Independent Predictor Of All-cause Mortality Research Articles

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

Abstract Background It is unclear whether admission blood glucose to albumin ratio (AAR) predicts clinical adverse outcomes in patients with ST-segment elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention (PCI). Purpose Here, we explored the predictive value of AAR. Methods Patients diagnosed with STEMI undergoing PCI between January 2010 and February 2020 were enrolled. The patients were classified into three groups according to AAR quantiles. In-hospital all-cause mortality was regarded as the primary outcome. Logistic regression, Kaplan-Meier analysis and Cox proportional hazard regression were mainly used to estimate outcomes. Results Among the 3,224 enrolled patients, 130 (3.9%) of them suffered in-hospital all-cause mortality and 181 (5.4%) experienced major adverse cardiac events (MACEs). After the adjustment, multivariate analysis demonstrated that an increase in AAR was associated with the increased risk of in-hospital all-cause mortality (adjusted OR: 2.72, 95% CI: 1.47–5.03, p = 0.001) and MACEs (adjusted OR: 1.91, 95% CI: 1.18–3.10, p = 0.009), as well as for long-term all-cause mortality (adjusted HR: 1.64, 95% CI: 1.19–2.28, p = 0.003) and MACEs (adjusted HR: 1.58, 95% CI: 1.16–2.14, p= 0.003). ROC analysis indicated that AAR could accurately predict in-hospital all-cause mortality (AUC = 0.718, 95% CI: 0.675–0.761) and MACEs (AUC = 0.672, 95% CI: 0.631–0.712). Conclusions AAR is a novel and convenient independent predictor of all-cause mortality and MACEs both at the in-hospital and long-term levels in STEMI patients receiving PCI.ROC curve of AARKaplan–Meier survival curves

Transcatheter-edge-to-edge-repair of functional mitral regurgitation in advanced HFrEF: the impact of intrinsic left ventricular performance on the degree of MR reduction and clinical outcome

Abstract Background Transcatheter-edge-to-edge-repair (TEER) of functional mitral regurgitation (FMR) reduces rehospitalisation and all-cause mortality in patients with HFrEF/HFmrEF. Not conclusively clarified is the interaction of pre-interventional intrinsic left ventricular (LV) function with TEER success and clinical outcome. By using the gold standard of LV contractility analysis, the invasive pressure-volume loop technique, we examined the interaction of pre-and post-interventional intrinsic LV performance with the degree of MR reduction and all-cause mortality after TEER in patients with advanced HFrEF. Methods In a prospective study of 71 patients with advanced HFrEF (median EF 26%, 22-31%) and severe FMR, we quantified different intrinsic parameters of LV performance by PV-loop analysis (single beat analysis) pre-and post-interventionally. Results In 83% of the patients a MR reduction to grad < 2 could be achieved (hospital discharge). In the ROC analysis, the best cut-off to separate medium-term survival from all-cause mortality (median FU 2.9 years) was a post-interventional regurgitation fraction (RF) < 20% (AUC 0.72, p<0.001, sensitivity 83%, specificity 60%) and a R-volume (RV) < 18ml (AUC 0,7, p=0.002, sensitivity 67%, specificity 72%). The PV-loop-derived intrinsic LV contractility (LV-endsystolic elastance, Ees), LV afterload (arterial elastance, Ea), LV-Ao-coupling (Ees/Ea), LV-mechanical efficacy (ME), PV-loop area (PVA), stroke work, Tau; end-diastolic elastance (Eed), LVEF, LVEDV, and LVESV, pre- and post-TEER, were not predictive for the extent of MR reduction acutely, after 6 months FU, and for all-cause mortality. In multivariate cox-regression analysis, only a post-interventional RF<20% (HR 0.36, p=0.017) or RV<18ml (HR 0.32, p=0.005) and the pre-interventional LV-contractile reserve (LV-CR: post-extra-systolic augmentation of LV-Ees) remained independent predictors of all-cause mortality. In a second model, we included the degree of LV-remodeling (LV-R: LVESV reduction from hospital discharge to 6 months) in the model. In addition to pre-interventional LV-CR, and RF<20%, the LV-R remains independent predictive for all-cause mortality. Conclusion In our peri-mitral-TEER LV-PV-loop study, only the extent of MR reduction and the pre-interventional LV-CR, but not the intrinsic LV performance at rest, determine the medium-term survival of patients with advanced HFrEF and FMR. TEER-mediated MR reduction itself seems not be determined by the LV performance.

