Independent Predictor Of Total Mortality Research Articles

Soluble ST2, a biomarker of fibrosis, is associated with multiple risk factors, chronic diseases and total mortality in the OPERA study

Several diseases have a deleterious fibrosis component. Biomarkers indicating potential clinical utility that reliably reflect the degree of fibrosis have been introduced, one of them being soluble suppression of tumorigenicity 2 (sST2). The aim of our study was to explore the association of cardiometabolic risk factors, different diseases and total mortality with biomarker sST2 and see, how fibrosis is portrayed in these conditions. In addition, we were interested to see if sST2 levels could predict fibrosis in the long-term (21 years). The Oulu Project Elucidating Risk of Atherosclerosis (OPERA) survey collected data on the same individuals in years 1991–1993 (baseline, n = 1045), 2013–2014 (follow-up, n = 600) and mortality data until year 2019. Smoking at baseline retained a significant association with sST2 levels reflecting fibrosis development 20 years later. In the multivariate model male gender, diabetes, quick-index, levels of alanine aminotransferase (ALAT), high-density lipoprotein (HDL) cholesterol and high-sensitivity C-reactive protein (hsCRP) were associated with elevated sST2 levels at the examination 2013–2014. sST2 levels were higher among subjects suffering from cardiovascular disease (p = .031), cancer (p = .021), mild cognitive decline (p = .046) and diabetes (p < .001). Total mortality was assessed by using the Cox proportional hazard survival model analysis. sST2 (log-transformed) was an independent predictor of total mortality (HR 9.4; 95% CI 2.8–31.4, p<.001) when age, gender, diabetes, smoking, quick-index, levels of ALAT, HDL-cholesterol and hsCRP were added as covariates. In addition, elevated levels indicated worse prognosis and predicted mortality.

Prognostic influence of objective nutritional indexes on mortality after surgical aortic valve replacement in elderly patients with severe aortic stenosis (from the nutrition-SAVR trial).

Several scoring systems, such as controlling nutritional status (CONUT) score, geriatric nutritional risk index (GNRI), and prognostic nutritional index (PNI), have been previously described to show nutritional status. In the present study, we aimed to investigate the value of these scoring systems in predicting in-hospital and long-term mortality in patients undergoing surgical aortic valve replacement (SAVR). PNI, GNRI, and CONUT were determined using the receiver operator characteristicscurve analysis in 150 consecutive elderly patients (age: 70 (66-74) years, male: 78) who underwent SAVR due to degenerative severe aortic stenosis (AS). Patients were divided into two groups according to cutoff values from these indexes. During the 50 ± 31 months follow-up period, a total of 36 (24%) patients died. 30-day mortality, 1-year mortality, and total mortality were significantly higher in lower PNI, lower GNRI, and higher CONUT groups. PNI cutoff value was 49.2, GNRI cutoff value was 102.5, and CONUT cutoff value was 1.5. PNI ≤ 49.2, GNRI ≤ 102.5, and CONUT > 1.5 values were found to be independent predictors of total mortality even after risk adjustment. In addition, in the mortality group, PNI (53.7 ± 5.9 vs. 47.4 ± 6.3; p < .001) and GNRI (108 ± 10 vs. 99 ± 6.3); p < .001) were significantly lower, while CONUT score (1 [0-2] vs. 2 [0.2-3]; p < .001) was significantly higher. Objective nutritional indexes including CONUT score, PNI, and GNRI are important prognostic factors and those indexes should be part of frailty assessment in patients with severe AS.

Left Ventricular Stimulation With Electrical Latency Predicts Mortality in Patients Undergoing Cardiac Resynchronization Therapy.

