Independent Predictor Of Long-term Outcomes Research Articles

Diagnostic and prognostic value of right ventricular strain in patients with pulmonary arterial hypertension and relatively preserved functional capacity studied with echocardiography and magnetic resonance

Right ventricular (RV) dysfunction harbingers adverse prognosis in pulmonary arterial hypertension (PAH). Although conventional two-dimensional echocardiography (2DE) is limited for RV systolic function quantitation, RV strain can be a useful tool. The diagnostic and prognostic impact of 2DE speckle-tracking RV longitudinal strain was evaluated, including other 2DE systolic indexes, in a group of PAH patients without severe impairment of functional capacity, chronic pulmonary thromboembolism or left ventricular dysfunction. Sixty-six group I PAH patients, 67 % NYHA functional class I or II (none in IV) were studied by 2DE to obtain: RV fractional area change, tricuspid annular plane systolic excursion, RV myocardial performance index, tissue Doppler tricuspid annulus systolic velocity. Global, free wall (RVFreeWSt) and septal RV longitudinal systolic strain were obtained. RV ejection fraction by cardiac magnetic resonance (CMR-RVEF) was also assessed. All patients were followed up to 3.9 years (mean 3.3 years). Combined endpoints were hospitalization for worsening PAH or cardiovascular death. Among all the 2DE indexes of RV systolic function, RVFreeWSt exhibited the best correlation with CMR-RVEF (r=0.83; p < 0.005). Combined endpoints occurred in 15 (22.7 %) patients (6 hospitalizations and 9 deaths). Multivariate analysis identified RVFreeWSt ≤-14 % as the only 2DE independent variable associated with combined endpoints [HR 4.66 (1.25-17.37); p < 0.05]. We conclude that RVFreeWSt may be a suitable non-geometric 2DE surrogate of CMR-RVEF in PAH patients, constituting a powerful independent predictor of long-term outcome in this cohort with relatively preserved functional capacity.

Serum macrophage migration inhibitory factor levels are associated with infarct volumes and long-term outcomes in patients with acute ischemic stroke

Purpose: Previous studies have shown that macrophage migration inhibition factor (MIF) plays a significant role in stroke. The aim of this study was to investigate the association of the serum MIF level with both infarct volume and long-term outcome in patients with acute ischemic stroke (AIS). Methods: This study included 146 patients who were identified within 24 h of first experiencing AIS symptoms. Serum MIF levels were tested at the time of admission and three months later. Logistic regression was used to evaluate the risk and long-term outcome of stroke according to serum MIF level. Results: Serum MIF levels were only higher in acute-stage AIS patients compared with those of the normal controls (p < 0.0001). Chronic-stage serum MIF levels were significantly lower than acute-stage serum MIF levels (p < 0.001) and were similar to serum MIF levels in the controls (p = 0.392). The serum MIF level was positively associated with infarct volume (r = 0.5515, p < 0.0001) and NIHSS score (r = 0.5190, p < 0.0001). After adjusting for other significant outcome predictors, the serum MIF level was an independent predictor of long-term outcome, with an adjusted OR of 1.113 (p = 0.005, 95% CI: 1.051–1.238). Conclusions: This study demonstrated that serum MIF levels were significantly increased after AIS. Serum MIF levels at admission were positively correlated with infarct volume and long-term outcome in patients with AIS. The serum MIF level could serve as a useful prognostic marker in patients with AIS.

Utilizing Post-Intervention Fractional Flow Reserve to Optimize Acute Results and the Relationship to Long-Term Outcomes

This study sought to evaluate the impact of fractional flow reserve (FFR) after percutaneous coronary intervention (PCI) on subsequent in-lab interventional management vessels that had undergone pre-PCI FFR and its prognostic value in predicting long-term (>1 year) outcomes. Post-PCI FFR has been shown to be a predictor of intermediate-term (6 months) adverse events. However, its impact on immediate post procedure clinical decision making and long-term outcomes is not known. Consecutive patients undergoing PCI who had pre- and post-PCI FFR evaluations were followed for major adverse cardiovascular events (MACE). In the study 574 patients (664 lesions) were followed for 31 ± 16 months. PCI led to significant improvement in FFR from 0.65 ± 0.14 to 0.87 ± 0.08 (p< 0.0001). Despite satisfactory angiographic appearance, 143 lesions (21%) demonstrated post-PCI FFR in the ischemic range (FFR≤0.81). After subsequent interventions, FFR in this subgroup increased from 0.78 ± 0.08 to 0.87 ± 0.06 (p< 0.0001). Final FFR cutoff of≤0.86 had the best predictive accuracy for MACE and≤0.85 for TVR. Patients who achieved final FFR >0.86 had significantly lower MACE compared to the final FFR≤0.86 group (17% vs. 23%; log-rank p= 0.02). Final FFR≤0.86 had incremental prognostic value over clinical and angiographic variables for MACE prediction. Post-PCI FFR reclassified 20% of angiographically satisfactory lesions, which required further intervention thereby providing an opportunity for complete functional optimization at the time of the index procedure. This is particularly important as FFR post-PCI FFR was a powerful independent predictor of long-term outcomes.