Impact of nutritional status and systemic immune-inflammation index on mortality in patients with acute myocardial infarction

Abstract Background It has been known that malnutrition and elevated inflammatory markers are associated with clinical outcome in patients with acute myocardial infarction (AMI). However, few studies have investigated the association between nutritional status, inflammatory markers and survival in patients with AMI. Purpose The aim of this study is to investigate combined impact of nutritional status and systemic immune-inflammatory index (SII) on outcome in patients with AMI. Methods We examined 1,984 patients (mean age = 64 ± 12 year-old, 1,493 males) admitted for AMI. Nutritional assessment was evaluated at the admission by geriatric nutritional risk index (GNRI) calculation. Malnutrition was defined as GRNI <92. We calculated SII from the equation, SII = P x N/L, where P, N and L are peripheral blood platelet, neutrophil and lymphocyte counts per liter at the time of admission, respectively. The primary endpoint was all-cause mortality at 1-year. Results GNRI was significantly correlated with SII (r = -0.135, p<0.001). GNRI (95.2 ± 8.4 versus 102.7 ± 7.3) was significantly lower, whereas SII (1,906.9 ± 2,016.0 x 109 cells/L versus 1,100.9 ± 981.6 x 109 cells/L) was significantly higher in non-survivors. Patients with malnutrition had significantly higher mortality compared with patients without malnutrition (19.2% versus 4.3%, log-rank p <0.001). In receiver operating characteristics curve analysis, area under the curve of SII for predicting all-cause mortality was 0.625. The optimum cut-off point for SII for a favorable prognosis was determined to be 1,425 x 109 cells/L. Patients with high SII had significantly higher mortality (9.6% versus 4.2%, log-rank p<0.001). The patients were divided into four groups based on GNRI & SII; high GNRI &low SII (Group 1), high GNRI & high SII (Group 2), low GNRI & low SII (Group 3), and low GNRI & high SII (Group 4). In Kaplan-Meier survival curve, all-cause mortality was significantly higher in Group 4 compared with Group 1, Group 2, and Group 3 (3.5% versus 6.7% versus 14.1% versus 25.6%, log-rank p<0.001; Figure). In Cox-proportional hazards model, compared with Group 1 (1, reference), Group 2 (HR 1.64, 95% CI 1.02 – 2.63; p=0.038), Group 3 (HR 1.97, 95% CI 1.06 – 3.68; p=0.032), and 4 (HR 4.17, 95% CI 2.40 – 7.24; p<0.001) was an independent predictor of all-cause mortality after adjusting for confounding variables. Conclusion Nutritional status was significantly correlated with immune-inflammatory index. Malnutrition and high SII was independent predictors of overall survival in patients with AMI.

Impact of anaemia and iron deficiency on long-term outcomes following transcatheter edge-to-edge repair in degenerative vs. secondary mitral regurgitation: results from a large single-center study

Abstract Background Transcatheter mitral valve edge-to-edge repair (TEER) is an established therapeutic option for significant mitral regurgitation (MR), as an alternative for patients at high risk for open heart surgery. While mitral valve reconstruction is the guideline-recommended treatment modality for degenerative mitral regurgitation (DMR), secondary mitral regurgitation (SMR) is more complex and requires a multifaceted approach. Anaemia and iron deficiency (ID) are both associated with unfavourable outcomes in patients with cardiovascular diseases, particularly in those with heart failure. In patients undergoing TEER, the prevalence of ID and anaemia is exceptionally high. However, data regarding the impact of anaemia and ID on outcomes are limited to short- and mid-term follow-up periods. Purpose This retrospective single center study, aimed to investigate effects of anaemia and ID on long-term outcomes following TEER for relevant MR, as well as to relate it to the underlying MR aetiology. Methods A total of 833 patients (mean age 76.1 ± 8.4 years, 40.7% female, 63.3% secondary MR) were treated by TEER between September 2008 and July 2019. Patients were stratified based on their anaemia status (anaemia was defined as hemoglobin <12 g/dL in females and <13 g/dL in males) or ID (defined according to current HF guidelines as a serum ferritin concentration of <100 ng/mL or 100–299 ng/mL and a transferrin saturation <20%). Clinical follow-up was conducted primarily through in-person visits or by structured telephone interviews at 6 and 12 months after intervention and annually thereafter. The median follow-up time was 5.5 years, with a maximum follow-up of 12.3 years. Results Anaemia and ID were prevalent among patients with 61.6% and 68.1%, respectively. Among all anaemic patients, 73.5% also had ID. Anaemic patients had a lower functional status at baseline and were less likely to show improvement after TEER. Additionally, anaemia was significantly associated with all-cause mortality (hazard ratio [HR]=1.68, 95%-confidence interval [CI]: 1.36-2.07, p<0.001) and the composite endpoint of death or heart failure rehospitalization (HR=1.30, 95%-CI: 1.10-1.54, p=0.002). Moreover, anaemia was found to be an independent predictor for all-cause mortality in patients with secondary MR, with a 5-year mortality rate of 69.9% in anaemic patients compared to 47.8% in non-anaemic patients (p<0.001). However, ID was not associated with an increased risk of all-cause mortality or the composite endpoint of death or heart failure rehospitalization for either degenerative or secondary MR. Conclusion The high prevalence of anaemia and ID in patients undergoing TEER is noteworthy. Anaemia was associated with poorer functional baseline status and less post-interventional improvement. Furthermore, and in contrast to ID, anaemia was linked to higher mortality rates and more heart failure rehospitalizations, particularly in patients with secondary MR.Kaplan Meier survival analysisPredictors for all-cause mortality

