Independent Predictor Of 12-month Mortality Research Articles

The utility of the surprise question by nurses to identify hospitalised older patients nearing the end-of-life and promotion of advance care planning: An interventional study.

To assess the prognostic accuracy of the surprise question (SQ) when used by nurses working in hospital wards to determine 1-year mortality in acutely hospitalised older patients. The predictive accuracy of the SQ, when used by general nurses caring for older hospitalised patients, has not been comprehensively studied. A prospective cohort study. This cohort study recruited consecutive 10,139 older patients (aged ≥65 years) who were admitted to Taipei City Hospital and were evaluated for the needs of palliative care in 2015. All patients were followed up for 12 months or until their death. The c-statistic value was calculated to indicate the predictive accuracy of the SQ and Palliative Care Screening Tool (PCST). Of all participants, 18.8% and 18.6% had a SQ response of 'no' and a PCST score ≥4, respectively. After controlling for other covariates, an SQ response of 'no' (adjusted hazard ratio [aHR], 2.05; 95% confidence interval [CI], 1.83-2.31) and a PCST score ≥4 (AHR = 1.50; 95% CI: 1.29-1.75) were found to be the independent predictors for patients' 12-month mortality. The C-statistic values of the SQ and the PCST at recognising patients in their last year of life were .663 and .670, respectively. Moreover, there was moderate concordance (k = .44) between the SQ and the PCST in predicting 12-month mortality. SQ response of 'no' and a PCST score ≥4 were independent predictors of 12-month mortality in older patients. The SQ, when used by nurses working in hospital wards, is effective in identifying older patients nearing the end of life, as well as in providing advance care planning for patients. Patients' palliative care needs at admission were assessed by general nurses using the SQ and PCST.

Differences in clinical characteristics and mortality of de novo acute heart failure and acutely decompensated chronic heart failure: A prospective cohort study

Background: Acute heart failure carries a high risk of mortality. Understanding the characteristics and outcomes of acute heart failure subgroups may have important implications for clinical risk stratification. Objective: We examined the clinical characteristics and rates of the 12-month all-cause mortality in a cohort of patients hospitalized with acute heart failure according to heart failure duration new-onset or de novo acute heart failure and acutely decompensated chronic heart failure (ADCHF). Methods and Materials: The cohort study, with a 12-month followup, was conducted at Nhan Dan Gia Dinh Hospital in Vietnam from February 2022 to October 2023. Results: Among 316 patients with acute heart failure, 159 patients (50%) were admitted presenting de novo AHF, while the remaining 157 patients (50%) exhibited ADCHF. Patients with ADCHF were characterized by a higher proportion of elders, comorbidities including chronic kidney disease and atrial fibrillation, and a larger left atrial diameter than those with de novo acute heart failure. The rates of mortality in patients with ADCHF were 1.69 times more than in patients with de novo acute heart failure (the hazard ratio (HR): 1.69 (The 95% confidence interval (CI 95%): 1.10 - 2.60, p = 0.016). However, patients with ADCHF had not an independent predictor of 12-month mortality after adjusting factors in multivariable Cox regression models, including age, chronic pulmonary disease, diabetes mellitus, coronary heart disease, atrial fibrillation, sodium, hemoglobin, N-terminal prohormone BNP (NT-proBNP). Conclusions: Among patients hospitalized with acute heart failure, acutely decompensated chronic heart failure was associated with poorer outcomes.

Observational, multicenter registry of Impella-assisted high-risk percutaneous coronary interventions and cardiogenic shock in Poland (IMPELLA-PL): efficacy and safety outcomes