The Pathophysiological Mechanism Is an Independent Predictor of Long-Term Outcome in Stroke Patients with Large Vessel Atherosclerosis

Etiopathological mechanisms underlying ischemic stroke play a crucial role in long-term prognosis. We aimed to investigate the association between the mechanism of stroke due to large vessel disease, and long-term outcome. All consecutive patients registered in the Athens Stroke Registry with atherosclerotic stroke between 1993 and 2010 were included in the analysis. The patients were subdivided into 3 groups according to the presumed underlying mechanism: low-flow infarcts, artery-to-artery embolism, and intrinsic atherosclerosis. They were followed up for up to 10 years or until death. The end points of the study were 10-year all-cause mortality, stroke recurrence, and composite cardiovascular events. Five hundred two patients were classified as follows: 156 (31%) as low-flow (watershed) strokes, 256 (51%) as artery-to-artery embolic strokes, and 90 (18%) as intrinsic atherosclerotic strokes. The cumulative probability of 10-year mortality rate was similar between groups of patients with different stroke mechanisms: 49.9% (95% confidence interval [CI], 38.5-61.3) for patients with low-flow mechanism, 47.6% (95% CI, 39.4-55.8) for patients with artery-to-artery embolism, and 48.5% (95% CI, 34.0-63.0) for patients with intrinsic atherosclerosis. Patients in the intrinsic atherosclerosis group had significantly higher risks of recurrence (adjusted hazard ratio [HR] = 2.1; 95% CI, 1.19-3.73) compared with those in the artery-to-artery embolism group. Moreover, patients in the intrinsic atherosclerosis and low-flow groups had significantly higher risks of composite cardiovascular events compared with those in the artery-to-artery embolism group (adjusted HR = 1.94; 95% CI, 1.26-3.00; and adjusted HR = 1.64; 95% CI, 1.13-2.38, respectively). Low-flow and intrinsic atherosclerosis strokes are associated with a high risk for future cardiovascular events and stroke recurrence. However, long-term mortality is similar across different subgroups.

Prognostic significance of perineural invasion in localized prostate cancer.

30 Background: While perineural invasion (PNI) has been associated with poorer clinical outcomes in prostate cancer patients, it is not well defined as a predictor of long-term endpoints in newly diagnosed prostate cancer. Therefore, we evaluated the role of PNI as a prognostic marker in patients with localized prostate cancer who underwent surgery or radiation. Methods: We analyzed a prospectively collected cohort of 5,034 consecutive patients with localized prostate cancer treated with surgery (n = 4,207) or radiation (n = 827) at University of Michigan from 1994-2013. The primary outcome measured was metastasis-free survival, with secondary outcomes of PSA-recurrence free survival and overall survival (OS). Covariates included age, treatment year, race, comorbidity index, pre-treatment PSA, Gleason score, and T-stage. Survival analysis was estimated using the Kaplan-Meir method, and multivariable analysis was performed using a Cox proportional hazards model. Results: 22.6% of surgery patients and 37.5% of radiation patients had PNI. 169 patients developed metastasis a median of 44 months (IQR 21-83 months) after primary therapy. In the combined cohort, PNI was a predictor of metastasis and PSA recurrence, but not OS (Table 1). For surgery, PNI was a predictor of metastasis, PSA recurrence, and OS. For radiation, PNI was a predictor of metastasis and PSA recurrence, but not OS. Conclusions: PNI is an independent predictor of long-term outcomes in newly diagnosed prostate cancer patients regardless of subsequent therapy. These data support the importance of PNI as a key factor denoting potentially aggressive prostate cancer and importing a significant increase in the likelihood of eventual metastatic progression. [Table: see text]

Abstract 17185: Hemodynamic Variables and Vasopressor Support After Out-of-hospital Cardiac Arrest: Associations With 1-year Neurologic Outcome