Natural history and predictors of all-cause mortality and major arrhythmic cardiac events in pediatric RASopathy associated hypertrophic cardiomyopathy

Abstract The RASopathies are a group of developmental disorders caused by germline variants in components of the RAS-MAPK pathway, commonly associated with hypertrophic cardiomyopathy (HCM). The aim of this study was to describe the natural history and predictors of all-cause mortality and major arrhythmic cardiac events (MACE) in a large, multi-centre cohort of paediatric patients with a RASopathy syndrome and HCM. One-hundred-and-forty-nine patients were included (111 (74.5%) Noonan Syndrome (NS); 12 (8.05%) Noonan Syndrome with Multiple Lentigines (NSML); 6 (4.03%) Costello Syndrome (CS); 6 (4.03%) Cardiofaciocutaneous Syndrome (CFCS); and 14 (9.4%) with Noonan-like syndrome patients). NSML patients had higher maximal left ventricular wall thickness (MLVWT) (z score 17.02 (10.57-32.78), p=0.004] and higher left ventricular outflow tract (LVOT) gradient values (60mmHg, 36-80, p=0.019), with no other significant echocardiographic differences between RASopathy syndromes. Over a median follow up of 197.5 months (93.58-370), 23 patients (15.43%) died, at a median age of 48.94 months (3.29-175.84). Overall survival was 96.45% (91.69-98.51), 90.42% (84.04-94.33) and 84.12 (75.42-89.94) at 1, 5 and 10 years, respectively, but this was varied according to RASopathy syndrome. RASopathy syndrome, specifically Noonan-like syndrome (Hazard ratio 4.18, p=0.032) and congestive cardiac failure admission (Hazard ratio 7.35, p=0.037) were independent predictors of all-cause mortality and LVOT gradient was an independent predictor for MACE (Hazard ratio 1.02, p=0.025). These findings highlight a distinct category of patients with Noonan-like syndrome with a milder HCM phenotype but significantly worse survival and identify predictors of adverse outcome in patients with RASopathy-related HCM.

Prognostic value of transthoracic echocardiography in the evaluation of suspected myocardial infarction

