Independent Predictor Of Adverse Events Research Articles

Prepectoral breast reconstruction is safe in the setting of post-mastectomy radiation therapy

Many breast reconstruction patients undergo post-mastectomy radiation therapy (PMRT), which is well known to increase the risk of complications. There is limited data on outcomes and safety of prepectoral breast reconstruction in this setting. The purpose of this study was to compare the outcomes of prepectoral versus subpectoral two-stage breast reconstruction in patients undergoing PMRT. We conducted a retrospective cohort study of two-stage breast reconstructions performed at our institution during a 22-month period. Patients who received PMRT were identified, and two cohorts were created: those who underwent prepectoral versus subpectoral reconstruction. We collected data including patient characteristics, operative variables, and clinical outcomes. Bivariate analyses and multivariable logistic regressions were conducted. We captured 313 patients (492 breasts) that had undergone two-stage reconstruction. A total of 69 breasts received PMRT; 28 were reconstructed prepectorally, and 41 breasts subpectorally. The two cohorts were well matched. We detected no differences in clinical outcomes between the two groups after a median follow-up time of 24 months. There, however, were differences in perioperative variables. Prepectoral reconstruction was associated with a shorter operative time, shorter length of hospital stay, higher cost, and shorter time to final reconstruction. Multivariable logistic regression demonstrated that prepectoral reconstruction is not an independent predictor of adverse events. Although radiation is a known risk factor for many complications following breast reconstruction, prepectoral device placement is safe in this high-risk population. Although the rate of capsular contracture is reported to be higher in the general prepectoral population, this was not found in our radiated prepectoral population.

Blood Pressure Hyperreactivity to Standing: a Predictor of Adverse Outcome in Young Hypertensive Patients.

The prognostic significance and the mechanisms of blood pressure (BP) hyperreactivity to standing remain controversial. This study aims to evaluate the association of orthostatic hyperreactivity with major adverse cardiovascular and renal events in a cohort of young hypertensive subjects. We studied 1207 untreated subjects screened for stage I hypertension with a mean age of 33.1±8.6 years. The orthostatic BP change was calculated as the difference between 6 standing and 6 supine BP readings obtained during 2 separate visits. Hyperreactivity to standing was defined as the standing-supine systolic BP difference in the top decile. The mean difference in the whole group was -2.5±7.3/4.6±5.4 mm Hg. Ambulatory hypertension evaluated with 24-hour recordings was more common in Hyperreactors than Normoreactors (90.8% versus 76.4%, P=0.001). In 630 participants in whom 24-hour urinary catecholamines were measured, epinephrine/creatinine ratio was higher in hyperreactors (118.4±185.6 versus 77.0±90.1 nmol/mol, P=0.005). During a 17.2-year follow-up, 105 major adverse cardiovascular and renal events were accrued. In a multivariate Cox model, hyperreactivity to standing was an independent predictor of major adverse cardiovascular and renal events with a hazard ratio of 1.97 (95% CI, 1.10-3.52). Hyperreactivity remained an independent predictor of adverse events even when ambulatory BP data and incident hypertension during follow-up were included in the Cox model (hazard ratio, 1.94 [95% CI, 1.10-3.44]). Our data indicate that in young-to-middle-age hypertensive subjects an exaggerated systolic BP response to standing is associated with sympatho-adrenergic hyperreactivity and is an independent predictor of major adverse cardiovascular and renal events. Orthostatic BP assessment gives the advantage of simple acquisition and provides prognostic information on top of ambulatory BP.

Exercise Testing In Patients with Sickle Cell Disease: Safety, Feasibility and Potential Prognostic Implication.

ResumoFundamento Pacientes com anemia falciforme (AF) têm risco aumentado de complicações cardiovasculares. O teste ergométrico é usado como marcador de prognóstico em uma série de doenças cardiovasculares. Entretanto, há uma escassez de evidências sobre exercícios em pacientes com AF, especialmente em relação à sua segurança, viabilidade e possível função prognóstica.Objetivos Usamos o teste em esteira máximo para determinar a segurança e a viabilidade do teste ergométrico em pacientes com AF. Além disso, os fatores associados à duração do exercício, bem como o impacto das alterações causadas pelo exercício em resultados clínicos, também foram avaliados.Métodos 113 pacientes com AF que passaram pelo teste ergométrico e por uma avaliação cardiovascular abrangente incluindo um ecocardiograma e os níveis do peptídeo natriurético do tipo B (BNP). O desfecho de longo prazo foi uma combinação de eventos incluindo morte, crises álgicas graves, síndrome torácica aguda ou internações hospitalares por outras complicações associadas â doença falciforme. A análise de regressão de Cox foi realizada para identificar as variáveis associadas ao resultado. Um p valor <0,05 foi considerado estatisticamente significativo.Resultados A média de idade foi de 36 ± 12 anos (intervalo, 18-65 anos), e 62 pacientes eram do sexo feminino (52%). A presença de alterações isquêmicas ao esforço e resposta pressórica anormal ao exercício foram detectadas em 17% e 9 % da´população estudada respectivamente. Dois pacientes apresentaram crise álgica com necessidade de internação hospitalar no período de 48 horas da realização do exame. Fatores associados à duração do exercício foram idade, sexo, velocidade máxima de regurgitação tricúspide (RT), e relação E/e’, após a padronização quanto aos marcadores da gravidade da doença. Durante o período médio de acompanhamento de 10,1 meses (variando de 1,2 a 26), 27 pacientes (23%) apresentaram desfechos clínicos adversos. Preditores independentes de eventos adversos foram a concentração de hemoglobina, velocidade do fluxo transmitral tardio (onda A), e a resposta da PA ao exercício.Conclusões A realização de testes ergométricos em pacientes com AF, clinicamente estáveis, é viável. A duração do exercício estava associada à função diastólica e a pressão arterial pulmonar. A resposta anormal da PA foi um preditor independente de eventos adversos.