Abstract Introduction Impella (Abiomed, Danvers, MA, USA) is the smallest and the least invasive mechanical circulatory support device used in the setting of cardiogenic shock (CS) and high-risk percutaneous coronary interventions (HR-PCI). Data regarding the efficacy and safety of Impella in the real-life setting are urgently needed. Purpose The main goal of the IMPELLA-PL registry is to evaluate the efficacy and safety of Impella in patients with CS and undergoing HR-PCI, identify independent predictors of in-hospital and 12-month outcomes and compare it with other registries. Methods IMPELLA-PL is a national, multicentre, retrospective registry including consecutive patients treated with Impella for CS and high-risk PCI in 20 Polish interventional cardiological centres from January 2014 until December 2021, with 12-month follow-up until December 2022. The main efficacy and safety endpoints included (i) in-hospital mortality, (ii) 12-month mortality, (iii) 12-month rate of major adverse cardiovascular events (MACE) following hospital discharge, evaluated according to the prespecified definitions. Results A total of 308 patients were enrolled in the registry: 55 had CS (56.4%) and 253 underwent HR-PCI (43.6%). In the CS group, in-hospital mortality rate was 76.4%, 12-month mortality rate was 80.0% and post-discharge MACE rate was 9.1%. Device-related complications included access site bleeding (30.9%), limb ischaemia (12.7%) and haemolysis (10.9%). In the HR-PCI group, in-hospital mortality rate was 8.3%, 12-month mortality rate was 18.2% and MACE rate post-discharge was 22.5%. Device-related complications included access site bleeding (14.6%), limb ischaemia (2.4%) and haemolysis (1.6%). The independent predictors of 12-month mortality included atrial fibrillation (OR 3.50, 95% CI 1.38-8.95), chronic kidney disease (OR 2.77, 95% CI 1.06-7.26). Conclusions The mortality and complications rate in patients with CS remains high, despite the use of Impella, and higher than reported in other registries. The mortality and complications rate in patients undergoing HR-PCI is acceptable and consistent with other registries.

The effect of ethnicity and social deprivation on outcomes after resuscitated out-of-hospital cardiac arrest

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): This work was part funded by King’s College Hospital R&D Grant and was supported by the Department of Health via a National Institute for Health Research Biomedical Research Centre award to Guy’s & St Thomas’ NHS Foundation Trust in partnership with King’s College London and King’s College Hospital NHS Foundation Trust. Background Out-of-hospital cardiac arrest (OOHCA) is a common cause of morbidity and mortality. There is substantial ethnic variation in OOHCA outcomes, though it is unclear if these discrepancies are due to arrest circumstances or socioeconomic and biological factors. Purpose To investigate the association of ethnicity, social deprivation and co-morbidities with rates of coronary artery disease, subsequent treatment and outcome in resuscitated OOHCA patients with primary cardiac aetiology. Methods 526 patients with resuscitated OOHCA of suspected cardiac aetiology were included in the study registry between 1-May-2012 and 31-December-2020. Ethnicity, social deprivation, arrest circumstances, comorbidities and extent of coronary artery disease (CAD) were measured. The primary endpoint was 12-month mortality. Results Of 526 patients (median age 62.0±21.1, 74.1% male), 78.1% had shockable rhythms, 83.6% were witnessed and 77.6% had bystander cardiopulmonary resuscitation (CPR). 414 patients (78.7%) were White, 35 (6.7%) were Asian, and 77 (14.6%) were Black. Black patients had more co-existent hypertension and cardiomyopathy, but less prior coronary revascularisation compared with White/Asian patients. There were no ethnic differences in location, witnesses, or bystander CPR, but Black patients had more non-shockable rhythms. Admission serum lactate and creatinine levels were higher in Black patients, but troponin levels were lower than in White/Asian patients. Black patients received less immediate coronary angiography (CAG) and percutaneous coronary intervention (PCI), but had lower rates of CAD, with less CAD complexity (lower SYNTAX and Jeopardy scores) than White/Asian patients. Mortality at 12 months was highest amongst Black followed by Asian and then White patients. In Black patients, this excess mortality was driven by higher rates of multi-organ dysfunction but lower cardiac death than White, and in particular Asian patients, amongst whom cardiac death was highest. Stratifying patients by socioeconomic status showed that higher social deprivation was associated with non-shockable and unwitnessed OOHCA but other demographics, arrest circumstances, rates of CAG and PCI were similar and no difference in mortality or cause of death at 12 months was observed. In a multi-variable logistic regression analysis, age, location of OOHCA, witnessed arrest and Black compared to White ethnicity were independent predictors of 12-month mortality, whilst social deprivation was not. Conclusion Black patients have higher mortality after resuscitated OOHCA than White patients due to differing underlying aetiology rather than differences in arrest circumstances or social deprivation. This should be reflected in cardiac arrest pathways, and patients conveyed to cardiac arrest centres should have access to coronary angiography but also advanced 24/7 imaging, renal replacement therapy and other advanced critical care therapies.