Abstract Introduction Transthoracic bedside echocardiography (TTE) in the emergency department is recommended in patients with suspected myocardial infarction (MI), who do not qualify for early discharge using accelerated protocols. The prognostic value of routine echocardiographic parameters like wall motion abnormalities in patients with suspected MI, has not been evaluated so far. Therefore, our aim was to analyze whether TTE is a suitable risk stratification tool in patients presenting with suspected MI. Methods In a prospective cohort study, 2,719 patients presenting to the emergency department with symptoms indicate of MI were recruited. Patients with ST-segment elevation myocardial infarction (STEMI) and without available TTE were excluded. In the final dataset of 2,086 patients, pathological TTE-findings were defined as the composite of reduced systolic left ventricular(LV) function <50%, regional wall motion abnormalities (WMA) and severe valvular defects. Patients were followed up for up to 5 years to assess all-cause mortality and major adverse cardiac events (MACE), composited of cardiac rehospitalization, revascularization, MI excluding the index events, and death. Kaplan-Meier survival curves were created and compared using the log rank test. Cox-proportional hazard ratios with adjustment for age, sex, cardiovascular risk factors and high-sensitivity troponin were calculated for individual echocardiographic pathological findings. Results Among 2,086 patients 63.7% were male and the mean age was 64 years. Acute myocardial infarction was present in 308 (14.7%). 32.5% showed any pathological TTE-findings: A reduced systolic LV-function was detected in 18.6%, 18.4% had wall motion abnormalities, composed of 7.5% with akinesia and 10.9% with hypokinesia. Severe valvular defects were present in 7.8%. In patients with any pathological TTE-finding the rate of MACE was significantly higher than in patients without pathological findings (p<0.001, Figure 1A): After 5 years, MACE occurred in 320 (29.99%) of patients with a normal TTE, whereas 319 (59.65%) patients with at least one pathology developed MACE after 5 years. Overall mortality as a single component of the combined endpoint occurred in 86 (8.71%) patients with a normal TTE, while in patients with pathologies 152 (30.46%) had died (p<0.001, Figure 1B). Following cox-regression, valvular defects (HR 2,23 (95% CI 1,66-2,78)), highly reduced systolic LV-function <30% (HR 2,51 (95% CI 1,68-3,76)), and akinesia (HR 1,94 (95% CI 1,30-2,91)), were independent predictors of all-cause mortality at five years (Figure 2). Conclusion We describe the value of TTE as prognostic tool in patients with suspected MI and found that patients with pathologies in TTE were at substantially higher cardiovascular risk compared to patients without pathologies. Especially regional akinesia, highly reduced LV-function and severe valvular defects were strong predictors of mortality within 5 years.Kaplan-Meier survival curvesAdjusted cox-proportional hazard ratios

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

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

Impact of coronary flow reserve on the mortality and major adverse cardiac and cerebrovascular event in hemodialysis patients, regardless of diabetes

Abstract Background Ischemic heart disease (IHD) is still a major problem not only in general patients but also in regular hemodialysis (HD) patients. We have reported about prognostic value of coronary flow reserve (CFR) derived from N13-ammonia PET in HD population for all-cause mortality and major adverse cardiac event (MACE) in prior studies. We investigated the impact of diabetes and low CFR on the mortality in HD population. Methods A total 1,027 HD patients who undergone 13N-ammonia PET for suspected IHD were enrolled. We divided them into four groups according to CFR (cut off value = 2.0) and whether DM or not. We collected and evaluated their all-cause mortality, cardiovascular (CV) mortality and MACE, and analyzed using Kaplan-Meier methods and uni/multivariate cox regression model. Results The number of DM with better CFR group was 194, DM with worse CFR was 244, non-DM with better CFR was 361 and non-DM with worse CFR was 221. We found 285 case of all-cause mortality, 121 case of CV mortality, 164 case of CV mortality and 424 case of MACCE. Whether DM or not, CFR predicts HD patients’ prognosis precisely (See figure). Furthermore, multivariate Cox regression model showed CFR (continuous value) was an independent predictor for all-cause mortality (hazard ratio (HR); 0.774, 95% confidential interval (CI) 0.606-0.979, p value=0.037) and MACCE (HR0.769, 95%CI0.630-0.932, p=0.009) in DM and HD population. Furthermore, CFR predicted all-cause mortality (HR0.731, 95%CI 0.569-0.940, p=0.015) and non-CV death (HR0.636, 95%CI0.451-0.896, p=0.010) in non-DM and HD population. Conclusion The HD patients with DM and low CFR had worst prognosis in all-cause mortality, CV death, non-CV death and MACCE.

Impact of left ventricular end-diastolic pressure as a marker for diastolic dysfunction on long-term outcomes in patients undergoing transcatheter aortic valve replacement

ObjectiveThe aim of this study was to investigate the proportion of elevated left ventricular end-diastolic pressure (LVEDP) as an indicator of diastolic function after transcatheter aortic valve replacement (TAVR) and its implication in predicting long-term mortality. MethodsWe analyzed retrospectively collected data on 3328 patients with severe aortic stenosis undergoing TAVR in our institution between July 2009 and June 2021. Patients were stratified into two groups based on invasive post-procedural LVEDP measurements: normal (<15 mmHg) vs. elevated (≥15 mmHg) LVEDP. ResultsMean age of the patients was 81.6 years, and 53.3% were female. Elevated post-procedural LVEDP was identified in 2408 (72.3%) patients. The 5-year mortality rates were higher in the group with elevated LVEDP compared with the group with normal LVEDP (27.4% vs. 8.3%, p = 0.01; hazard ratio [HR] 1.22, 95% CI 1.05-1.41). A multivariate model revealed the following independent predictors of mortality after TAVR: post-procedural elevated LVEDP (HR 1.24, 95% CI 1.01-1.53), pre-procedural significant tricuspid regurgitation (HR 1.24, 95% CI 1.02-1.52) and pulmonary hypertension (PH) (HR 1.53, 95% CI 1.26-1.86). In the present study, a significant paravalvular leak after TAVR was not associated with higher mortality (HR 1.45, 95% CI-0.95-2.19, p = 0.75). ConclusionElevated post-procedural LVEDP in patients who undergo TAVR is an independent predictor of all-cause mortality. Furthermore, PH and tricuspid regurgitation were also identified as predictors of mortality. These data confirm that diastolic dysfunction is an important predictor of mortality in TAVR and should be considered to guide procedure timing, favoring an early interventional approach and management in aortic stenosis patients.