Post-systolic shortening is superior to global longitudinal strain in predicting adverse events in patients with stable coronary artery disease and preserved systolic function

BackgroundPost-systolic shortening (PSS) is an important indicator for early identifying myocardial dysfunction. We aimed to investigate the predictive value of PSS assessed with speckle tracking automated functional imaging (AFI) on adverse events in patients with stable coronary artery disease (CAD) and preserved systolic function.MethodsA total of 204 consecutive patients clinically diagnosed with stable CAD and left ventricular ejection fraction (LVEF) > 50% were included. Multiple parameters were analyzed with AFI technique. The composite endpoint included all-cause mortality, heart failure, myocardial infarction and stroke.ResultsDuring a median follow-up of 24 months (IQR 19–28 months), 30 patients (14.7%) reached the endpoint. Patients experiencing the endpoint had a lower absolute global longitudinal strain (GLS), a higher post-systolic index (PSI), and more left ventricle walls displaying PSS than patients without events. PSI (hazard ratio, 1.15; 95% CI, 1.04–1.27; p = 0.005) and per 1 increase in the number of left ventricle walls with PSS (hazard ratio 1.52, 95% CI 1.21–1.91, p < 0.000) were independent predictors of the endpoint, whereas GLS was not significantly associated with the endpoint after adjustment models. For patients with absolute value of GLS > 15.4%, a significant prognostic superiority was found in PSI compared with GLS (AUC = 0.73 [PSI] vs. 0.58 [GLS], p = 0.024).ConclusionsPSS is an independent predictor for adverse events in stable CAD patients with preserved systolic function, and the prognostic value may be superior to GLS in patients with normal or mildly reduced GLS.

Right ventricular diastolic dysfunction in breast cancer patients undergoing chemotherapy

Abstract Funding Acknowledgements Type of funding sources: None. Right ventricular (RV) diastolic dysfunction has been recognized as an independent predictor of adverse events and mortality in a wide range of diseases (1,2). Experimental and clinical data indicate that pathophysiological factors induce the development of RV diastolic dysfunction first, and only later - systolic dysfunction (3). The aim of the study was to assess the right ventricle diastolic function in patients with breast cancer undergoing chemotherapy. Material and methods The study included 40 women receiving anthracycline-based chemotherapy for cancer, and 25 age-matched and comorbidity-matched women without cancer as a control group. RV systolic (s"t, Tei-index, and TAPSE) and diastolic (Et, At, Et/At, e"t, a"t, e"t/a"t) function parameters at baseline and after treatment were compared and evaluated. Results In cancer patients during anthracycline-based chemotherapy, no signs of cardiotoxicity were detected according to the indicators of the left ventricular ejection fraction and global longitudinal strain. Progressive decline in RV diastolic function was noted in patients receiving anticancer therapy. Et was 53.0 (46.0; 62.0) sm/sec in control, 50.0 (41.0; 53.0) sm/sec in cancer group before treatment, and 45.0 (41.0; 51.0) sm/sec after one-year treatment (p = 0.017 for trend). Et/At was 1.4 (1.28; 1.6), 1.34 (1.23; 1.58), and 1.12 (0.81; 1.35), respectively (p = 0.002 for trend). RV systolic function was without changes during treatment. TAPSE was 2.5 (2.2; 2.8) sm in control, 2.3 (2.2; 2.5) sm in cancer group before treatment, and 2.3 (2.0; 2.4) sm after one-year treatment (p = 0.091 for trend). Conclusion Patients undergoing chemotherapy experience a decline in right ventricular filling rates despite not showing clear signs of anthracycline-associated cardiotoxicity. More research is needed to indicate the clinical and prognostic significance of such changes.

