patients included in the "Trieste CA Registry" from January 1, 1990 through December 31, 2021 were divided into a historical cohort (diagnosed before 2016) and a contemporary cohort (diagnosed after 2016). Light chain (AL), transthyretin (ATTR) and other forms of CA were defined according to international recommendations. The primary and secondary outcome measures were all-cause mortality and cardiac death, respectively. We enrolled 182 patients: 47.3% AL-CA, 44.5% ATTR-CA, 8.2% other etiologies. The number of patients diagnosed with AL and ATTR-CA progressively increased over time, mostly ATTR-CA patients (from 21% before 2016 to 67% after 2016) diagnosed non-invasively. The more consistent increase in event-rate was observed in the long-term (after 50 months) in ATTR-CA compared to the early increase in mortality in AL-CA. In the contemporary cohort, during a median follow up of 16 [4-30] months, ATTR-CA was associated with improved overall and cardiac survival compared to AL-CA. At multivariable analysis, ATTR-CA (HR 0.42, p = 0.03), eGFR (HR 0.98, p = 0.033) and ACE-inhibitor therapy (HR 0.24, p < 0.001) predicted overall survival in the contemporary cohort. Incidence and prevalence rates of ATTR-CA and, to a less extent, of AL-CA have been increasing over time, with significant improvements in 2-year survival of ATTR-CA patients from the contemporary cohort. Reaching an early diagnosis and starting disease-modifying treatments will improve long-term survival in CA.

Thrombolysis Experience in Costa Rica Compared Against Individual Patient Data from two Randomized Controlled Trials

ObjectivesWe sought to compare thrombolysis outcomes from the Costa Rican Stroke Registry Program (CRSRP) with published individual patient data from NINDS and CLOTBUST-ER trials using matching and outcome modeling from randomized clinical trials (RCTs). Materials and methodsA retrospective observational study matching subjects on baseline characteristics, from the CRSRP, the control arm of CLOTBUST-ER, and the interventional arm of NINDS trials. Day 7-10/discharge modified Rankin Score (mRS), and early mortality was compared between matched subjects. A mortality model derived from RCTs was developed, and outcomes were compared at similar baseline NIHSS scores. CRSRP symptomatic hemorrhage (SICH) rate was compared with an Ibero-American cohort (IAC). ResultsOf 540 CRSRP patients, 351 received rt-PA under 3 hours and were matched with NINDS subjects yielding 292 pairs; 161 CRSRP subjects treated within 4.5 hours were matched with CLOTBUST-ER subjects resulting in 151 pairs. The proportion of patients achieving excellent outcomes (mRS 0-1) did not differ between CRSRP and either NINDS or CLOTBUST-ER (CRSRP vs NINDS: 36.6% vs 32.9%, p=0.3; CRSRP vs CLOTBUST-ER: 26.5% vs 24.5%, p=0.8). Mortality was higher for CRSRP vs CLOTBUST-ER (7.3% vs 0.7%, p=0.006), but not vs NINDS (6.5% vs 4.5%, p=0.4). A pooled mortality model derived from 15 RCTs representing 4410 patients (R2=0.39) showed CRSRP and NINDS within expected mortality, while CLOTBUST-ER showed lower than expected mortality. CRSRP SICH rate equaled IAC (5.7% vs 5.7%; p=0.9). ConclusionsFunctional outcomes and SICH of thrombolysed Costa Rican patients compared favorably with published datasets, with a potential increase in early mortality.