Implantation depth of balloon-expandable transcatheter heart valves and risks for permanent pacemaker implantation and midterm adverse events.

Permanent pacemaker implantation (PPI) remains a relevant complication after transcatheter aortic valve implantation (TAVI) and its impact on outcome remains controversial. This study aimed to analyze the effects of implantation depth on PPI at 30 days and assess its impact on outcome with the balloon-expandable Sapien 3 (S3) prosthesis. Between 2014 and 2018, 849 patients without previous pacemaker undergoing transfemoral TAVI with the S3 were included. Prosthesis implantation depth was measured and divided into Quintiles. An ordinal logistic regression was used to assess its association with PPI, while a multivariate logistic regression was performed to identify predictors of PPI. Survival analyses were performed with the Kaplan-Meier method and a multivariable Cox regression was performed to ascertain the impact of PPI on mortality. Overall, incidence of PPI at 30 days was 9.7%. Implantation depth decreased consistently from a median of 6.7 mm [5.55-8.00] in 2014 to 2.7 mm [2.30-3.50] in 2018 (p < 0.001). When considering Quintiles of implantation depth, incidence of PPI was significantly higher in upper Quintiles and risk for PPI was significantly lower for the 1. Quintile compared to the 5. Quintile (OR: 0.34, 95% CI: [0.16-0.73]; p = 0.003). In the adjusted multivariable logistic regression implantation depth persisted ad independent predictor of PPI at 30 days. Patients requiring PPI at 30 days displayed significantly higher mortality at 4 years compared to patients without PPI (49.5% vs. 40.0%; log-rank = 0.022). In a multivariate analysis, increased logistic EuroScore, diabetes mellitus, and history of atrial fibrillation, were independent predictors of all-cause mortality at 2 years. Higher prosthesis implantation relative to the virtual aortic annulus was significantly associated with reduced risk for PPI at 30 days. Patients with PPI at 30 days exhibited higher mortality during follow-up, however, only logistic EuroScore, diabetes mellitus, and history of atrial fibrillation were identified as independent predictors of mortality at 2 years.

Association between lactate/albumin ratio and 28-day all-cause mortality in ischemic stroke patients without reperfusion therapy: a retrospective analysis of the MIMIC-IV database.

The lactate/albumin ratio (LAR) has been used as a novel prognostic indicator for aneurysmal subarachnoid hemorrhage, traumatic brain injury, sepsis, heart failure, and acute respiratory failure. However, its potential in predicting all-cause mortality in patients with ischemic stroke (IS) has not been evaluated. Therefore, this study aimed to elucidate the correlation between LAR and 28-day all-cause mortality in IS patients without reperfusion therapy. This retrospective cohort study used data from the Medical Information Mart for Intensive Care (MIMIC-IV) (v2.0) database. It included 568 IS adult patients admitted to the intensive care unit (ICU). The correlation between LAR and ICU 28-day all-cause mortality rate was analyzed using multiple COX regression analysis and Kaplan-Meier survival analysis. Restricted cubic spline (RCS) curves were used to assess the relationship between LAR and 28-day mortality. In addition, a subgroup analysis was performed to investigate the impact of other influencing factors on outcomes. The primary outcome was the ability of LAR to predict 28-day mortality in IS patients. Among the 568 patients with IS, 370 survived (survival group) and 198 died (non-survival group) within 28 days of admission (mortality rate: 34.9%). A multivariate COX regression analysis indicated that LAR was an independent predictor of all-cause mortality within 28 days after admission for patients with IS (hazard ratio: 1.32; 95% confidence interval: 1.03-1.68; P = 0.025). We constructed a model that included LAR, age, race, sex, white blood cell count, Sequential Organ Failure Assessment (SOFA) score, and anion gap (AG) and established a prediction model with an area under the curve (AUC) value of 71.5% (95% confidence interval: 67.1%-75.8%). The optimal cutoff value of LAR that separated the survival group and the non-survival group based on the Youden index was 0.55. The Kaplan-Meier survival curves plotted using this critical value showed that patients with LAR ≥ 0.55 had a significantly higher 28-day all-cause mortality rate than patients with LAR < 0.55 (P = 0.0083). LAR can serve as an independent predictor of all-cause mortality within 28 days after admission for patients with IS.