Epicardial fat volume improves prediction of adverse clinical events

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Recent studies have demonstrated the potential of epicardial fat volume (EFV) to predict obstructive coronary artery disease (CAD), however its impact in clinical outcomes remains elusive. Objectives To assess the association between EFV and demo­graphic and morphometric data, coronary atherosclerotic burden and adverse events in a population of patients (pts) referred for coronary computed tomography angiography (CTA). ­Methods: Retrospective analysis of pts without known CAD referred for coronary CTA in a single tertiary care centre. A standardized protocol for quantification of EFV, thoracic fat volume (TFV), coronary artery calcification (CAC) and coronary angiography was performed. Endpoint was composite of cardiovascular death, nonfatal myocardial infarction and urgent hospitalization leading to revascularization at 12 months. Results 72 pts were included, 58% male, mean age 67 ± 9 years. The prevalence of hypertension, dyslipidemia and diabetes was 75%, 82% and 24%, respectively. Median EFV was 101 (68) ml and total TFV 1504 (694) ml. EFV was directly related with age (rs= 0.42, p &amp;lt;0.001), male sex (135 ± 50 vs 78 ± 30, p &amp;lt;0.001), body mass index (rs= 0.32, p= 0.008) and TFV (rs= 0.27, p= 0.025). A positive correlation with CAC (rs= 0.47, p &amp;lt;0.001) and a significant association with CAD (116 ± 50 vs 90 ± 37, p= 0.029) and obstructive CAD (141 ± 60 vs 97 ± 39, p= 0.031) were demonstrated. Composite endpoint was observed in 13 pts (18%). After adjusting for all considered confounders, EFV remained an independent predictor of adverse events (OR: 1.015, 95%CI: 1.003-1.027, p= 0.041). ROC analysis of EFV (AUC 0.751, p = 0.005) allowed to estimate that EFV &amp;gt;124 ml had a sensibility and specificity to predict clinical outcomes of 69% and 71%, respectively. Conclusion EFV positively relates to coronary atherosclerotic burden. This study also advocates that EFV may improve risk stratification for clinical outcomes. Larger studies are required to evaluate these results. Abstract Figure 1

Resident and Fellow Participation Does Not Affect Short-Term Postoperative Complications After Distal Radius Fracture Fixation.

Background Complications after open reduction internal fixation (ORIF) for distal radius fractures (DRF) are well documented, but the impact of trainee involvement on postoperative outcomes has not been studied. Questions Does trainee involvement affect postoperative complication rates and length of hospital stay? Methods The American College of Surgeons National Surgical Quality Improvement Program was queried from 2006 to 2012 for patients undergoing DRF ORIF. A 1:1 propensity score matched resident/fellow involved cases to attending-only cases. Demographics, length of stay, and postoperative complications were compared between the two groups. Logistic regression was used to evaluate independent predictors of adverse events and to evaluate cases with and without trainee involvement. Results Overall, 3,003 patients underwent DRF ORIF from 2006 to 2012. After matching, 1,150 cases (50% with resident/fellow involvement) were included. The overall rate of adverse events was 4.4% (46/1,050). There were no significant differences in the short-term complication rate in trainee-involved (2.3%) versus attending-only cases (3.9%) ( p = 0.461). For ORIF of DRF, there were no significant differences, between attending-only cases and resident/fellow-involved cases, with regard to short-term major complications ( p = 0.720) or minor complications ( p = 0.374). Length of hospital stay was similar between cohorts (1.22 vs. 0.98 days) ( p = 0.723). On multivariate analysis, trainee involvement was not an independent predictor of minor, major, or any complication after DRF fixation after controlling for multiple independent factors (all p > 0.364). Discussion Trainee participation in DRF ORIF is not associated with increased risk of short-term (30 days) medical or surgical postoperative complications. Level of Evidence This is a Level IV case-control study.