Globalization and life lost due to tuberculosis: evidence from a multi-country study

Background: Tuberculosis affects around 30% of the population of the world. Tuberculosis causes an increase in early mortality and thus has the potential to increase the number of years of life lost. Globalization directly or indirectly by affecting the factors that increase the susceptibility for tuberculosis infection has the potential to increase the spread and mortality due to tuberculosis. This study assessed the causal link between globalization and the years of life lost due to tuberculosis. Methods: Data from the Demographic and Health Survey (DHS) and World Bank for 2004 and 2005 were used for a number of covariates and possible mediators. Data from the Institute of Health Metrics and Evaluation (IHME) were used for the outcome variable and important globalization indicators. The primary health outcome that was studied is tuberculosis and the measure that was used to quantify tuberculosis mortality is the years of life lost (YLL). Path analysis was used. Results: The main independent variables of economic and social integration were not statistically significant. For every unit increase in the proportion of people that were using treated drinking water, there was a -0.0002 decrease in the YLL due to tuberculosis. For every unit increase in the proportion of people with earth floor, there was a 0.0002 units increase in YLL due to tuberculosis. For every unit increase in the proportion of people living using clean fuel, there was a 0.0004 decrease in the YLL due to tuberculosis. Conclusions: Social and economic globalization have no effect on the years of life lost due to tuberculosis, highlighting that globalization actually does not contribute to tuberculosis mortality. However, improving other important determinants such as sanitation, providing safe drinking water and clean households will reduce the mortality due to tuberculosis, highlighting the need to invest in them.

Does the timing of treatment with intraaortic balloon pump in cardiac surgery affect survival?

Background: The intraaortic balloon pump (IABP) is the most common mechanical assist device used as an adjunctive therapy for patients with low cardiac output among cardiac surgery. However, controversy still exists about the optimal time for IABP insertion. The study evaluated the association between timing of IABP insertion and outcome in cardiac surgical patients. Patients and Methods: Patients who underwent cardiac surgery between August 2007 and June 2014 were included. 273 of 3480 patients (7.84%) required perioperative IABP support. Of whom 21 (7.7%) received a preoperative IABP, 180 (65.9%) received an intraoperative IABP and 72 (26.4%) received a postoperative IABP. Predictors of early mortality were measured in stepwise multivariate logistic regression analyses. Results: The overall mortality rate for all patients requiring IABP was 29.3%. The incidence of mortality in patients who underwent pre-, intra- and postoperative IABP insertion was 19.0%, 22.8%, and 48.6%, respectively. The independent predictors of early mortality were age, cross clamp time, and postoperative IABP. However, either pre or intraoperative IABP insertion was not associated with increase in early mortality. Conclusions: IABP treatment in patients undergoing cardiac surgery was relatively safe accompanied by few complications. Timing of IABP insertion appears to be associated with survival as early insertion results are much more desirable compared to postoperative insertion.

Globalization and life lost due to tuberculosis: evidence from a multi-country study.

Background: Tuberculosis affects around 30% of the population of the world. Tuberculosis causes an increase in early mortality and thus has the potential to increase the number of years of life lost. Globalization directly or indirectly by affecting the factors that increase the susceptibility for tuberculosis infection has the potential to increase the spread and mortality due to tuberculosis. This study assessed the causal link between globalization and the years of life lost due to tuberculosis. Methods: Data from the Demographic and Health Survey (DHS) and World Bank for 2004 and 2005 were used for a number of covariates and possible mediators. Data from the Institute of Health Metrics and Evaluation (IHME) were used for the outcome variable and important globalization indicators. The primary health outcome that was studied is tuberculosis and the measure that was used to quantify tuberculosis mortality is the years of life lost (YLL). Path analysis was used. Results: The main independent variables of economic and social integration were not statistically significant. For every unit increase in the proportion of people that were using treated drinking water, there was a -0.0002 decrease in the YLL due to tuberculosis. For every unit increase in the proportion of people with earth floor, there was a 0.0002 units increase in YLL due to tuberculosis. For every unit increase in the proportion of people living using clean fuel, there was a 0.0004 decrease in the YLL due to tuberculosis. Conclusions: Social and economic globalization have no effect on the years of life lost due to tuberculosis, highlighting that globalization actually does not contribute to tuberculosis mortality. However, improving other important determinants such as sanitation, providing safe drinking water and clean households will reduce the mortality due to tuberculosis, highlighting the need to invest in them.