Calcium score of the entire thoracic aorta is an independent predictor of all-cause mortality in patients referred to chest computed tomography.

Thoracic arterial calcifications (TAC) are not routinely reported or quantified in chest CT scans. We aimed to evaluate the association between TAC of the entire thoracic aorta and all-cause mortality (ACM) in patients referred to standard chest CT. A retrospective analysis of consecutive standard chest CT scans (non-gated, non-contrast) for the quantification of TAC, CAC and aortic valve calcification. TAC was divided into 4 sample-derived categories (TAC 1 = 0, TAC 2 = 1-65, TAC 3 = 66-439 and TAC 4 ≥ 440). Data regarding ACM was retrieved from the health care provider database. Multivariate Cox proportional regression models were used to assess associations between the TAC categories and ACM. The study cohort included 415 patients (mean age 67 years, 52% male); 107 ACM events were recorded during a median follow-up of 9 years (inter-quartile range: 7.4-10.4). The rate of ACM was 13%, 25%, 32%, 41% according to TAC category (p < 0.001). The highest TAC category (≥ 440) was a strong and independent predictor of ACM [HR = 1.69 (1.13-2.52; 0.01)] in multivariate analysis. Other independent predictors of ACM included age [HR = 1.07 (1.04-1.10; p < 0.001)], male sex [HR = 2.27 (1.49-3.46; 0.001)] and malignancy [HR = 2.21 (1.49-3.23; < 0.001)]. Severe TAC (≥ 440) was found to be an independent predictor of ACM. Thus, we suggest that documenting and quantifying TAC should be routinely incorporated into standard chest CT reports.

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

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

Predictive value for mortality of left ventricular wall thickness in dilated cardiomyopathy.

The purpose of this study was to explore the predictive value of wall thickness measured by cardiac magnetic resonance (CMR) for all-cause mortality in dilated cardiomyopathy (DCM) patients. DCM patients who underwent CMR and completed the regular follow-up were included in this study. The left ventricular end-diastolic diameter (LVDd), left ventricular end-diastolic volume (LVEDV), left ventricular posterior wall thickness (PWT), interventricular septum thickness (IVST), left ventricular ejection fraction, and left ventricular mass (LVM) were measured by CMR. The presence and extent of late gadolinium enhancement (LGE) were also assessed. The relative posterior wall thickness (RWTPW ) and relative interventricular septum wall thickness (RWTIVS ) were defined by the following equations: RWTPW =(2×PWT)/LVDd, and RWTIVS =(2×IVST)/LVDd. All patients received regular telephone and outpatient follow-up. The primary endpoint was all-cause mortality. A total of 161 patients were enrolled in this study, including 126 (78.3%) males. The mean age was 52.3±13.6years. During the median follow-up of 47months (interquartile range 32-57months), 41 (24.8%) patients died. Compared with the non-death group, LVDd (75.2±11.9 vs. 70.5±8.8mm; P=0.025) was greater in the death group, while PWT [5.2mm (3.7-6.8) vs. 6.9mm (5.3-8.6); P<0.001], IVST [8.2mm (6.5-9.5) vs. 9.3mm (7.4-10.5); P=0.005], RWTPW [0.15 (0.11-0.19) vs. 0.20 (0.15-0.25); P<0.001], RWTIVS [0.22 (0.17-0.26) vs. 0.26 (0.22-0.31); P<0.001], and LVM/LVEDV ratio (0.5±0.2 vs. 0.7±0.2g/mL; P<0.001) were lower. The presence of LGE [LGE(+)] was more frequent in the death group (75.6% vs. 58.3%; P=0.048). However, the LGE extent was not significantly different between the two groups [4 (1-7) vs. 2 (0-6); P=0.096]. Multivariate Cox regression analysis showed that PWT [hazard ratio (HR) 0.086, 95% confidence interval (CI) 0.665-0.976; P<0.05] and RWTPW (HR 0.001, 95% CI 0.000-0.502; P<0.05) were independent predictors of all-cause death. In contrast, IVST, RWTIVS , and the presence of LGE were not clearly associated with death. PWT measured by CMR is an independent predictor of all-cause mortality in DCM patients. However, there was no significant correlation between septum wall thickness and mortality.