This study sought to evaluate the prognostic value of the time interval from left ventricular (LV) pacing to the earliest onset of QRS complex (S-QRS) for long-term clinical outcomes in patients who underwent cardiac resynchronization therapy (CRT). The electrical latency during LV pacing evaluated by S-QRS is associated with local tissue property, and the S-QRS ≥37ms has been previously proposed as an independent predictor of mechanical response to CRT. This study included 82 consecutive patients with heart failure with reduced LV ejection fraction (≤35%) and a wide QRS complex (≥120ms) who underwent CRT. Patients were divided into a short S-QRS group (SS-QRS;<37ms) and a long S-QRS group (LS-QRS;≥37ms). The primary endpoint was total mortality, including LV assist device implantation or heart transplantation, whereas the secondary endpoint was total mortality or HF hospitalization. S-QRS was 25.9 ± 5.3ms in SS-QRS and 51.5 ± 13.7ms in LS-QRS (p<0.01), and baseline QRS duration and electrical activation at the LV pacing site (i.e., Q-LV) were similar. During mean follow-up of 44.5 ± 21.1months, 24patients (29%) reached the primary endpoint, whereas the secondary endpoints were observed in 47 patients (57%). LS-QRS had significantly worse event-free survival for both endpoints. LS-QRS was an independent predictor of total mortality (hazard ratio: 2.6; 95% confidence interval: 1.11 to 6.12; p=0.03) and the secondary composite events (hazard ratio: 2.4; 95% confidence interval: 1.31 to 4.33; p<0.01). The S-QRS ≥37ms at the LV pacing site was a significant predictor of total mortality and HF hospitalization. S-QRS-guided optimal LV lead placement is critical in patients who receive CRT.

Abstract 12719: Diagnostic and Prognostic Contributions of Cardiac Computed Tomography for Infective Endocarditis Surgery

Background: Cardiac computed tomography (CT) is emerging as an adjunctive modality to echocardiography in the evaluation of infective endocarditis (IE) and surgical planning. CT studies in IE have, however, focused on its diagnostic rather than prognostic utility, the latter of which is important in high-risk diseases like IE. We evaluated the associations between cardiac CT and transesophageal echocardiography (TEE) findings and adverse outcomes after IE surgery. Methods: Of 833 consecutive patients with surgically proven IE during 5/1/2014-5/1/2019 at Cleveland Clinic, 155 underwent both pre-operative ECG-gated contrast-enhanced CT and TEE. Multivariable analyses were performed to identify CT and TEE biomarkers that predict adverse outcomes after IE surgery, adjusting for EuroSCORE II. Results: CT and TEE were positive for IE in 123 (75.0%) and 124 (75.6%) of patients respectively. CT identified an additional 11% of vegetations, 13% of pseudoaneurysms or abscesses, 5% of dehiscences and 14% of fistulae when TEE was negative. Thirty-day mortality occurred in 3 (1.9%) patients, and composite mortality and/or morbidities in 72 (46.5%). Pseudoaneurysm or abscess detected on TEE was the only imaging biomarker to show independent association with composite mortality and/or morbidities in-hospital, with odds ratio (95%CI) of 3.66 (1.76-7.59), P=0.001. There were 17 late deaths, and both pseudoaneurysm or abscess detected on CT and fistula detected on CT were the only independent predictors of total mortality during follow-up, with hazards ratios (95%CI) of 3.82 (1.25, 11.7), P&lt;0.001 and 9.84 (1.89, 51.0), P=0.007 respectively (Figure). Conclusion: We identified cardiac CT and TEE features that predicted separate adverse outcomes after IE surgery. Imaging biomarkers can play important roles incremental to conventional clinical factors for risk stratification in patients undergoing IE surgery.

Time interval from left ventricular stimulation to QRS onset is a predictor of mortality in patients with cardiac resynchronization therapy