Balloon Aortic Valvuloplasty for Severe Aortic Stenosis as Rescue or Bridge Therapy.

The study aimed to assess procedural complications, patient flow and clinical outcomes after balloon aortic valvuloplasty (BAV) as rescue or bridge therapy, based on data from our registry. A total of 382 BAVs in 374 patients was performed. The main primary indication for BAV was a bridge for TAVI (n = 185, 49.4%). Other indications included a bridge for AVR (n = 26, 6.9%) and rescue procedure in hemodynamically unstable patients (n = 139, 37.2%). The mortality rate at 30 days, 6 and 12 months was 10.4%, 21.6%, 28.3%, respectively. In rescue patients, the death rate raised to 66.9% at 12 months. A significant improvement in symptoms was confirmed after BAV, after 30 days, 6 months, and in survivors after 1 year (p < 0.05 for all). Independent predictors of 12-month mortality were baseline STS score [HR (95% CI) 1.42 (1.34 to 2.88), p < 0.0001], baseline LVEF <20% [HR (95% CI) 1.89 (1.55–2.83), p < 0.0001] and LVEF <30% at 1 month [HR (95% CI) 1.97 (1.62–3.67), p < 0.0001] adjusted for age/gender. In everyday clinical practice in the TAVI era, there are still clinical indications to BAV a standalone procedure as a bridge to surgery, TAVI or for urgent high risk non-cardiac surgical procedures. Patients may improve clinically after BAV with LV function recovery, allowing to perform final therapy, within limited time window, for severe AS which ameliorates long-term outcomes. On the other hand, in patients for whom an isolated BAV becomes a destination therapy, prognosis is extremely poor.

29 Predicting Unplanned Readmission and Death After Hospital Discharge: How Do Frailty Tools Compare to Electronic Health Record Frailty Markers?

Abstract Introduction Numerous frailty tools and definitions have been described. Amongst hospitalised patients, the validity of face-to-face instruments may be confounded by acute illness. However, patient assessment after recovery at the point of hospital discharge, or recognition of electronic health record (EHR) frailty markers, may overcome this issuep. Methods In a consented, prospective observational cohort study, we recruited patients ≥70 years old within 24 hours of expected discharge from the cardiology ward of the Royal Infirmary of Edinburgh. Three established frailty instruments were tested: the Fried phenotype, Short Physical Performance Battery and nurse-administered Clinical Frailty Scale (CFS). An unweighted 32-item EHR score was generated using frailty markers (e.g. falls risk, continence, cognition) recorded within mandated admission documentation. Comorbidity was assessed by count of chronic health conditions. Outcomes were a 90-day composite of unplanned readmission or death and 12-month mortality. Adjusted Cox modelling determined the hazard ratio (HR) per standard deviation increase in each frailty score. Results 186 patients (mean age 79 ± 6 years, 64% male) were included, of whom 55 (30%) had a 90-day composite outcome, and 21 (11%) died within 12 months. All four frailty tools were moderately correlated with age and comorbidity (Pearson’s r 0.21 to 0.43, all p &amp;lt; 0.05). The Fried phenotype (HR 1.47, 95% CI 1.18–1.81), CFS (HR 1.24, 95% CI 1.01–1.51) and EHR score (HR 1.26, 95% CI 1.03–1.55) independently predicted 90-day readmission or death, after adjustment for age, sex and comorbidity. All frailty instruments were independent predictors of 12-month mortality, with age, sex and comorbidity losing predictive power (p &amp;gt; 0.05) once frailty was included in modelling. Conclusions At hospital discharge, the Fried phenotype and CFS added to age and comorbidity in risk prediction for future unplanned readmission or death. EHR frailty markers appeared comparable to face-to-face assessment. An automated trigger for high-risk patients using routine EHR data merits prospective evaluation.