Bi-atrial or left atrial ablation of atrial fibrillation during concomitant cardiac surgery: A Bayesian network meta-analysis of randomized controlled trials.

Surgical ablation of atrial fibrillation (AF) has become a routine procedure during concomitant cardiac surgery, however, the extension of lesion sets remaincontroversial. We sought to compare the relative benefit and risk of different lesion sets through a Bayesian network meta-analysis (NMA). Pubmed, Embase, and Cochrane Trialsdatabases were searched for randomized controlled trials (RCTs) comparing the rhythm outcome of AF patients undergoing pulmonary vein isolation (PVI), left atrial Maze (LAM), bi-atrial Maze (BAM), or no ablation during concomitant cardiac surgery. An NMA was conducted to explore the difference of over 1 year AF freedom as well as risks for early mortality and permanent pacemaker implantation (PPMI). A total of 2031 patients of 19 RCTs were included. PVI, LAM, and BAM (OR[95% Cr.I]: 5.02 [2.72, 10.02], 7.97 [4.93, 14.29], 8.29 [4.90, 14.86], p < .05) demonstrated higher freedom of AF compared with no ablation, however, no significant difference of rhythm outcome was found among the three ablation strategies based on the random-effects model. BAM was associated with an increase in early mortality when compared with no ablation (OR[95% Cr.I]: 4.08 [1.23, 17.30], p < .05), while none of the remaining comparisons reached statisticaldifference in terms of early mortality and PPMI. Bi-atrial ablation is notsuperior to left atrial ablation strategies in reducing AF recurrence for un-selected surgical patients. BAM has a higher risk of early mortality than no ablation, but no difference was found between bi-atrial and left atrial ablation in regard to early mortality and PPMI based on the current evidence.

Early Outcomes of Cardiac Surgery in Patients with Liver Cirrhosis

Background: Liver cirrhosis is known to be associated with increased morbidity and mortality in patients undergoing cardiac surgery. Objective: The purpose of this study was to evaluate the early outcomes of cardiac surgery in patients with liver cirrhosis in our settings, and to assess the performance of the Child-Pugh classification as a predictor of early mortality. Patients and Methods: A retrospective observational study included 58 patients operated between March 2012 and October 2019. Among these 52 patients required open-heart procedures and 6 were operated without the use of cardiopulmonary bypass. The primary endpoint being examined was early mortality. Results: The overall mortality was 20.7%. Higher Child-Pugh (CP) class was associated with marked rise in mortality. The mortality rate increased from 10.8% patients in class A of the Child-Pugh, to 25% in class B patients to 80% in class C patients. The need for urgent or emergent procedures was also found to be associated with an increased risk of mortality. Conclusion: Early results of cardiac surgery in Child-Pugh class A patients although apparently higher than the general population, remain acceptable. The mortality in patients with CP class C is extremely high and almost prohibitive. Non-elective procedures also seemed to be associated with a significant increase in early mortality. This should be borne in mind while assessing surgical risk in cirrhotic patients.

Drug Transporter ABCB1 SNP Predicts Outcome in Patients with Acute Myeloid Leukemia Treated with Gemtuzumab Ozagamicin: A Report from Children's Oncology Group AAML0531 Trial