Abstract Introduction In our previous report, the time interval from left ventricular (LV) pacing to the earliest onset of QRS (S-QRS interval) has been found to be an independent predictor of mechanical response to cardiac resynchronization therapy (CRT). The S-QRS interval may indicate the conduction disturbance relevant to the localized tissue property such as scar or fibrotic lesion. Therefore, S-QRS interval longer than 37ms was associated with poor response to CRT, and proposed as suboptimal LV lead position. Then, we hypothesized that the longer S-QRS interval at the LV pacing site could be related to long term mortality and heart failure events in patients with CRT. Methods This retrospective study included 82 consecutive heart failure patients with sinus rhythm, reduced LV ejection fraction (≤35%), and a wide QRS complex (≥120ms), who undergone CRT implantation between 2012 January and 2017 December. Patients were divided into Short S-QRS group (&amp;lt;37ms, SS-QRS) and Long S-QRS group (≥37ms, LS-QRS) according to the previously reported optimal cut off value. A responder was defined as one with ≥15% reduction in LV end-systolic volume assessed by echocardiography at 6 months after CRT. The primary endpoint was total mortality, which included LV assist device implantation or heart transplantation. The secondary endpoints included the composite endpoint of total mortality or heart failure hospitalization. Results The study patients were divided into SS-QRS (N=43, age 65.9±13.2 years, 77% male) and LS-QRS (N=39, age 63.0±13.4, 85% male). In the electrocardiographic measurements, there were no significant differences in baseline QRS duration (162.4±30.3ms in SS-QRS vs. 154.5±31.6ms in LS-QRS, P=0.19) and LV local activation time assessed as Q-LV interval (118.3±34.3ms in SS-QRS vs. 115.3±32.0ms in LS-QRS, P=0.71). S-QRS interval was 25.9±5.3ms in SS-QRS and 51.5±13.7ms in LS-QRS (P&amp;lt;0.01), and the responder rate was significantly higher in SS-QRS compared with LS-QRS (79% vs. 29%, P&amp;lt;0.01). During mean follow up of 47.7±22.4 months, 24 patients (29%) reached to the primary endpoint, while the secondary endpoints were observed in 47 patients (57%). LS-QRS patients had significantly worse event-free survival for both primary and secondary endpoints (Figure). After the multivariate Cox regression analysis, LS-QRS (≥37ms) was an independent predictor of total mortality (HR=2.6, 95% CI: 1.11 to 6.12, P=0.03) and the secondary composite events (HR=2.4, 95% CI: 1.31 to 4.33, P&amp;lt;0.01). Conclusion The S-QRS interval longer than 37ms, which may reflect the conduction disturbance relevant to the scar or fibrotic lesion at the LV pacing site, was a significant predictor of the total mortality and heart failure hospitalization. These findings have implications for the optimal LV lead placement in patients with CRT device. Clinical outcomes according to S-QRS Funding Acknowledgement Type of funding source: None

Complementary Diagnostic and Prognostic Contributions of Cardiac Computed Tomography for Infective Endocarditis Surgery.

Cardiac computed tomography (CT) is emerging as an adjunctive modality to echocardiography in the evaluation of infective endocarditis (IE) and surgical planning. CT studies in IE have, however, focused on its diagnostic rather than prognostic utility, the latter of which is important in high-risk diseases like IE. We evaluated the associations between cardiac CT and transesophageal echocardiography (TEE) findings and adverse outcomes after IE surgery. Of 833 consecutive patients with surgically proven IE during May 1, 2014 to May 1, 2019, at Cleveland Clinic, 155 underwent both preoperative ECG-gated contrast-enhanced CT and TEE. Multivariable analyses were performed to identify CT and TEE biomarkers that predict adverse outcomes after IE surgery, adjusting for EuroSCORE II (European System for Cardiac operative Risk Evaluation II). CT and TEE were positive for IE in 123 (75.0%) and 124 (75.6%) of patients, respectively. Thirty-day mortality occurred in 3 (1.9%) patients and composite mortality or morbidities in 72 (46.5%). Pseudoaneurysm or abscess detected on TEE was the only imaging biomarker to show independent association with composite mortality or morbidities in-hospital, with odds ratio (95% CI) of 3.66 (1.76-7.59), P=0.001. There were 17 late deaths, and both pseudoaneurysm or abscess detected on CT and fistula detected on CT were the only independent predictors of total mortality during follow-up, with hazards ratios (95% CI) of 3.82 (1.25-11.7), P<0.001 and 9.84 (1.89-51.0), P=0.007, respectively. We identified cardiac CT and TEE features that predicted separate adverse outcomes after IE surgery. Imaging biomarkers can play important roles incremental to conventional clinical factors for risk stratification in patients undergoing IE surgery.

The Effect of Thyroid Stimulating Hormone Level Within the Reference Range on In-Hospital and Short-Term Prognosis in Acute Coronary Syndrome Patients.