Real-world retrospective observational study exploring the effectiveness and safety of antifibrotics in idiopathic pulmonary fibrosis

BackgroundPirfenidone and nintedanib are the only disease-modifying treatments available for idiopathic pulmonary fibrosis (IPF). Our aim was to test their effectiveness and safety in clinical practice.MethodsThis is a single-centre retrospective...

Serum potassium dynamics during acute heart failure hospitalization.

Available information about prognostic implications of potassium levels alteration in the setting of acute heart failure (AHF) is scarce. We aim to describe the prevalence of dyskalemia (hypo or hyperkalemia), its dynamic changes during AHF-hospitalization, and its long-term clinical impact after hospitalization. We analyzed 1779 patients hospitalized with AHF who were included in the REDINSCOR II registry. Patients were classified in three groups, according to potassium levels both on admission and discharge: hypokalemia (potassium < 3.5mEq/L), normokalemia (potassium = 3.5-5.0mEq/L and, hyperkalemia (potassium > 5mEq/L). The prevalence of hypokalemia and hyperkalemia on admission was 8.2 and 4.6%, respectively, and 6.4 and 2.7% at discharge. Hyperkalemia on admission was associated with higher in-hospital mortality (OR = 2.32 [95% CI: 1.04-5.21] p = 0.045). Among patients with hypokalemia on admission, 79% had normalized potassium levels at discharge. In the case of patients with hyperkalemia on admission, 89% normalized kalemia before discharge. In multivariate Cox regression, dyskalemia was associated with higher 12-month mortality, (HR = 1.48 [95% CI, 1.12-1.96], p = 0.005). Among all patterns of dyskalemia persistent hypokalemia (HR = 3.17 [95% CI: 1.71-5.88]; p < 0.001), and transient hyperkalemia (HR = 1.75 [95% CI: 1.07-2.86]; p = 0.023) were related to reduced 12-month survival. Potassium levels alterations are frequent and show a dynamic behavior during AHF admission. Hyperkalemia on admission is an independent predictor of higher in-hospital mortality. Furthermore, persistent hypokalemia and transient hyperkalemia on admission are independent predictors of 12-month mortality.

Early palliative care: the surprise question and the palliative care screening tool—better together

ObjectiveThe ‘surprise question’ (SQ) and the palliative care screening tool (PCST) are the common assessment tools in the early identification of patients requiring palliative care. However, the comparison of their...

Intravascular Imaging and 12-Month Mortality After Unprotected Left Main Stem PCI: An Analysis From the British Cardiovascular Intervention Society Database

ObjectivesThe authors used the British Cardiovascular Intervention Society (BCIS) national percutaneous coronary intervention (PCI) database to explore temporal changes in the use of intravascular imaging for unprotected left main stem PCI (uLMS PCI), defined the associates of imaging use, and correlate clinical outcomes including survival with imaging use. BackgroundLimited registry data support the use of intravascular imaging during uLMS PCI to improve outcomes. MethodsData were analyzed from 11,264 uLMS PCI procedures performed in England and Wales between 2007 and 2014. Multivariate logistic regression was used to identify associates of imaging use. Propensity matching created 5,056 pairs of subjects with and without imaging and logistic regression was performed to quantify the association between imaging and outcomes. Multivariate logistic regression to identify the independent predictors of 12-month mortality was performed. ResultsImaging use increased from 30.2% in 2007 to 50.2% in 2014 (p for trend < 0.001). The factors associated with imaging use included stable angina presentation (odds ratio [OR]: 1.200; 95% confidence interval [CI]: 1.147 to 1.246; p < 0.001), bifurcation LMS disease (OR: 1.220; 95% CI: 1.140 to 1.300; p < 0.001), previous PCI (OR: 1.320; 95% CI: 1.200 to 1.440; p < 0.001), and radial access (OR: 1.266; 95% CI: 1.217 to 1.317; p < 0.001). A lower rate of coronary complications, lower in-hospital major adverse cardiac events (OR: 0.470; 95% CI: 0.37 to 0.590; p < 0.001), and improved 30-day (OR: 0.540; 95% CI: 0.430 to 0.680; p < 0.001) and 12-month (OR: 0.660; 95% CI: 0.570 to 0.770; p < 0.001) mortality were observed with imaging use compared with no imaging use. Greater mortality reductions were observed with higher operator LMS PCI volume. In logistic regression modeling, imaging use was associated with improved 12-month survival. ConclusionsThe observed lower mortality with use of intravascular imaging to guide uLMS PCI justifies the undertaking of a large-scale randomized trial.