Background: Gemtuzumab Ozogamicin (GO), is first ever approved immunotherapy for relapsed AML patients. GO is a humanized anti-CD33 antibody linked with the toxin calicheamicin gamma. Calicheamicin induces DNA damage and cell death once the linked CD33 antibody facilitates its uptake. Previous studies have shown that the drug efflux transporter PgP1, which is encoded by gene ABCB1, influences the cellular accumulation of calicheamicin. PgP1 activity in leukemic cells is also inversely correlated with GO response in patients with AML. Although GO was withdrawn from market due to lack of benefit and increase in early mortality observed in SWOG-S0106 study subsequent multiple randomized studies have shown benefit of GO with significant improvement observed in patients with favorable cytogenetic risk features. In light of these results and recent favorable voting by FDA oncology drug advisory committee based on results of ALFA-0701 trail demonstrating a favorable risk:benefit profile for GO there is increased enthusiasm among AML investigators. Given the potential comeback of GO, it is very timely to focus efforts on identifying genetic biomarkers that can improve our ability to develop personalized treatment with GO. In this study evaluate whether single nucleotide polymorphisms (SNPs) in ABCB1 gene are predictive of GO response in patients with AML.Method: Genomic DNA samples from 942 patients enrolled in the COG trial AAML0531 who gave consent for the study were genotyped for 12 SNPs in the ABCB1 gene . Since AAML0531 was designed to test the benefit of GO in a randomized manner, we analyzed the effect of ABCB1 genotypes on outcomes and risk of relapse (RR) between patients treated with or without addition of GO (GO vs. No-GO respectively).Results: The ABCB1 SNP C3435T (rs1045642) was significantly associated with outcome when analyzed by GO vs. No-GO arm. Presence of C3435T change has been previously associated with lower PgP1 expression. For AML patients in the GO arm, presence of variant allele (CT and TT genotype) was significantly associated with lower risk of relapse (RR) from the end of course 1 (GO vs. No-GO arm: RR: 30 ± 6%, n = 259 vs. 46 ± 7%, n= 235; P < 0.0001) and better 5-year event free survival (EFS) from study than for those in the No-GO arm (GO vs. No-GO arm: 55 ± 6%, n = 340 vs. 45 ± 5%, n= 337; P= 0.006). However, patients with the CC genotype showed no differences in RR (GO and No-GO arms: 45 ± 10%, n = 97 vs. 40 ± 11%, n= 91; P= 0.514) and EFS (GO and No-GO arms: 44 ± 9%, n = 128 vs. 50 ± 9%, n= 132; P= 0.425) between the GO and No-GO arms (Fig 1). Further the rs1045642 genotype was significantly associated with EFS (CC vs. CT/TT: 44 ± 9% vs. 55 ± 6%; P=0.022) and RR (CC vs. CT/TT 45 ± 10% vs. 30 ± 6%, P=0.007) for patients in the GO arm but for those in the No-GO arm no difference in outcome between the genotypes was observed (RR: P=0.278; EFS P=0.466).Conclusion: Our results show that for the nonsynonymous SNP rs1045642 (C>T) in an drug efflux transporter ABCB1, the presence of T allele is associated with better response in patients treated with GO based as compared to standard arm. Since ABCB1 is involved in efflux of calicheamicin the presence of a low expression T allele might result in higher intracellular accumulation of calicheamicin and thus better response in patients treated with GO. [Display omitted] DisclosuresLoken:Hematologics Inc: Employment, Equity Ownership. Walter:ADC Therapeutics: Research Funding; Aptevo Therapeutics: Research Funding.

Missing Mayberry: How whiteness shapes perceptions of health among white Americans in a rural Southern community.

Elucidating how the racialized social system of whiteness affects the health of white Americans is critically important given current trends. Mirroring the nation, whites in rural North Carolina are currently experiencing increases in early mortality at greater levels than any other racial group in the state. Health focused oral history interviews conducted with whites (n=13) in an economically distressed, rural community provide insight into potential determinants of this trend. Interview transcripts were coded and analyzed using a modified grounded theory approach. Analysis was guided by the whiteness and health framework, which considers how structural racism is both health promoting and health harmful for whites. Analysis highlighted three key themes: color-blind ideology, belief in the American Creed, and resistance to change. Whiteness influenced these rural whites' beliefs such that they were blind to the experiences of people of color in their community. Their explicit and figurative nostalgia for The Andy Griffith Show's idyllic town of Mayberry (a fictional Southern community devoid of Black American characters and racial tension during the 1960s) exposed color-blind expectations of what it means to have a healthy community. Additionally, interviewees attributed health status to individual effort and health behaviors, rather than considering how macro-level social determinants impact health. Individual level blame and resistance to change influenced interviewees' political views and suspicion of some social programs that could benefit the health of their community. These meritocratic beliefs about hard-work and self-sufficiency have implications for individual and community level health outcomes.