251 Prognostic role of acute myocardial infarction diagnostic criteria in non-ST segment elevation myocardial infarction

Abstract Aims Although patients with ST segment elevation myocardial infarction (STEMI) and non-ST segment elevation myocardial infarction (NSTEMI) share similar risk factors and similar pathophysiology, their outcomes differ considerably. The Fourth Universal Definition of Myocardial Infarction (UDMI) defined acute myocardial infarction (AMI) by an acute myocardial injury together with clinical evidence of acute myocardial ischaemia. However, the prognostic role of each single diagnostic criteria has never been explored. To evaluate the prognostic role of the different diagnostic criteria of AMI according to the Fourth UDMI in patients with STEMI vs. NSTEMI. Methods and results We enrolled all consecutive patients with AMI undergoing coronary angiogram at our Centre. We used a combination of criteria, according to the current ESC guidelines, to meet the diagnosis, namely the detection of an increase and/or decrease of high-sensitivity cardiac troponin I, with at least one value above the 99th percentile of the upper reference limit and at least one of the following: symptoms of ischaemia; ECG changes (new ST-T changes or new left bundle branch block); development of pathological Q waves in the ECG; echocardiographic evidence of new loss of viable myocardium, or new regional wall motion abnormality. According to the ECG presentation at admission, patients with AMI were divided into STEMI and NSTEMI subgroups. All-cause mortality and a composite endpoint of all-cause mortality, re-hospitalization for heart failure, and myocardial re-infarction were collected. The predictive value of diagnostic criteria alone and their association was evaluated using Kaplan–Meier survival curves and subsequent Cox-regression analysis to find independent predictors of adverse events. 2345 patients were evaluated (41.6% STEMI and 58.4% NSTEMI). The two groups had similar baseline characteristics. The total number of events was 689 (292 in STEMI group and 397 in NSTEMI group). We found that clinical criteria alone showed a positive predictive value in NSTEMI (P &amp;lt; 0.001). Moreover, electrocardiographic and echocardiographic criteria correlated with a worse prognosis in STEMI group (P &amp;lt; 0.01). No other significant prognostic correlation was found. Multivariable Cox-regression model demonstrated that clinical criteria were the only independent predictors of better prognosis in patients with NSTEMI (HR = 0.48; 95% CI: 0.31–0.74; P &amp;lt; 0.001). We did not find any predictor of outcome in patients with STEMI (HR = 0.6; 95% CI: 0.3–1.5, P = 0.3; HR = 1.1; 95% CI: 0.5–2.6, P = 0.7; HR = 0.6; 95% CI: 0.3–1.2, P = 0.2 for clinical and echocardiographic criteria alone and their combination, respectively). Conclusions Our data suggest that in NSTEMI the prognosis is considerably better if clinical criteria alone are present at admission. We hypothesize that the absence of electrocardiographic and echocardiographic alterations in NSTEMI could indirectly indicate smaller infarct sizes or other causes of acute myocardial injury.

249 Prognostic role of diagnostic criteria of acute myocardial infarction

Abstract Aims The term acute myocardial infarction (AMI) reflects cell death of cardiac myocytes caused by ischaemia. The Fourth Universal Definition of Myocardial Infarction (UDMI) defined AMI by a typical rise and fall in the level of biochemical markers of myocardial necrosis together with criteria of myocardial ischaemia. However, the prognostic role of each single diagnostic criteria has never been explored. To evaluate the prognostic role of the different diagnostic criteria of AMI according to the Fourth UDMI. Methods and results We enrolled all consecutive patients with AMI admitted from 2016 to 2019. We used a combination of criteria, according to the current ESC guidelines, to meet the diagnosis, namely the detection of an increase and/or decrease of high-sensitivity cardiac troponin I, with at least one value above the 99th percentile of the upper reference limit and at least one of the following: symptoms of ischaemia; ECG changes (new ST-T changes or new left bundle branch block); development of pathological Q waves in the ECG; imaging evidence of new loss of viable myocardium or new regional wall motion abnormality, in our study evaluated by transthoracic echocardiogram. All-cause mortality and a composite endpoint of all-cause mortality, re-hospitalization for heart failure, and myocardial re-infarction were collected. The predictive value of diagnostic criteria alone and its association were evaluated using Kaplan–Meier survival curves and subsequent Cox-regression analysis to find independent predictors of adverse events. 2386 patients were evaluated. The median follow-up time was 23.3 ± 14.5 months. The total number of events was 703 (29.5%). Kaplan–Meier curves showed that major adverse cardiac events (MACEs) were statistically different depending on the diagnostic criteria of AMI at admission. Particularly, clinical criteria alone showed a better predictive value (P &amp;lt; 0.001) than other diagnostic AMI criteria. Multivariable Cox-regression model demonstrated that clinical criteria were the independent predictor of good prognosis in patients with AMI (HR = 0.43; 95% CI: 0.28–0.67; P &amp;lt; 0.001). Conversely, the other diagnostic criteria (electrocardiographic and echocardiographic) and the combination of all diagnostic criteria were not independent prognostic factors of MACEs (HR = 1.1; 95% CI: 0.6–2.4, P = 0.6; HR = 1.1; 95% CI: 0.7–1.9, P = 0.6; HR = 0.9; 95% CI: 0.7–1.0, P = 0.2, respectively). Conclusions Our data suggest that the prognosis is considerably better among patients with a diagnosis of AMI if clinical criteria alone are present at admission. We also demonstrated that clinical criteria are a strong prognostic predictor of good outcomes in patients with AMI. We hypothesize that the absence of electrocardiographic and echocardiographic alterations could indirectly indicate a smaller infarct sizes that contribute to patients’ outcome.