Introduction: Optimal blood pressure target in resuscitated patients is unknown but current guidelines recommend maintaining mean arterial pressure (MAP) between 60 to 90 mmHg. Our aim was to determine associations between time-weighted MAP levels and vasopressor load (VL) during the first 48 hours after OHCA and 1-year neurologic outcome in a prospective observational cohort of OHCA patients treated in the ICU. Methods: We included 503 patients with out-of-hospital-cardiac arrest (OHCA) treated in 21 ICUs from the FINNRESUSCI study between 2010 and 2011. Hemodynamic data and vasopressor doses were collected prospectively in two, five or 15 minute intervals depending on the ICU. Totally 1.2 million blood pressure values were analysed. We identified optimal thresholds for time-weighted (TW) MAP and outcome with receiver operating characteristic curve analysis (ROC). Using multivariate regression including co-morbidities, factors at resuscitation, sequential organ failure scores, TW MAP and total VL, we tested associations with 1-year neurologic outcome, dichotomized to good (CPC 1-2) and poor (CPC 3-5), respectively. Results: Of 503 patients, 202 (40 %) patients had a good and 301 (60 %) patients had poor 1-year outcome. Receiver operating characteristic analysis regarding poor one year outcome was performed for different MAP areas: hypotension areas under 65 mmHg (AUC 0.607, 95% CI 0.558 - 0.656, P-value &lt; 0.001) and under 70 mmHg (AUC 0.605, 95% CI 0.555 - 0.654, P- value &lt; 0.001). The mean vasopressor load was higher in patients with good 1-year outcome than in those with poor outcome (p-value &lt; 0.001). With multivariate regression analysis neither TWA MAP below 70mmHg (OR 1.0, 95% CI 0.999 - 1.001, p-value 0.909) nor vasopressor load (OR 1.004, 95% CI 0.994 - 1.013, p-value 0.52) were independent predictors of long-term outcome. Conclusions: In this large prospective study of OHCA patients, we found no associations between MAP values during the first 48h and long-term outcome. Contrary to previous expectations, higher MAP values had no neuroprotective effect. Neither did vasopressor load associate with outcome.

Abstract 16730: Prognostic Biomarker for Prediction of Sinus Rhythm Maintenance, Stroke and Long-Term Survival Following Successful Electrical Cardioversion of Non-Valvular Atrial Fibrillation: The Role of Left Atrial Appendage Flow

Introduction: Left atrial appendage (LAA) flow depends largely on left ventricular compliance and may play a role in mediating the regulation of left atrial volume-pressure relationships. Hypothesis: We hypothesize that LAA emptying flow velocity (LAAEV) is a predictive factor of long-term outcomes (e.g. recurrent AF, stroke, and survival) after cardioversion for non-valvular AF. Method: We identified 3,251 consecutive patients with non-valvular AF who underwent successful TEE-guided electrical cardioversion (ECV) at our institution between May 2000 and March 2012. Successful ECV was defined as sinus rhythm at time of discharge from the cardioversion unit. Patients were monitored following their ECV procedure for first documentation of recurrent AF, stroke or death. Multivariate Cox proportional hazards models were used to identify independent predictors of long-term outcomes. Patients with &gt;= moderate valvular regurgitation or stenosis were excluded. Results: Among the 3,251 patients who were successfully cardioverted to sinus rhythm, the mean (±SD) LAAEV was 38.43±23 cm/s and the median was 33 cm/s, (interquartile range [IQR], 20-50). Patients with LAAEV &lt;=33 cm/s had higher CHA 2 DS 2 -VASc score (2.6±1.2 vs. 1.9±1.3, P =.009), larger LAVI (52.0±20.9 cc/m 2 vs. 43.3±13.6 cc/m 2 , P &lt;.001) than those with LAAEV &gt;33 cm/s. Pre or post-procedure antiarrhythmic drug use was similar between the two groups. During 1-year follow-up, patients with LAAEV &lt;=33 cm/s had significantly higher rate of AF recurrence than those with LAAEV &gt;33 cm/s (55% vs 45%, P &lt;.001). Likewise, during a mean follow-up of 4.9±3.6 years, similar patterns in 5-year rates were observed for first recurrence of AF (81% vs 73%, P &lt;.001), stroke (7% vs 4%, P =.003) and mortality (31% vs 23%, P &lt;.001) for LAAEV &lt;=33 vs &gt; 33cm/s, respectively. Stepwise multivariate Cox regression analysis revealed that LAAEV &lt;=33 cm/s, age, CHA 2 DS 2 -VASc score were independent predictors of AF recurrence, stroke and mortality. Conclusions: LAA emptying flow velocity is an effective and convenient method for risk stratification of patients undergoing cardioversion for AF. Our data showed that patients with reduced LAAEV have an increased risk for AF recurrence, stroke and death following electrical cardioversion.