Prognostic impact of baseline C-reactive protein levels on mortality after transcatheter aortic valve implantation.

To determine whether baseline C-reactive protein (CRP) levels can predict mortality after transcatheter aortic valve implantation (TAVI), we performed a meta-analysis of currently available studies. All studies investigating the prognostic impact of baseline (preprocedural) CRP levels on all-cause mortality after TAVI were identified by means of searching PubMed and Google Scholar through May 2019. For each study, (preferentially, adjusted rather than unadjusted) odds/hazard ratios (ORs/HRs) with corresponding 95% confidence intervals of mortality per standard-deviation (SD) (or unit) increase in CRP levels or those for high vs low CRP levels. Our search identified 14 eligible studies including a total of 3449 patients undergoing TAVI and reporting early (in-hospital to 3-month) and midterm (1-year to 3-year) all-cause mortality after TAVI. Pooled analyses demonstrated associations of high-baseline CRP levels with a marginal, but statistically nonsignificant increase in early mortality (pooled OR/HR per SD increase in CRP levels, 2.72; P = .09 and pooled OR/HR for high vs low CRP levels, 3.32; P = .07) and a statistically significant increase in midterm mortality after TAVI (pooled OR/HR per SD increase in CRP levels, 1.45; P < .0001 and pooled OR/HR for high vs low CRP levels, 1.78; P < .00001). Excluding HRs for high-sensitivity CRP, combining ORs/HRs of 1-year mortality, pooling HRs of ≥2-year mortality, and combining adjusted HRs did not alter the primary results. High-baseline CRP levels may predict increased midterm, but not early, mortality after TAVI.

Perioperative beta-blockers for preventing surgery-related mortality and morbidity in adults undergoing non-cardiac surgery.

Perioperative beta-blockers for preventing surgery-related mortality and morbidity in adults undergoing non-cardiac surgery.

Meta-analysis of prognostic impact of peripheral arterial disease on mortality after transcatheter aortic valve implantation.

The aim of this study was to determine whether peripheral arterial disease (PAD) is an independent predictor of mortality in patients who undergo transcatheter aortic valve implantation (TAVI) and we performed meta-analysis of currently available studies. MEDLINE and EMBASE were searched through June 2018 using Web-based search engines (PubMed and OVID). We included comparative studies of patients with PAD versus those without PAD and cohort studies which investigated PAD as one of prognostic factors of mortality, which used the multivariable analysis and reported an adjusted odds and hazard ratio (OR/HR) for early (30-day or in-hospital) and late (including early) mortality after TAVI. Study-specific estimates were combined using inverse variance-weighted averages of logarithmic ORs/HRs in the random-effects model. The primary meta-analysis which pooled all the ORs/HRs demonstrated that PAD was associated with a statistically significant increase in both early (OR, 1.21; P=0.02) and midterm (1-year to 7-year) mortality (HR, 1.31; P<0.00001). The secondary meta-analysis which exclusively pooled approach-adjusted/stratified ORs/HRs demonstrated that PAD was associated with a strong trend toward (though statistically non-significant) an increase in early mortality (OR, 1.18; P=0.07) and a still statistically significant increase in midterm mortality (OR, 1.24; P=0.0001). Meta-regression coefficients for the proportion of patients who underwent transfemoral TAVI were not statistically significant (P for early/midterm mortality =0.24/0.52). The present meta-analysis clearly highlighted that PAD was an independent predictor of both early and midterm mortality in patients who underwent TAVI.