Background and objectives: Despite being within the normal reference range, changes in thyroid stimulating hormone (TSH) levels have negative effects on the cardiovascular system. The majority of patients admitted to hospital with acute coronary syndrome (ACS) are euthyroid. The aim of this study was to investigate the effect of TSH level on the prognosis of in-hospital and follow-up periods of euthyroid ACS patients. Materials and Methods: A total of 629 patients with acute coronary syndrome without thyroid dysfunction were included in the study. TSH levels of patients were 0.3–5.33 uIU/mL. Patients were divided into three TSH tertiles: TSH level between (1) 0.3 uIU/mL and <0.90 uIU/mL (n = 209), (2) 0.90 uIU/mL and <1.60 uIU/mL (n = 210), and (3) 1.60 uIU/mL and 5.33 uIU/mL (n = 210). Demographic, clinical laboratory, and angiographic characteristics were compared between groups in terms of in-hospital and follow-up prognosis. Results: Mean age was 63.42 ± 12.5, and 73.9% were male. There was significant difference between tertiles in terms of TSH level at admission (p < 0.001), the severity of coronary artery disease (p = 0.024), in-hospital mortality (p < 0.001), in-hospital major hemorrhage (p = 0.005), total adverse clinical event (p = 0.03), follow-up mortality (p = 0.022), and total mortality (p < 0.001). In multivariate logistic regression analysis, the high–normal TSH tertile was found to be cumulative mortality increasing factor (OR = 6.307, 95%; CI: 1.769–22.480; p = 0.005) during the 6-month follow-up period after hospitalization and discharge. Conclusions: High–normal TSH tertile during hospital admission in euthyroid ACS patients is an independent predictor of total mortality during the 6-month follow-up period after hospitalization and discharge.

Periodic repolarization dynamics as a risk predictor after myocardial infarction: Prospective validation study

Periodic repolarization dynamics (PRD) is a novel electrocardiographic phenomenon that refers to sympathetic activity-associated low-frequency modulations of cardiac repolarization. Retrospective post-myocardial infarction (MI) studies revealed that increased PRD indicates an increased risk of subsequent death. This is the first prospective study to validate PRD in patients after MI receiving up-to-date treatment. Four hundred fifty-five survivors of MI (age ≤80 years) in sinus rhythm were enrolled. PRD was assessed from 20-minute electrocardiographic recordings (2048 Hz) and prospectively dichotomized at 5.75 deg2. Primary and secondary end points were total mortality and cardiovascular mortality, respectively. Multivariable analyses additionally included Global Registry of Acute Coronary Events score (dichotomized at >140), left ventricular ejection fraction (dichotomized at ≤35%), diabetes mellitus, and deceleration capacity of heart rate (dichotomized at ≤2.5ms). The prognostic power of PRD was evaluated using receiver operating characteristic curve analysis, Cox regression analysis, and the integrated discrimination improvement index. During a median follow-up period of 27 months, 47 patients died. Twenty-three of these deaths were classified as cardiovascular. Increased PRD was significantly associated with both end points, yielding areas under receiver operating characteristic curves of 69.3% (60.2%-77.8%) and 79.1% (69.7%-86.7%) for total mortality and cardiovascular mortality, respectively (P < .001 for both). In multivariable analysis, increased PRD indicated a 2.2- and 9.5-fold risk of total mortality and cardiovascular mortality (P = .024 and P = .003, respectively). Addition of PRD to the models significantly improved the integrated discrimination improvement index for total (P = .047) and cardiovascular mortality (P = .007). PRD is a strong and independent predictor of total mortality and cardiovascular mortality in patients after MI treated with contemporary therapy.

Combined value of left ventricular ejection fraction and the Model for End-Stage Liver Disease (MELD) score for predicting mortality in patients with acute coronary syndrome who were undergoing percutaneous coronary intervention

BackgroundThe purpose of the study was to investigate whether the addition of left ventricular ejection fraction (LVEF) to the MELD score enhances the prediction of mortality in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI).MethodsThis retrospective study analyzed 846 consecutive patients with ACS undergoing PCI who were not receiving previous anticoagulant therapy. The patients were grouped as survivors or non-survivors. The MELD score and LVEF were calculated in all patients. The primary end point was all-cause death during the median follow-up of 28 months.ResultsDuring the follow-up, there were 183 deaths (21.6%). MELD score was significantly higher in non-survivors than survivors (10.1 ± 4.4 vs 7.8 ± 2.4, p < 0.001). LVEF was lower in non-survivors compared with survivors (41.3 ± 11.8% vs. 47.5 ± 10.0%, p < 0.001). In multivariate analysis, both MELD score and LVEF were independent predictors of total mortality. (HR: 1.116, 95%CI: 1.069–1.164, p < 0.001; HR: 0.972, 95%CI: 0.958–0.986, p < 0.001, respectively). The addition of LVEF to MELD score was associated with significant improvement in predicting mortality compared with the MELD score alone (AUC:0.733 vs 0.690, p < 0.05). Also, the combining LVEF with MELD score improved the reclassification (NRI:24.6%, p < 0.001) and integrated discrimination (IDI:0.045, p < 0.001) of patients compared with MELD score alone.ConclusionsOur study demonstrated that the combining LVEF with MELD score may be useful to predict long-term survival in patients with ACS who were undergoing PCI.