Shock-index as a novel predictor of long-term outcome following primary percutaneous coronary intervention.

Early identification of higher risk patients presenting with ST-elevation myocardial infarction (STEMI) and undergoing primary percutaneous coronary intervention (PPCI) will allow a more aggressive strategy and approach. The aim of this study was to evaluate the shock index (ratio of heart rate/systolic blood pressure on admission) as a predictor of mortality post PPCI in addition to other parameters. We analysed prospectively collected data on 3049 STEMI patients treated with PPCI in a large tertiary centre between March 2008-December 2011, out of which 2424 patients were aged up to 75 years (young) and 625 patients were older than 75 years (elderly). Compared to younger patients, in-hospital mortality rates were four-fold higher in the elderly (11.5% vs 2.8%, odds ratio (OR) 3.5, 95% confidence interval (CI) 2.0-5.9). Cardiogenic shock (OR 8.7 (5.1-14.6)), non-TIMI3 (Thrombosis In Myocardial Infarction) flow post percutaneous coronary intervention (PCI) (OR 5.0 (3.1-7.9)), age over 75 (OR 3.5 (2.3-5.3)) and a positive shock index pre PPCI (OR 3.5 (2.0-5.9)) were the strongest independent predictors of in-hospital mortality. For long-term outcome (median follow-up period 454 days) we excluded 141 (4.6%) patients that died during the initial hospital stay. Previous angina (hazard ratio (HR) 2.9), and previous cerebrovascular events (HR 3.7) were predictors of adverse outcome in the younger patients, while previous myocardial infarction (HR 2.0) and a positive shock index (HR 2.3) were predictors in the elderly. Cardiogenic shock prior to PPCI was not able to predict long-term outcome for in-hospital survivors. Mortality rates following PPCI were higher in elderly patients although remained acceptable. Invasively measured shock index before PPCI is the strongest independent predictor of long-term outcome in elderly patients. In addition, predictors of in-hospital mortality were similar across different age groups but differed significantly in relation to longer-term mortality.

Von Willebrand factor improves risk prediction in addition to N-terminal pro-B-type natriuretic peptide in patients referred to coronary angiography and signs and symptoms of heart failure and preserved ejection fraction.

Heart failure with preserved ejection fraction (HFpEF) represents a growing health burden associated with substantial mortality and morbidity. Consequently, risk prediction is of highest importance. Endothelial dysfunction has been recently shown to play an important role in the complex pathophysiology of HFpEF. We therefore aimed to assess von Willebrand factor (vWF), a marker of endothelial damage, as potential biomarker for risk assessment in patients with HFpEF. Concentrations of vWF were assessed in 457 patients with HFpEF enrolled as part of the LUdwigshafen Risk and Cardiovascular Health (LURIC) study. All-cause mortality was observed in 40% of patients during a median follow-up time of 9.7 years. vWF significantly predicted mortality with a hazard ratio (HR) per increase of 1 SD of 1.45 (95% confidence interval, 1.26-1.68; P<0.001) and remained a significant predictor after adjustment for age, sex, body mass index, N-terminal pro-B-type natriuretic peptide (NT-proBNP), renal function, and frequent HFpEF-related comorbidities (adjusted HR per 1 SD, 1.22; 95% confidence interval, 1.05-1.42; P=0.001). Most notably, vWF showed additional prognostic value beyond that achievable with NT-proBNP indicated by improvements in C-Statistic (vWF×NT-proBNP: 0.65 versus NT-proBNP: 0.63; P for comparison, 0.004) and category-free net reclassification index (37.6%; P<0.001). vWF is an independent predictor of long-term outcome in patients with HFpEF, which is in line with endothelial dysfunction as potential mediator in the pathophysiology of HFpEF. In particular, combined assessment of vWF and NT-proBNP improved risk prediction in this vulnerable group of patients.