Total Arterial Off-Pump Coronary Artery Bypass Grafting

Background:Arterial grafts had better mid-term and long-term patency than saphenous vein grafts in coronary artery bypass grafting (CABG). We summarized our experience with total arterial off-pump coronary artery bypass grafting (OPCAB) and assessed the early clinical results, surgical complications, and follow-up.Methods:From January 2007 to May 2017, 508 coronary artery disease patients undergoing total arterial OPCAB were enrolled. Clinical features, approaches, outcomes of surgical treatments, and follow-up data of these patients were studied retrospectively. A total of 122 patients underwent single left internal mammary artery (IMA)-left anterior descending artery grafts, whereas the other 386 patients underwent multiple vessel grafts.Results:The average distal anastomosis was 2.34 ± 0.97 (range: 1–4). All the patients were discharged from hospital except one died. A total of 457 (90.32%) patients were followed up. In the 4-, 7-, and 10-year follow-up groups, the rate of death from any cause was 1.19%, 6.47%, and 10.67%; rate of cardiac death was 0.60%, 2.88%, and 3.33%; rate of repeat revascularization was 0.00%, 3.60%, and 8.67%; rate of ischemic symptoms was 1.79%, 7.91%, and 11.33%; and incidence of stroke was 2.38%, 4.32%, and 6.67%, respectively. Poor medication adherence was observed in 9.38% of the follow-up population.Conclusions:Total arterial OPCAB with bilateral IMA, radial artery, and right gastroepiploic artery grafting yielded satisfactory early and midterm outcomes in this patient group, without a significant increase in early mortality or morbidity. Moreover, the long-term outcomes are also positive.

Analysis of the prevalence of vitamin 25-OH-D deficiency in hemodialysis (HD) patients and its relationship with nutritional status

Rationale: Vitamin 25-OH-D deficit has been related to an increase in early mortality in patients on HD, but its supplementation is not part of routine therapy and its prevalence is highly variable depending on established cutoffs and the clinical profile of the patients. The aim of this study was to determine the status of vitamin D and its correlation with parameters related to phosphocalcic metabolism and protein energy wasting (PEW) syndrome.

Use of objective evidence of myocardial ischemia to facilitate the diagnostic and prognostic distinction between type 2 myocardial infarction and myocardial injury.

First, describe how acute myocardial infarction criteria are used to diagnose type 1 (T1MI) and 2 (T2MI) myocardial infarction. Second, determine whether subjective or objective criteria are used for T2MI. Third, examine outcomes for T2MI based on the presence or absence of objective evidence of myocardial ischemia compared with myocardial injury. Post-hoc analysis of UTROPIA (NCT02060760), a prospective, observational, cohort study involving 1640 consecutive emergency department patients with serial high-sensitivity cardiac troponin I among whom 74 (4.5%) had T1MI, 103 (6.3%) T2MI, and 245 (15%) myocardial injury. Compared with T1MI, patients with T2MI were less likely to have ischemic symptoms (97% vs. 83%), Q waves (24% vs. 1%), new ST-T wave changes (74% vs. 51%), new regional wall motion abnormality (64% vs. 11%), and a culprit lesion on coronary angiography (59% vs. 0%) (all p <0.05). T2MIs were more likely to be diagnosed using subjective criteria (symptoms alone) than T1MI (42% vs. 12%, p <0.0001). Patients with objective T2MI, but not subjective T2MI, had a two-fold increase in early mortality compared with myocardial injury, with 30- and 60-day hazard ratios (95% confidence interval) of 2.3 (0.9, 6.2) and 2.0 (0.9, 4.7) respectively. Among patients with T2MI, many cases are diagnosed using subjective criteria. The presence of objective evidence of myocardial ischemia may identify a higher-risk group of T2MI patients in whom early outcomes are worse than myocardial injury. Emphasis on using objective evidence of myocardial ischemia to diagnose T2MI may result in a more precise and specific disease definition.