Fractional flow reserve in patients with type 1 or type 2 non-ST elevation acute myocardial infarction.

We assessed a combined strategy of fractional flow reserve (FFR) plus angiography in stratifying cardiovascular risk in patients with type 1 myocardial infarction (T1MI) or type 2 (T2MI) non-ST elevation acute myocardial infarction (NSTEMI). A cohort of 150 NSTEMI patients were prospectively studied. Clinical and angiographic features guided the identification of T1MI vs T2MI and the treatment of culprit lesions. Subsequently, T1MI patients underwent FFR evaluation of nonculprit stenoses. In T2MI patients all angiographically significant stenoses were evaluated by FFR. FFR < 0.80 was an indication for revascularization. Based on FFR results, two groups were compared: patients with all lesions ≥0.80 ('defer' group, n = 87) and those with at least one lesion <0.80 ('perform' group, n = 63). The primary end point was the composite of all-cause death, nonfatal MI and unplanned coronary revascularization. Median clinical follow-up was of 35 months (interquartile range 14-44). Primary end-point rates in the 'defer' and 'perform' groups were 14.5% and 30.0% at 12 months and 28% and 46% at 36 months, respectively (log-rank test: at 1 year, P = 0.007; at the end of follow-up P = 0.014). On multivariable analysis, chronic kidney disease (HR 3.50, 95% CI: 1.89-6.46, P = 0.0001) and FFR group ('perform' vs 'defer': HR 1.75 95% CI: 1.01-3.04, P = 0.046) were independent predictors of adverse events. In NSTEMI patients, our results indicated that FFR combined with angiography allowed the treatment of nonfunctional significant lesions to be safely deferred and patient cardiovascular risk to be identified.

Predictive value of SPECT myocardial perfusion imaging in patients with unrevascularized coronary chronic total occlusion.

Data involved the association between myocardial ischaemia and the outcome for unrevascularized coronary chronic total occlusion (CTO) patients were limited. The purpose of this study was to evaluate the predictive value of ischaemia detected by single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) for the adverse events in unrevascularized CTO patients. We further explored whether ischaemia generated from CTO vessel can independently predict the outcome. Patients with at least one unrevascularized CTO on coronary angiography were enrolled in this study. Exercise stress/rest SPECT MPI was performed in all patients. All patients were then followed by telephone interview and reviewing of medical records. Patients with ischaemia experienced significantly higher rate of adverse events than non-ischaemia patients (40.7% vs 7.1%, P = 0.002). Ischaemia demonstrated on MPI [odds ratio (OR) = 7.656; 95% confidence interval (CI) 1.598-36.677; P = 0.011] was an independent predictor for adverse events. Moreover, CTO-ischaemia (OR = 5.466; 95% CI 1.015-29.420; P = 0.048), non-CTO ischaemia (OR = 29.174; 95% CI 3.245-262.322; P = 0.003), mixed-ischaemia (OR = 7.130, 95% CI 1.257-40.445; P = 0.027) were all independent predictors for outcome. Ischaemia demonstrated on MPI, especially CTO-ischaemia were independent predictors for the adverse events. SPECT MPI can aid to identify patients at risk of adverse events, who may benefit from subsequent CTO percutaneous coronary intervention.

Adverse events of Oxford/AstraZeneca's COVID-19 vaccine among health care workers of Ayder Comprehensive Specialized Hospital, Tigray, Ethiopia

Background: The safety of COVID vaccines should be continuously followed. This study reports adverse events of the Oxford/AstraZeneca COVID-19 vaccine. Methods: A prospective single-cohort study design was conducted to assess adverse events following immunization and associated factors of the first dose of Oxford/AstraZeneca's COVID-19 vaccine in Ayder Comprehensive specialized hospital. A structured questionnaire was administered consecutively to 423 participants. Follow-up data were collected 72 hours after vaccination via phone. Bivariate and multivariate logistic regression models were used to find associations between adverse events and independent variables. Statistical significance was declared at P<0.05. Results: Out of 423 health care workers approached, 395 responded. At least one adverse event (95% CI: 63.58, 72.77) was reported by 270 participants. Local and systemic symptoms occurred in 46.8% (95% CI: 41.94, 51.79) and 58.48% (95% CI: 53.53, 63.26)], respectively. Muscle ache, fatigue, headache and fever were the most common local symptoms. No reports of hospitalization, disability or death. Age (adjusted odds ratio [AOR]=0.97, P=0.048), female sex (AOR=1.84, P=0.028), and comorbidity (AOR=2.28, P=0.040) were independent predictors of adverse events. Conclusion and recommendation: Adverse events following immunization are commonly reported after the first dose of the Oxford/AstraZeneca COVID-19 vaccine; age, female sex and comorbidity are independent predictors.