A Panel to Predict Long-term Outcome of Infliximab Therapy for Patients With Ulcerative Colitis

Infliximab is effective for patients with refractory ulcerative colitis (UC), but few factors have been identified that predict long-term outcome of therapy. We aimed to identify a panel of markers associated with outcome of infliximab therapy to help physicians make personalized treatment decisions. We collected data from the first 285 patients with refractory UC (41% female; median age, 39 y) treated with infliximab before July 2012 at University Hospitals Leuven, in Belgium. We performed a Cox regression analysis to identify independent factors that predicted relapse-free and colectomy-free survival, and used these factors to create a panel of markers (risk panel). During a median follow-up period of 5 years, 61% of patients relapsed and 20% required colectomy. Independent predictors of relapse-free survival included short-term complete clinical response (odds ratio [OR], 3.75; 95% confidence interval [CI], 2.35-5.97; P < .001), mucosal healing (OR, 1.87; 95% CI, 1.17-2.98; P= .009), and absence of atypical perinuclear antineutrophil cytoplasmic antibodies (pANCA) (OR, 1.96; 95% CI, 1.23-3.12; P= .005). Independent predictors of colectomy-free survival included short-term clinical response (OR, 7.74; 95% CI, 2.76-21.68; P < .001), mucosal healing (OR, 4.02; 95% CI, 1.16-13.97; P= .028), baseline level of C-reactive protein (CRP) of 5 mg/L or less (OR, 2.95; 95% CI, 1.26-6.89; P= .012), and baseline level of albumin of 35 g/L or greater (OR, 3.03; 95% CI, 1.12-8.22; P= .029). Based on serologic analysis of a subgroup of 112 patients, levels of infliximab greater than 2.5 μg/mL at week 14 of treatment predicted relapse-free survival (P < .001) and colectomy-free survival (P= .034). A risk panel that included levels of pANCA, CRP, albumin, clinical response, and mucosal healing identified patients at risk for UC relapse or colectomy (both P < .001). Clinical response and mucosal healing were confirmed as independent predictors of long-term outcome from infliximab therapy in patients with UC. We identified additional factors (levels of pANCA, CRP, and albumin) to create a risk panel that predicts long-term outcomes of therapy. Serum levels of infliximab at week 14 of treatment also were associated with patient outcomes. Our risk panel and short-term serum levels of infliximab therefore might be used to guide therapy.

Red cell distribution width predicts short- and long-term outcomes of acute congestive heart failure more effectively than hemoglobin.

The present study compared short- and long-term prognostic values of red blood cell distribution width (RDW) with those of hemoglobin (Hgb) among patients with acute congestive heart failure (CHF) in a cardiac care unit. The cross-sectional study examined data from 521 patients with acute CHF who were admitted to a cardiac care unit and followed up for 24 months (median). Mean Hgb levels in patients who succumbed (DIH) or remained alive (AIH) were 11.0±1.8 and 11.8±2.6 g/l (P>0.05), respectively. Median values of RDW were 16.2% and 14.4%, respectively (P<0.0001). During the 24-month follow-up, mean levels of Hgb in groups with and without endpoints were 11.4±2.5 and 12.5±2.4 g/dl (P<0.0001), respectively. Median RDW values were 14.9 and 13.8%, respectively (P<0.0001). Logistic regression analysis showed that in-hospital mortality was significantly associated with RDW (P=0.044), New York Heart Association (NYHA) functional class IV (P=0.0037), estimated glomerular filtration rate (eGFR) (P=0.042) and C-reactive protein (P=0.0044), but not with Hgb (P=0.10). The multivariate Cox proportional hazard model selected RDW [hazard ratio (HR), 2.19; P<0.0001], left ventricular ejection fraction (HR 0.81, P=0.0016), age (10-year increase; HR 1.19, P=0.0017) and NYHA functional classes III/IV (HR 1.52, P=0.0029) as independent predictors of long-term outcomes after adjustment, but not Hgb (HR 1.01, P=0.86). Higher RDW values in acute CHF patients at admission were associated with worse short- and long-term outcomes and RDW values were more prognostically relevant than Hgb levels.

31 Shock-Index as a Novel Predictor of Longterm Outcome Following Primary Percutaneous Coronary Intervention

Early identification of higher risk patients presenting with ST-elevation myocardial infarction (STEMI) and undergoing primary percutaneous coronary intervention (PPCI) will allow a more aggressive strategy and approach. The aim of...