Cardiac surgery in patients with end-stage renal disease on dialysis

:Objectives. Over the past decade, the number of patients on dialysis and with cardiovascular diseases has steadily increased. This retrospective analysis compares the postoperative mortality after cardiac surgery between patients on hemodialysis and peritoneal dialysis. Methods. Between 1998 and 2015, 136 patients with end-stage renal disease initiating dialysis more than one month before surgery underwent cardiac surgery. Demographics, preoperative hemodynamic and biochemical data were collected from the patient records. Vital status and date of death was retrieved from a national register. Results. Hemodialysis was undertaken in 73% and peritoneal dialysis in 22% of patients aged 59.7 ± 12.9 years, mean EuroSCORE 8.6% ± 3.5. Isolated coronary artery bypass graft was performed in 46%, isolated valve procedure in 29% and combined procedures in 24% with no significant statistical difference between groups. The 30-day mortality was 14% for hemodialysis patients and 3% for peritoneal dialysis patients (p = .056). One-year and 5-year mortality were, 30% and 59% in the hemodialysis group, 30% and 57% in the peritoneal dialysis group (p = .975, p = .852). Independent predictors of total mortality were age (p = .001), diabetes (p = .017) and active endocarditis (p = .012). Conclusion. No statistically significant difference in mortality was found between patients in hemo- or peritoneal dialysis. However, we observed that patients with end-stage renal disease on dialysis have two times higher mortality rate than estimated by EuroSCORE.

Excess Pressure Integral Predicts Long-Term All-Cause Mortality in Stable Heart Failure Patients.

Excess pressure integral (XSPI) derived from reservoir-excess pressure analysis is proposed as a novel indicator of cardiovascular dysfunction in hypertensives. Our study investigated the prognostic value of XSPI for stable heart failure (HF) patients. In total, 238 subjects (mean age 63 ± 18 years, 111 male), comprising 168 stable HF patients with either reduced (SHF; n = 64) left ventricular (LV) ejection fraction (EF) or isolated diastolic dysfunction (DHF, n = 104), and 70 healthy controls, were enrolled. Tonometry-derived carotid pressure waveforms were analyzed with the reservoir pressure theory. XSPI was calculated by subtracting the reservoir pressure from carotid pressure waveform. XSPI in SHF and DHF (14.01 ± 5.16 and 13.90 ± 5.05 mm Hg•s) were significantly higher than that in controls (11.01 ± 3.67 mm Hg•s, both P < 0.001). During a median follow-up of 9.9 years, 56 deaths occurred. XSPI was a significant independent predictor of total mortality after adjusting for age, sex, left ventricular ejection fraction (LVEF), glomerular filtration rate (GFR), and N-terminal pro-B-type natriuretic peptide (NT-proBNP) (hazard ratio = 4.37 per 1 SD, 95% confidence interval, 1.31-14.58). In subgroup analysis by different baseline characteristics including age, gender, NT-proBNP, LVEF, and GFR, higher XSPI was consistently associated with greater risk of total mortality. In patients with stable HF, XSPI, a novel maker of cardiovascular dysfunction, was associated with long-term risk of total mortality.