The impact of COVID-19 infection before the vaccination era on the hospitalized patients requiring hemodialysis: a single-center retrospective cohort

Due to effective vaccinations, the COVID-19 (coronavirus disease 2019) infection that caused the pandemic has a milder clinical course. We aimed to assess the mortality of hospitalized COVID-19 patients before the vaccination era. We investigated the mortality in those patients between 1 October 2020 and 31 May 2021 who received hemodialysis treatment [patients with previously normal renal function (nCKD), patients with chronic kidney disease previously not requiring hemodialysis (CKDnonHD), chronic kidney disease (CKD), and patients on regular hemodialysis (pHD)]. In addition, participants were followed up for all-cause mortality in the National Health Service database until 1 December 2021. In our center, 83 of 108 (76.9%) were included in the analysis due to missing covariates. Over a median of 26 (interquartile range 11–266) days of follow-up, 20 of 22 (90.9%) of nCKD, 23 of 24 (95.8%) of CKDnonHD, and 17 of 37 (45.9%) pHD patients died (p < 0.001). In general, patients with nCKD had fewer comorbidities but more severe presentations. In contrast, the patients with pHD had the least severe symptoms (p < 0.001). In a model adjusted for independent predictors of all-cause mortality (C-reactive protein and serum albumin), CKDnonHD patients had increased mortality [hazard ratio (HR) 1.91, 95% confidence interval (CI), 1.02–3.60], while pHD patients had decreased mortality (HR 0.41, 95% CI 0.20–0.81) compared to nCKD patients. After further adjustment for the need for intensive care, the difference in mortality between the nCKD and pHD groups became non-significant. Despite the limitations of our study, it seems that the survival of previously hemodialysis patients was significantly better.

Elevated serum FGF21 is an independent predictor for adverse events in hemodialysis patients from two large centers: a prospective cohort study

Introduction We explored the relationship and the predictive value of serum fibroblast growth factor 21 (FGF21) with all-cause mortality, major adverse cardiovascular events (MACEs) and pneumonia in hemodialysis (HD) patients. Methods A total of 388 Chinese HD patients from two HD centers were finally enrolled in this prospective cohort study (registration number: ChiCTR 1900028249) between January 2018 and December 2018. Serum FGF21 was detected. Patients were followed up with a median period of 47 months to record the MACEs and pneumonia until death or 31 December 2022. Results The incidence of all-cause mortality, MACEs and pneumonia in HD patients were 20.6%, 29.6%, and 34.8%, respectively. The optimal cutoffs for FGF21 to predict all-cause mortality, MACEs and pneumonia were 437.57 pg/mL, 216.99 pg/mL and 112.79 pg/mL. Multivariate Cox regression analyses showed that FGF21, as a categorical variable, was an independent predictor for all-cause mortality, MACEs and pneumonia (HR, 3.357, 95% CI, 2.128–5.295, p < 0.001; HR, 1.575, 95% CI, 1.046–2.371, p = 0.029; HR, 1.784; 95% CI, 1.124–2.830; p = 0.014, respectively). The survival nomogram, MACEs-free survival nomogram and pneumonia-free survival nomogram based on FGF21 constructed for individualized assessment of HD patients had a high C-index with 0.841, 0.706 and 0.734. Conclusion Higher serum FGF21 is an independent predictor of all-cause mortality, MACEs and pneumonia in HD patients.

Determinants of Atrial Fibrillation Progression and Its Influence on Overall Mortality in a Cohort of Patients From South India.