Relationship between Selvester ECG Score and Cardiovascular Outcomes in Patients with Non-ST Elevation Myocardial Infarction.

Early risk stratification plays a crucial role in the treatment of non-ST-elevation myocardial infarction (NSTEMI). Selvester score is an electrocardiography (ECG)-based method for estimating infarcted myocardial mass, however it has not been studied in NSTEMI before. In this study, we aimed to investigate the relationship between Selvester score and cardiovascular outcomes in a 1-year follow-up period in NSTEMI patients. One hundred and forty-three consecutive patients with NSTEMI were analyzed. TIMI and GRACE risk scores were calculated accordingly. Selvester score was calculated on surface ECG as reported in prior studies. Syntax score was calculated using an online calculator. The study population was divided into two groups based on a cut-off value from receiver operating characteristic curve analysis for the discriminative ability of Selvester score for mortality: low score (≤ 4), and high score (> 4) groups. Age was higher, left ventricle ejection fraction and high-density lipoprotein-cholesterol levels were significantly lower, and TIMI, GRACE and SYNTAX scores were significantly higher in the high Selvester score group. In multivariate Cox regression analysis, ejection fraction [hazard ratio (HR): 0.926, 95% confidence interval (CI): 0.883-0.971, p = 0.002] and Selvester score > 4 (HR: 3.335, 95% CI: 1.306-8.503, p = 0.012) were found to be independent predictors of adverse events after 1 year of follow-up. Selvester score is a fast and feasible method that has prognostic value for mortality and other major adverse outcomes in low and intermediate risk NSTEMI patients treated with urgent percutaneous coronary intervention for 12 months.

Left atrial volume index predicts adverse events in asymptomatic moderate or severe aortic stenosis.

In aortic stenosis (AS), chronic pressure overload on left ventricle (LV) leads to LV hypertrophy, impaired relaxation, increased chamber stiffness, fibrosis and left atrial (LA) dilatation. An enlarged LA may be a marker of longstanding diastolic dysfunction (DD) and more advanced disease in AS. We aimed to assess the impact of LA volume index (LAVI) on events in patients with moderate or severe AS. A total of 324 patients (mean age 69±13 years, 61% men) were included. LA volume was measured by biplane Simpson's method using apical four- and two-chamber views and indexed to body surface area. An increased LAVI was defined as>34ml/m2 . The mean EF was 64±8%, LAVI 35±14ml/m2 and flow rate 244±70ml/s. The number of total events was 275 (85%): 243 (75%) aortic valve replacement and 32 (10%) deaths. Mean follow-up 23.7±23.8 months (median 15.2 months). An increased LAVI (45% [n=145]) was associated with adverse events (HR 1.86; 95% CI 1.24-2.82, p=0.003) independent of age, smoking, diabetes, atrial fibrillation, LV ejection fraction, LV mass, aortic valve area, and low flow rate (<200ml/s). In the same multivariate model, when increased LAVI was replaced by E/e' ratio ≥14cm, no association was found between E/e' ratio ≥14cm and adverse events (HR 1.18; 95% CI .78-1.78, p=0.430). LAVI was an independent predictor of adverse events in patients with moderate or severe AS and preserved ejection fraction. Including LAVI in the risk assessment of AS patients may further improve risk stratification.

Prognostic role of diagnostic criteria of acute myocardial infarction

Abstract Background The term acute myocardial infarction (AMI) reflects cell death of cardiac myocytes caused by ischaemia. The Fourth Universal Definition of Myocardial Infarction (UDMI) defined AMI by a typical rise and fall in the level of biochemical markers of myocardial necrosis together with criteria of myocardial ischaemia. However, the prognostic role of each single diagnostic criteria has never been explored. Purpose To evaluate the prognostic role of the different diagnostic criteria of AMI according to the Fourth UDMI. Methods We enrolled all consecutive patients with AMI admitted from 2016 to 2019. We used a combination of criteria, according to the current ESC guidelines, to meet the diagnosis, namely the detection of an increase and/or decrease of high-sensitivity cardiac troponin I, with at least one value above the 99th percentile of the upper reference limit and at least one of the following: symptoms of ischaemia; ECG changes (new ST-T changes or new LBBB); development of pathological Q waves in the ECG; imaging evidence of new loss of viable myocardium or new regional wall motion abnormality, in our study evaluated by transthoracic echocardiogram. All-cause mortality and a composite endpoint of all-cause mortality, re-hospitalization for heart failure and myocardial re-infarction were collected. The predictive value of diagnostic criteria alone and its association were evaluated using Kaplan-Meier survival curves and subsequent Cox-regression analysis to find independent predictors of adverse events. Results 2386 patients were evaluated. The median follow-up time was 23.3±14.5 months. The total number of events was 703 (29.3%). Kaplan-Meier curves showed that major adverse cardiac events (MACE) were statistically different depending on the diagnostic criteria of AMI at admission. Particularly, clinical criteria alone showed a better predictive value (p&amp;lt;0.001) than other diagnostic AMI criteria. Multivariable Cox-regression model demonstrated that clinical criteria was the independent predictor of good prognosis in patients with AMI (HR=0.43; CI 95% 0.28–0.67; p&amp;lt;0.001). Conversely, the others diagnostic criteria (electrocardiographic and echocardiographic) and the combination of all diagnostic criteria were not independent prognostic factors of MACE (HR=1.1 CI 95% 0.6–2.4, p=0.6; HR=1.1 CI 95% 0.7–1.2, p=0.6; HR=0.9 CI 95% 0.7–1.0, p=0.8 respectively). Conclusions Our data suggest that the prognosis is considerably better among patients with a diagnosis of AMI if clinical criteria alone are present at admission. We also demonstrated that clinical criteria are a strong prognostic predictor of good outcomes in patients with AMI. We hypothesize that the absence of electrocardiographic and echocardiographic alterations could indirectly indicate a smaller infarct sizes that contribute to patients' outcome. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): None