Deceleration capacity: A novel predictor for total mortality in patients with non-ischemic dilated cardiomyopathy

ObjectivesWe hypothesized that deceleration capacity (DC), a novel marker of cardiac autonomic modulation, is an independent predictor for mortality in patients with non-ischemic dilated cardiomyopathy (NICM). BackgroundNICM is associated with a high risk for sudden cardiac death (SCD). However there are no clinically established parameters available for risk stratification beyond LVEF.DC has been previously shown to be a strong independent predictor for total mortality in patients after myocardial infarction. MethodsHolter-ECG recordings of 201 patients NICM (83.1% male, mean age: 61.4years, mean LVEF: 33.3%) were analyzed by the method of phase-rectified-signal-averaging (PRSA) to obtain DC. ResultsDuring a minimum follow-up of 40month 59 patients died. Kaplan Meyer Analysis showed a significantly higher mortality in patients with a DC below 4.5ms (log rank p=0.012) irrespective to the presence of atrial fibrillation. ConclusionsImpaired DC is a powerful independent predictor for mortality in patients with NICM.

The Prognostic Impact of In-Hospital Change in Mean Platelet Volume in Patients With Non-ST-Segment Elevation Myocardial Infarction.

It is unclear whether changes in mean platelet volume (MPV) are associated with total mortality in acute coronary syndromes. We investigated whether the change in MPV predicts total mortality in patients with non-ST-segment elevation myocardial infarction (NSTEMI). We retrospectively analyzed 419 consecutive patients (19 patients were excluded). The remaining patients were categorized as survivors (n = 351) or nonsurvivors (n = 49). Measurements of MPV were performed at admission and after 24 hours. The difference between the 2 measurements was considered as the MPV change (ΔMPV). The end point of the study was total mortality at 1-year follow-up. During the follow-up, there were 49 deaths (12.2%). Admission MPV was comparable in the 2 groups. However, both MPV (9.6 ± 1.4 fL vs 9.2 ± 1.0 fL, P = .044) and ΔMPV (0.40 [0.10-0.70] fL vs 0.70 [0.40-1.20] fL, P < .001) at the first 24 hours were higher in nonsurvivors than survivors. In multivariate analysis, ΔMPV was an independent predictor of total mortality (odds ratio: 1.84, 95% confidence interval: 1.28-2.65, P = .001). An early increase in MPV after admission was independently associated with total mortality in patients with NSTEMI. Such patients may need more effective antiplatelet therapy.

Red Cell Distribution Width and the Risk of Mortality in Patients With Acute Heart Failure With or Without Cardiorenal Anemia Syndrome

Red cell distribution width (RCDW) has not been fully investigated for its prognostic impact in patients with acute heart failure (AHF) with or without the cardiorenal anemia syndrome (CRAS). A total of 978 patients (age 75 ± 14 years, 70% men, 43% with CRAS) hospitalized for AHF were enrolled. During a median follow-up duration of 31 months, 472 subjects (48%) died. The postdischarge mortality was positively associated with the increasing RCDW. After accounting for age, gender, co-morbidities, hemoglobin, renal function, sodium level, and N-terminal probrain natriuretic peptide, RCDW remained an independent predictor of mortality (hazard ratio [HR] and 95% CI for a 1% increase of RCDW: 1.09, 1.00 to 1.17, p = 0.04). In the subgroups of patients with or without CRAS, RCDW was an independent predictor of total mortality for both subgroups (HR 1.05, 95% CI 1.00 to 1.10 and HR 1.11, 95% CI 1.07 to 1.15, respectively). In conclusion, elevated RCDW was independently associated with mortality in patients hospitalized for AHF, with or without CRAS.

Reduced Irregularity of Ventricular Response During Atrial Fibrillation and Long-term Outcome in Patients With Heart Failure

Reduced heart rate variability (HRV) is associated with poor outcome in patients with heart failure (HF). However, the data on predictive value of RR variability during atrial fibrillation (AF) are limited. Therefore, the aim of this study was to evaluate the association between ventricular response characteristics and long-term clinical outcome in the population of ambulatory patients with mild-to-moderate HF and AF at baseline. The study included 155 patients (mean age 69 ± 10years) with AF at 20-minute Holter electrocardiographic (ECG) recordings at enrollment. HRV analysis included SDNN, rMSSD, and pNN50, whereas irregularity indexes included 2 nonlinear parameters: approximate entropy (ApEn) and Shannon entropy. After median 41months of follow-up, 54 patients died, including 21 HF related and 16 sudden deaths. Patients with ApEn ≤1.68 (lower tertile) had 40% mortality versus 12% in others (p <0.001) at 2years of follow-up. Only nonlinear HRV parameters (irregularity but not variability indexes) identified patients at higher risk during follow-up. Decreased ApEn ≤1.68 was an independent predictor of total mortality (hazard ratio [HR] 2.81, 95% confidence interval [CI] 1.61 to 4.89, p <0.001), sudden cardiac death (HR 3.83, 95% CI 1.31 to 11.25, p= 0.014), and HF death (HR 3.45, 95% CI 1.42 to 8.38, p= 0.006) in a multivariate Cox analysis. In conclusion, in a post hoc analysis of Muerte Subita en Insufficiencia Cardiaca study AF cohort, reduced irregularity of RR intervals during AF, likely caused by autonomic dysfunction, was an independent predictor of all-cause mortality and sudden death and HF progression in patients with mild-to-moderate HF, whereas traditional HRV indexes did not predict outcome.