The Emerging Role of Neutrophil to Lymphocyte Ratio in Determining Colorectal Cancer Treatment Outcomes: A Systematic Review and Meta-Analysis

There is growing evidence suggesting that the neutrophil to lymphocyte ratio (NLR) can act as an independent predictor of long-term outcomes in patients undergoing treatment for colorectal cancer (CRC). This study aims to systematically review the role of NLR in predicting survival for patients with CRC undergoing treatments, and to evaluate its utility within a CRC surveillance program. This meta-analysis was performed according to PRISMA guidelines. Outcomes of interest included disease-free survival (DFS) for patients undergoing treatment with curative intent and progression-free survival (PFS) in patients undergoing treatments with palliative intent. Thirteen observational cohort studies published from 2007 to 2013 evaluated the role of NLR as a predictor of outcome following treatment for CRC. These included (i) patients undergoing surgery to resect the primary cancer (seven studies); (ii) those undergoing palliative chemotherapy (three studies); and (iii) patients undergoing potentially curative treatments for CRC liver metastases (three studies). When all studies were considered, a high pretreatment NLR independently predicted survival (HR 2.08; 95% CI 1.64-2.64). A high NLR also predicted significantly poorer survival in each of the three groups. Finally, over a 3-year follow-up period, high NLR became a significant predictor of poor outcome at year 2 (HR 2.76; 95% CI 2.06-3.69; p<0.00001) and 3 (HR 2.03; 95% CI 1.48-2.78; p<0.0001), but not in the first year of follow-up (HR 1.47; 95% CI 0.89-2.41; p=0.13). Elevated preoperative NLR is associated with poorer survival in CRC patients undergoing treatment and may have a role in CRC surveillance programs as a means of delivering more personalized cancer care.

Imaging growth and isocitrate dehydrogenase 1 mutation are independent predictors for diffuse low-grade gliomas.

We explored whether spontaneous imaging tumor growth (estimated by the velocity of diametric expansion) and isocitrate dehydrogenase 1 (IDH1) mutation (estimated by IDH1 immunoexpression) were independent predictors of long-term outcomes of diffuse low-grade gliomas in adults. One hundred thirty-one adult patients with newly diagnosed supratentorial diffuse low-grade gliomas were retrospectively studied. Isocitrate dehydrogenase 1 mutations were present in 107 patients. The mean spontaneous velocity of diametric expansion was 5.40 ± 5.46 mm/y. During follow-up (mean, 70 ± 54.7 mo), 56 patients presented a malignant transformation and 23 died. The median malignant progression-free survival and the overall survival were significantly longer in cases of slow velocity of diametric expansion (149 and 198 mo, respectively) than in cases of fast velocity of diametric expansion (46 and 82 mo; P < .001 and P < .001, respectively) and in cases with IDH1 mutation (100 and 198 mo, respectively) than in cases without IDH1 mutation (72 mo and not reached; P = .028 and P = .001, respectively). In multivariate analyses, spontaneous velocity of diametric expansion and IDH1 mutation were independent prognostic factors for malignant progression-free survival (P < .001; hazard ratio, 4.23; 95% CI, 1.81-9.40 and P = .019; hazard ratio, 2.39; 95% CI, 1.19-4.66, respectively) and for overall survival (P < .001; hazard ratio, 26.3; 95% CI, 5.42-185.2 and P = .007; hazard ratio, 17.89; 95% CI, 2.15-200.1, respectively). The spontaneous velocity of diametric expansion and IDH1 mutation status are 2 independent prognostic values that should be obtained at the beginning of the management of diffuse low-grade gliomas in adults.

Influence of Diabetes Mellitus on Long-Term Clinical and Economic Outcomes After Coronary Artery Bypass Grafting

China has the most patients with diabetes mellitus (DM) in the world and, annually, approximately 1 million Chinese become diabetic. We investigated both clinical and economic outcomes in a large Chinese cohort of diabetic patients undergoing coronary artery bypass graft surgery (CABG). All 9,240 consecutive patients who underwent isolated, primary, elective CABG between January 1999 and December 2008 were included and analyzed for long-term major adverse cardiovascular and cerebrovascular events and economic outcomes up to 2 years after the procedure. The DM patients were divided into DM subgroups controlled by diet (n= 375), medication (n=1,826) or insulin (n= 481). During the study period, the proportion of patients undergoing CABG who have DM increased from 20.1% to 31.8% in China. None of the DM subgroups wasindependently associated with in-hospital death, but DMwas an independent predictor for long-term major adverse cardiovascular and cerebrovascular events (hazard ratio 1.29, 95% confidence interval: 1.14 to 1.46). Medically controlled DM and insulin-dependent DM, but not diet-controlled DM were independent predictors of long-term outcomes after CABG. Cost for initial hospitalization was higher for DM patients (76,782 Ren Min Bi [RMB] versus 65,521 RMB, respectively; p < 0.001). At 2 years after CABG, costs for DM patients were 11,261 RMB (approximately US $1,623) higher than for non-DM patients (p < 0.001). CABG for patients with DM was significantly more expensive and was associated with worse long-term outcomes compared with non-DM patients. The rising incidence of DM, combined with the significant incremental costs represents significant clinical, economic, and social challenges for the Chinese healthcare system.