Association Between Sarcopenia and Adverse Events Following Transcatheter Aortic Valve Implantation

BackgroundSarcopenia, the age-related loss of skeletal muscle mass/function, has been identified as a marker of frailty. We examined the association between sarcopenia and adverse events following transcatheter aortic valve implantation (TAVI). MethodsA retrospective cohort study was conducted at Toronto General Hospital. All patients who underwent TAVI in the time period 2007-2017 with preoperative computed tomography were included. Skeletal muscle index (SMI) was calculated radiographically using psoas muscle area at the L3 vertebral level, divided by height. Various measures of sarcopenia, including mean SMI, SMI below the sex-specific median, and SMI in the lowest sex-specific quartile were calculated. The primary outcome was postoperative adverse events, defined as a composite of in-hospital mortality and morbidity including cardiovascular, pulmonary, neurologic, access-related, and gastrointestinal complications. Univariate and multivariate logistic regression were performed to determine the association between sarcopenia and adverse events. ResultsA total of 468 patients (mean age: 80.7 years) were included. Baseline comorbidity burden was high, particularly congestive heart failure (93.4%). Postoperative adverse events occurred in 62 patients (13.2%). Univariate logistic regression demonstrated that postoperative adverse events were correlated with mean SMI (odds ratio [OR] 0.81, 95% confidence interal [CI] 0.66-0.97), events were less than the SMI (OR 2.16, 95% CI 1.24-3.84), and SMI in the sex-specific lowest quartile (OR 2.34, 95% CI 1.33-4.07). On multivariate analysis, SMI in the sex-specific lowest quartile was an independent predictor of adverse events (OR 2.53, 95% CI 1.41-4.50). ConclusionsSarcopenia defined by radiologic psoas muscle measurements was independently associated with in-hospital mortality and morbidity following TAVI.

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

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

Mid-term (up to 12\xa0years) clinical and echocardiographic outcomes of percutaneous transvenous mitral commissurotomy in patients with rheumatic mitral stenosis

BackgroundRheumatic heart disease (RHD) is still a concerning issue in developing countries. Among delayed RHD presentations, rheumatic mitral valve stenosis (MS) remains a prevalent finding. Percutaneous transvenous mitral commissurotomy (PTMC) is the intervention of choice for severe mitral stenosis (MS). We aimed to assess the mid-term outcome of PTMC in patients with immediate success.MethodsIn this retrospective cohort study, out of 220 patients who had undergone successful PTMC between 2006 and 2018, the clinical course of 186 patients could be successfully followed. Cardiac-related death, undergoing a second PTMC or mitral valve replacement (MVR) were considered adverse cardiac events for the purpose of this study. In order to find significant factors related to adverse cardiac outcomes, peri-procedural data for the studied patients were collected.The patients were also contacted to find out their current clinical status and whether they had continued secondary antibiotic prophylaxis regimen or not. Those who had not suffered from the adverse cardiac events were additionally asked to undergo echocardiographic imaging, in order to assess the prevalence of mitral valve restenosis, defined as mitral valve area (MVA) < 1.5 cm2 and loss of ≥ 50% of initial area gain.ResultsDuring the mean follow-up time of 5.69 ± 3.24 years, 31 patients (16.6% of patients) had suffered from adverse cardiac events. Atrial fibrillation rhythm (p = 0.003, HR = 3.659), Wilkins echocardiographic score > 8 (p = 0.028, HR = 2.320) and higher pre-procedural systolic pulmonary arterial pressure (p = 0.021, HR = 1.031) were three independent predictors of adverse events and immediate post-PTMC mitral valve area (IMVA) ≥ 2 cm2 (p < 0.001, HR = 0.06) was the significant predictor of event-free outcome. Additionally, follow-up echocardiographic imaging detected mitral restenosis in 44 patients (23.6% of all patients). The only statistically significant protective factor against restenosis was again IMVA ≥ 2 cm2 (p = 0.001, OR = 0.240).ConclusionThe mid-term results of PTMC are multifactorial and may be influenced by heterogeneous peri-procedural determinants. IMVA had a great impact on the long-term success of this procedure. Continuing secondary antibiotic prophylaxis was not a protective factor against adverse cardiac events in this study. (clinicaltrial.gov registration: NCT04112108).