Analysis of acute myocardioal infarction complicated with cardiogenic shock due to unprotected left-main coronary artery disease

Objective To analyze the clinical characteristics and prognosis of the patients with acute myocardial infarction (AMI) complicated with cardiogenic shock (CS) due to unprotected left-main coronary artery (ULMCA) disease. Methods From January 1999 to May 2014, 5 798 emergency coronary angiographies were performed. The AMI patients with infarction of related artery of ULMCA conformed by angiography were enrolled. Clinical characteristics and prognosis of the patients were studied. The patients were divided into two groups according to the occurrence of CS during hospitalization. The interventional data and outcome during short term and long term followed up were compared between the two groups. The causes of CS and mortality were analyzed. Results Fifty-eight patients were enrolled, and CS occurred in 31 patients (53.4%). Compared with CS free group, left ventricular ejection fraction, occurrence of TIMI grade 2-3 during diagnostic angiography, collateral circulation with Rentrop grade 2-3 and final flow of TIMI grade 3 were lower in the group with CS. Logistic analysis revealed poor collateral circulation (less than Rentrop grade 2) was related with occurrence of CS (OR=0.19, P=0.02). Twenty-three patients died in hospital, and the mortality in CS group was higher than that in the group without CS (64.5%vs. 11.1%, P <0.01). CS was confirmed as a powerful predictor of in-hospital mortality by Logistic analysis (OR=6.94, P=0.01). Long term follow up was performed in the 35 survivors with the duration of median time of 42.0 (12.0, 60.0) months. The accumulative total survival rate was 20.3% in patients with CS and 51.8% in patients without CS (Log-rank, P <0.01). Multivariable COX regression analysis revealed the only independent predictor of total mortality during long-term follow up was CS during hospitalization (HR=4.67, P=0.004). Conclusions AMI due to ULMCA disease was critically risky with high incidence of CS. The short term and long term prognosis of these patients with AMI caused by ULMCA disease complicated with CS was poor. Key words: Acute myocardial infarction; Cardiacgenic shock; Left-main coronary artery; Percutaneous coronary intervention

Prediction of mortality by stress echocardiography in 2835 diabetic and 11 305 nondiabetic patients.

To compare the capability by stress echocardiography results to predict overall mortality in a large unselected cohort of diabetic and nondiabetic patients. The study group comprised 14 140 patients (2835 diabetics and 11 305 nondiabetics) who underwent stress echocardiography for evaluation of known (n=5671) or suspected (n=8469) coronary artery disease. Ischemia at stress echocardiography was observed in 768 (27%) diabetics and 2644 (23%) nondiabetics. During a median follow-up of 30 months (first quartile, 9; third quartile, 63), 1213 patients died. In diabetics, multivariable indicators of mortality were age (hazard ratio [HR], 1.07, 95% confidence interval [CI], 1.06-1.09), rest wall motion abnormality (HR, 2.43; 95% CI, 1.83-3.22), and ischemia at stress echocardiography (HR, 1.71; 95% CI, 1.34-2.18). In nondiabetics, multivariable indicators of mortality were age (HR, 1.07; 95% CI, 1.06-1.08), rest wall motion abnormality (HR, 2.19; 95% CI, 1.86-2.57), male sex (HR, 1.65; 95% CI, 1.41-1.93), ischemia at stress echocardiography (HR, 1.54; 95% CI, 1.32-1.80), and antischemic therapy at the time of test (HR, 1.15; 95% CI, 1.00-1.32). In stress echo negative subjects for ischemia, antischemic therapy showed increased annual mortality in nondiabetic patients with (3.8% versus 3.1%; P=0.04) or without rest wall motion abnormality (1.6% versus 0.9%; P<0.0001); it failed to do so in diabetic patients with (5.7% versus 5.8%; P=0.89) or without rest wall motion abnormality (2.6% versus 1.9%; P=0.10). Ischemia at stress echocardiography is a strong and independent predictor of total mortality in diabetic as well as nondiabetic patients. Antischemic therapy markedly affects the negative predictive value of stress echocardiography in nondiabetic patients, whereas it is prognostically neutral in the diabetic population.