(730) - Donor Hemoglobin Is an Independent Predictor of Long-Term Outcomes in Heart Transplant - A Hypothesis Generating Preliminary Data From a Single Center

Donor characteristics such as age, LV hypertrophy, CMV status, etc have been described as prognosticators of poor outcomes post heart transplant. In spite of careful donor selection outcomes could be suboptimal suggesting possible role of other unknown variables. Donor hemoglobin has been found to impact outcomes in liver transplantation (Otmane et al, 2010). We therefore set out to determine if a similar association is present in heart transplant. Patients that underwent heart transplantation at our center from 2000-2002 were included. Retrospective review of donor data and post-transplant outcomes was performed. Univariate analysis was performed and variables with a p-value < 0.2 were included in the multivariate logistic regression analysis, and AUC determined for the significant parameters. A total of 55 patients were included in the study. Mean donor age was 34 ± 13, 75% were male, 78% were on pressors at the time of harvest, 51% expired due to trauma, 30% due to CVA and 20% due to other causes. After multivariate analysis with known donor risk factors, donor hemoglobin was a significant predictor of post-transplant 10-year death (p-value <0.05, see table). A hemoglobin <10 mg/dl had an AUC of 0.69 (p-value 0.02). Donor laboratory markers are rarely considered in organ selection criteria in heart transplantation. In our small sample study, donor hemoglobin seems to have an independent impact on long term post-transplant outcomes. This finding needs to be further confirmed by larger analysis.

Long-Term Evolution and Prognostic Stratification of Biopsy-Proven Active Myocarditis

Active myocarditis is characterized by large heterogeneity of clinical presentation and evolution. This study describes the characteristics and the long-term evolution of a large sample of patients with biopsy-proven active myocarditis, looking for accessible and valid early predictors of long-term prognosis. From 1981 to 2009, 82 patients with biopsy-proven active myocarditis were consecutively enrolled and followed-up for 147±107 months. All patients underwent clinical and echocardiographic evaluation at baseline and at 6 months. At this time, improvement/normality of left ventricular ejection fraction (LVEF), defined as a LVEF increase > 20 percentage points or presence of LVEF≥50%, was assessed. At baseline, left ventricular dysfunction (LVEF<50%) and left atrium enlargement were independently associated with long-term heart transplantation-free survival, regardless of the clinical pattern of disease onset. At 6 months, improvement/normality of LVEF was observed in 53% of patients. Persistence of New York Heart Association III to IV classes, left atrium enlargement, and improvement/normality of LVEF at 6 months emerged as independent predictors of long-term outcome. Notably, the short-term reevaluation showed a significant incremental prognostic value in comparison with the baseline evaluation (baseline model versus 6 months model: area under the curve 0.79 versus 0.90, P=0.03). Baseline left ventricular function is a marker for prognosis regardless of the clinical pattern of disease onset, and its reassessment at 6 months appears useful for assessing longer-term outcome.

Preoperative estimated glomerular filtration rate as a significant predictor of long-term outcomes after coronary artery bypass grafting in Japanese patients

PurposesThe aim of this retrospective study was to investigate the effect of chronic kidney disease (CKD) on outcomes after coronary artery bypass grafting (CABG), and to determine whether preoperative estimated glomerular filtration rate (eGFR) can be a predictor of long-term outcomes after CABG.Methods486 Japanese patients who underwent isolated CABG between December 2000 and August 2010 were evaluated. Preoperative eGFR was estimated by the Japanese equation according to guidelines from the Japanese Society of Nephrology. We defined CKD as a preoperative eGFR of less than 60 ml/min/1.73 m2. 203 patients had CKD (CK group) and 283 patients did not (N group).ResultsDuring a mean observation time of 53 months, the overall survival rate was significantly lower in the CK group than in the N group (p = 0.0044). Similarly, the CK group had significantly more unfavorable results with regard to freedom from cardiac death, major adverse cardiovascular and cerebrovascular events (MACCE), and hemodialysis. Using multivariate analyses, preoperative eGFR was an independent predictor of all-cause mortality (HR 0.983; p = 0.026), cardiac mortality (HR 0.963; p = 0.006), and incidence of MACCE (HR 0.983; p = 0.002).ConclusionsThe CK group had significantly more unfavorable outcomes than the N group. Preoperative eGFR was an independent predictor of long-term outcomes after CABG in Japanese patients.