Atrial fibrillation (AF) is a prevalent cardiac arrhythmia associated with increased morbidity and mortality. However, factors influencing AF progression and their impact on all-cause mortality in South Indian patients remain poorly understood. We conducted a retrospective cohort study involving 500 individuals diagnosed with AF. Patient characteristics, including age, sex, and comorbidities, were collected. Left atrial diameter (LAD) and left ventricular ejection fraction (LVEF) were measured via echocardiography. Participants were followed for a median of three years. Cox proportional hazard regression was used to analyzefactors associated with AF progression and all-cause mortality. Of the participants, 60% exhibited persistent or permanent AF, and 40% had paroxysmal AF. The mean age was 63.5 ± 10.8 years, with 60% males and 40% females. Common comorbidities included hypertension (80%), diabetes (50%), and coronary artery disease (35%). The mean LAD was 42.3 ± 5.6 mm and the mean LVEF was 52.7 ± 6.8%; left atrial appendage thrombus (LAAT) was present in 15% of patients. Over the follow-up, 24% experienced all-cause mortality. Multivariate analysis revealed age, hypertension, diabetes, LAD, and LVEF as significant predictors of AF progression (p<0.05). Patients with persistent or permanent AF exhibited a higher risk of progression than those with paroxysmal AF (hazard ratio=1.74, 95% CI, 1.23-2.45). Age, hypertension, heart failure, and AF progression were independent predictors of all-cause mortality (p<0.05). Our study identified age, hypertension, diabetes, LAD, and LVEF as independent predictors of AF progression. Additionally, age, hypertension, heart failure, and AF progression independently predicted all-cause mortality. These findings underscore the need for early detection and management of AF progression and comorbidities to improve outcomes in South Indian AF patients. Prospective studies with larger cohorts are warranted to confirm these findings and explore interventions to prevent AF progression and enhance patient outcomes.

Monocyte to high-density lipoprotein ratio is associated with mortality in patients with coronary artery diseases

BackgroundWhether the monocyte to high-density lipoprotein ratio (MHR) is associated with the prognosis of coronary artery disease (CAD) is inconclusive.MethodsPatients with CAD were enrolled and their data were collected. Blood was sampled within 24 h after admission. Multivariate Cox regression analysis was performed to determine the relationship between the MHR and all-cause mortality as well as complications during hospitalization.ResultsWe included 5371 patients in our cohort study. Among them, 114 (2.12%) patients died in hospital. MHR was independently associated with all-cause mortality (hazard ratio [HR], 1.81; 95% confidence interval [CI] 1.35, 2.42), cardiovascular mortality (1.69; 1.17, 2.45) and non-cardiovascular mortality (2.04; 1.27, 3.28). This association was only observed in patients with hypertension (P for interaction = 0.003). Patients with higher MHR levels also have a higher risk of complications, including infection, pneumonia, electrolyte disturbance, gastrointestinal bleeding, multiple organ dysfunction syndrome, and disturbance of consciousness. The receiver operating characteristic (ROC) analysis showed that the MHR had higher prognostic values than monocytes and high-density lipoprotein.ConclusionMHR was an independent predictor of all-cause mortality and in-hospital complications in patients with CAD, especially in patients with hypertension.

Low levels of circulating methylated IRX3 are related to worse outcome after transcatheter aortic valve implantation in patients with severe aortic stenosis

BackgroundAortic stenosis (AS) is one of the most common cardiac diseases and major cause of morbidity and mortality in the elderly. Transcatheter aortic valve implantation (TAVI) is performed in such patients with symptomatic severe AS and reduces mortality for the majority of these patients. However, a significant percentage dies within the first two years after TAVI, such that there is an interest to identify parameters, which predict outcome and could guide pre-TAVI patient selection. High levels of cardiac fibrosis have been identified as such independent predictor of cardiovascular mortality after TAVI. Promoter hypermethylation commonly leads to gene downregulation, and the Iroquois homeobox 3 (IRX3) gene was identified in a genome-wide transcriptome and methylome to be hypermethylated and downregulated in AS patients. In a well-described cohort of 100 TAVI patients in which cardiac fibrosis levels were quantified histologically in cardiac biopsies, and which had a follow-up of up to two years, we investigated if circulating methylated DNA of IRX3 in the peripheral blood is associated with cardiac fibrosis and/or mortality in AS patients undergoing TAVI and thus could serve as a biomarker to add information on outcome after TAVI.ResultsPatients with high levels of methylation in circulating IRX3 show a significantly increased survival as compared to patients with low levels of IRX3 methylation indicating that high peripheral IRX3 methylation is associated with an improved outcome. In the multivariable setting, peripheral IRX3 methylation acts as an independent predictor of all-cause mortality. While there is no significant correlation of levels of IRX3 methylation with cardiac death, there is a significant but very weak inverse correlation between circulating IRX3 promoter methylation level and the amount of cardiac fibrosis. Higher levels of peripheral IRX3 methylation further correlated with decreased cardiac IRX3 expression and vice versa.ConclusionsHigh levels of IRX3 methylation in the blood of AS patients at the time of TAVI are associated with better overall survival after TAVI and at least partially reflect myocardial IRX3 expression. Circulating methylated IRX3 might aid as a potential biomarker to help guide both pre-TAVI patient selection and post-TAVI monitoring.Graphical abstract

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

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