Impact of Frailty on Morbidity and Mortality in Adult Patients Presenting with an Acute Traumatic Cervical Spinal Cord Injury

The aim of this study was to determine if baseline frailty was an independent predictor of adverse events (AEs) and in-hospital mortality in patients being treated for acute cervical spinal cord injury (SCI). A retrospective cohort study was performed using the National Trauma Database (NTDB) from 2017. Adult patients (>18 years old) with acute cervical SCI were identified using the International Classification of Diseases, Tenth Revision, Clinical Modification diagnostic and procedural coding systems. Patients were categorized into 3 cohorts based on the criteria of the 5-item modified frailty index (mFI-5): mFI= 0, mFI= 1, or mFI≥2. Patient demographics, comorbidities, type of injury, diagnostic and treatment modality, AEs, and in-patient mortality were assessed. A multivariate logistic regression analysis was used to identify independent predictors of in-hospital AEs and mortality. Of 8986 patients identified, 4990 (55.5%) were classified as mFI= 0, 2328 (26%) as mFI= 1, and 1668 (18.5%) as mFI≥2. On average, the mFI≥2 cohort was 5 years older than the mFI= 1 cohort and 22 years older than the mFI= 0 cohort (P < 0.001). Most patients in each cohort sustained either complete SCI or central cord syndrome after a fall or transport accident (mFI= 0, 77.31% vs. mFI= 1, 89.5% vs. mFI≥2, 93.65%). With respect to in-hospital events, the proportion of patients who experienced any AE increased significantly along with frailty score (mFI= 0, 30.42% vs. mFI= 1, 31.74% vs. mFI≥2, 34.95%; P < 0.001). In-hospital mortality followed a similar trend, increasing with frailty score (mFI= 0, 10.53% vs. mFI= 1, 11.33% vs. mFI≥2, 16.23%; P < 0.001). On multivariate regression analysis, both mFI= 1 1.21 (odds ratio [OR], 1.21; 95% confidence interval [CI], 1.05-1.4; P= 0.008) and mFI≥2 (OR, 1.23; 95% CI, 1.05-1.45; P= 0.012) predicted AEs, whereas only mFI≥2 was found to be a predictor for in-hospital mortality (OR, 1.45; 95% CI, 1.14-1.83; P= 0.002). Increasing frailty is associated with an increased risk of AEs and in-hospital mortality in patients undergoing treatment for cervical SCI.

Prognostic value of 6-min walk stress echocardiography in patients with interstitial lung disease.

The 6-min walk test (6MWT) provides prognostic information for patients with interstitial lung disease (ILD). Parameter determined by Doppler echocardiography after the 6MWT (6MW stress echocardiography) is shown to be a predictor of future development of pulmonary hypertension in patients with connective tissue disease. However, the clinical utility of 6MW stress echocardiography in predicting cardiopulmonary events in patients with ILD remains unknown. We examined whether parameters determined by 6MW stress echocardiography independent predictors of adverse events in patients with ILD. Echocardiographic examinations were performed in 68 consecutively enrolled patients with ILD (age, 65 ± 10years, 65% men). A pressure gradient of tricuspid regurgitation (TRPG) and pulmonary vascular resistance (PVRecho) calculated using the following formula [PVRecho = (peak velocity of TR × 10/time-velocity integral of right ventricular outflow (RVOT-VTI)) + 0.16] were measured at baseline and at post 6MWT. Data for parameters of pulmonary functional tests and for 6MWT were collected. During a mean follow-up period of 22 ± 12months, 22 patients experienced cardiopulmonary events. In univariate analysis, %VC, TRPG, PVRecho, TRPG post 6MWT, and PVRecho post 6MWT were significantly associated with cardiopulmonary events. Multivariate analysis using the Cox proportional hazards model indicated that %VC [hazard ratio (HR): 0.97, p = 0.009] and PVRecho post 6MWT (HR: 1.77, p = 0.004) were independent predictors of cardiopulmonary events in patients with ILD. In addition to parameters of pulmonary function tests, increased PVRecho post 6MWT is a significant predictor of cardiopulmonary events in patients with ILD. A 6MW stress echocardiography is useful in assessing the risk of adverse events in patients with ILD.