Residual syntax score and long-term outcomes among patients who underwent CTO-PCI

Backgrounds: Although favorable outcomes have been reported, role of CTO-PCI is still controversial because of its difficult procedure and unpredictable benefit. Assessment of patients with CTO by syntax score may help to establish appropriate indication and strategy of CTO-PCI. Methods: We investigated consecutive 245 patients who underwent CTO-PCI adjunctive to medical therapy. All those patients were assessed by syntax score based on their initial angiogram. We divided them into the three groups by tertiles of SYNTAX score analysis (low score ( 32), and investigated occurrence of major adverse cardiac event (MACE) during subsequent follow-up periods. We employed residual syntax score (define as score after the PCI) for assessment of revascularization. MACE comprises from all cause death, non-fatal myocardial infarction, initially unplanned revascularization including bypass surgery. Results: Mean age (y) was 65.0±11, 65.7±10, and 69.3±10 (P=0.04). Ejection fraction (%) was 57.5±15, 55.8±15, and 51.5±16 (P=0.04). According to baseline syntax score, syntax score of each groups was 14.2±5, 25.4±4, and 44.1±10 (P<0.001), specific score at CTO site was 10.2±3, 15.2±7, and 15.4±7 (P<0.001). Procedural success rate among those groups was 85.7%, 90.8% and 80.0% (P=0.16) and their residual syntax score after the PCI was 3.5±6, 4.3±7, and 13.6±16 (P<0.0001). According to survival analysis, success of CTO-PCI was effective to reduce occurrence of MACE compared to failure cases among patients with high and intermediate syntax score, in contrast to the low syntax score group (median 769 days, success vs. failure (%); 12.4 vs. 0: P=0.967, 18.5 vs. 61.9: P=0.008, and 22.9 vs. 53.8: P=0.004). By multivariate analysis, residual syntax score after PCI was only independent predictor of occurrence of MACE (hazard ratio: 1.05, 95% confidence interval: 1.02-1.08, P=0.002). Conclusion: Independent predictor of long-term outcome among patients who underwent CTO-PCI was residual syntax score after PCI. Specific score of CTO segment may be useful to identify optimal indication of CTO-PCI, and efficacy of CTO-PCI among patients with low syntax subset needs further investigation.

Race, exercise training, and outcomes in chronic heart failure: Findings from Heart Failure - A Controlled Trial Investigating Outcomes in Exercise TraiNing (HF-ACTION)

The strength of race as an independent predictor of long-term outcomes in a contemporary chronic heart failure (HF) population and its association with exercise training response have not been well established. We aimed to investigate the association between race and outcomes and to explore interactions with exercise training in patients with ambulatory HF. We performed an analysis of HF-ACTION, which randomized 2331 patients with HF having an ejection fraction ≤35% to usual care with or without exercise training. We examined characteristics and outcomes (mortality/hospitalization, mortality, and cardiovascular mortality/HF hospitalization) by race using adjusted Cox models and explored an interaction with exercise training. There were 749 self-identified black patients (33%). Blacks were younger with significantly more hypertension and diabetes, less ischemic etiology, and lower socioeconomic status versus whites. Blacks had shorter 6-minute walk distance and lower peak VO2 at baseline. Over a median follow-up of 2.5 years, black race was associated with increased risk for all outcomes except mortality. After multivariable adjustment, black race was associated with increased mortality/hospitalization (hazard ratio [HR] 1.16, 95% CI 1.01-1.33) and cardiovascular mortality/HF hospitalization (HR 1.46, 95% CI 1.20-1.77). The hazard associated with black race was largely caused by increased HF hospitalization (HR 1.58, 95% CI 1.27-1.96), given similar cardiovascular mortality. There was no interaction between race and exercise training on outcomes (P > .5). Black race in patients with chronic HF was associated with increased prevalence of modifiable risk factors, lower exercise performance, and increased HF hospitalization, but not increased mortality or a differential response to exercise training.