Long-term prognosis of complete percutaneous coronary revascularisation in patients with diabetes with multivessel disease

ObjectiveThere is a paucity of data on the impact of complete revascularisation (CR) following percutaneous coronary intervention (PCI) among patients with diabetes with multivessel coronary disease. In this study, we...

Prevalence and Prognosis of Percutaneous Coronary Intervention-associated Nephropathy in Patients With Acute Coronary Syndrome and Normal Kidney Function

Introduction and objectivesThe aim of this study was to analyze the prevalence, risk factors, and short- and long-term prognosis of patients with acute coronary syndrome and normal renal function who developed percutaneous coronary intervention-associated nephropathy. MethodsThis was an observational, retrospective, single-center study with a prospective follow-up of 470 consecutive patients hospitalized for acute coronary syndrome (not in cardiogenic shock) who underwent percutaneous coronary intervention, with no preexisting renal failure (admission creatinine ≤ 1.3mg/dL). Percutaneous coronary intervention-associated was defined as an increase in baseline creatinine ≥ 0.5 mg/dL or ≥ 25% baseline. The mean follow-up was 26.7 (14) months. ResultsOf the 470 patients, 30 (6.4%) developed percutaneous coronary intervention-associated nepfhropathy. The independent predictors for acute renal failure were admission hemoglobin level (odds ratio = 0.71) and maximum troponin I level prior to the procedure (odds ratio = 1.02). During the long-term follow-up, the patients whose renal function deteriorated had a higher incidence of total mortality (5 [16.7%] vs 27 [6.1%]; P = .027). In the Cox regression analysis, percutaneous coronary intervention-associated nepfhropathy was not an independent predictor for total mortality, but could be a predictor for cardiac mortality (hazard ratio=5.4; 95% confidence interval 1.35-21.3; P = .017). ConclusionsPercutaneous coronary intervention-associated nephropathy in patients with acute coronary syndrome and normal preexisting renal function is not uncommon and influences long-term survival.

Prevalencia y pronóstico de la nefropatía tras intervencionismo coronario percutáneo de pacientes con síndrome coronario agudo y función renal normal

Introduction and objectivesThe aim of this study was to analyze the prevalence, risk factors, and short- and long-term prognosis of patients with acute coronary syndrome and normal renal function who developed percutaneous coronary intervention-associated nephropathy. MethodsThis was an observational, retrospective, single-center study with a prospective follow-up of 470 consecutive patients hospitalized for acute coronary syndrome (not in cardiogenic shock) who underwent percutaneous coronary intervention, with no preexisting renal failure (admission creatinine ≤ 1.3mg/dL). Percutaneous coronary intervention-associated nephropathy was defined as an increase in baseline creatinine ≥ 0.5mg/dL or ≥ 25% baseline. The mean follow-up was 26.7 (14) months. ResultsOf the 470 patients, 30 (6.4%) developed percutaneous coronary intervention-associated nepfhropathy. The independent predictors for acute renal failure were admission hemoglobin level (odds ratio=0.71) and maximum troponin I level prior to the procedure (odds ratio=1.02). During the long-term follow-up, the patients whose renal function deteriorated had a higher incidence of total mortality (5 [16.7%] vs 27 [6.1%]; P=.027). In the Cox regression analysis, percutaneous coronary intervention-associated nepfhropathy was not an independent predictor for total mortality, but could be a predictor for cardiac mortality (hazard ratio=5.4; 95% confidence interval 1.35-21.3; P=.017). ConclusionsPercutaneous coronary intervention-associated nephropathy in patients with acute coronary syndrome and normal preexisting renal function is not uncommon and influences long-term survival.Full English text available from:www.revespcardiol.org/en