Prognostic Value of Delirium in Patients With Acute Heart Failure in the Intensive Care Unit

BackgroundDelirium is a common adverse event observed in patients admitted to the intensive care unit (ICU). However, the prognostic value of delirium and its determinants have not been thoroughly investigated in patients with acute heart failure (AHF). MethodsWe investigated 408 consecutive patients with AHF admitted to the ICU. Delirium was diagnosed by means of the Confusion Assessment Method for ICU tool and evaluated every 8 hours during the patients’ ICU stays. ResultsDelirium occurred in 109 patients (26.7%), and the in-hospital mortality rate was significantly higher in patients with delirium (13.8% vs 2.3%; P < 0.001). Multivariate logistic regression analysis showed that delirium independently predicted in-hospital mortality (odds ratio [OR] 4.33, confidence interval [CI] 1.62-11.52; P = 0.003). Kaplan-Meier analysis showed that the 12-month mortality rate was significantly higher in patients with delirium compared with those without (log-rank test: P < 0.001), and Cox proportional hazards analysis showed that delirium remained an independent predictor of 12-month mortality (hazard ratio 2.19, 95% CI 1.49-3.25; P < 0.001). The incidence of delirium correlated with severity of heart failure as assessed by means of the Get With The Guidelines–Heart Failure risk score (chi-square test: P = 0.003). Age (OR 1.05, 95% CI 1.02-1.09; P = 0.003), nursing home residential status (OR 3.32, 95% CI 1.59-6.94; P = 0.001), and dementia (OR 5.32, 95% CI 2.83-10.00; P < 0.001) were independently associated with the development of delirium. ConclusionsDevelopment of delirium during ICU stay is associated with short- and long-term mortality and is predicted by the severity of heart failure, nursing home residential, and dementia status.

The Predictivity of N-Terminal Pro b-Type Natriuretic Peptide for All-Cause Mortality in Various Follow-Up Periods among Heart Failure Patients.

Plasma N-terminal pro-brain natriuretic peptide (NT-proBNP) is an excellent prognostic–predictive tool in heart failure (HF) patients, but its plasma level changes following therapy. The comparison of prognosis–predictivity of a single measurement of plasma NT-pro BNP in different follow-up periods in acute HF patients has been less studied. This study aimed to evaluate whether the association between initial plasma NT-proBNP levels and all-cause mortality would decrease along with an increased follow-up period in patients with acute HF. The retrospective study was carried out, enrolling adult patients with hospitalization-requiring acute HF who fulfilled the predefined criteria from January 1, 2011, to December 31, 2013. We evaluated the independent predictors of 12-month mortality, and subsequently compared the predictivity of NT-proBNP level at initial presentation for 1-, 3-, 6-, 9- and 12-month mortality. In total, 269 patients (mean age, 74.45 ± 13.59 years; female, 53.9%) were enrolled. The independent predictors of 12-month mortality included higher “Charlson Comorbidity Index” (adjusted hazard ratio (aHR) = 1.22; 95% confidence interval (CI), 1.10–1.34), increased “age” (aHR = 1.07; 95% CI, 1.04–1.10), “administration of vasopressor” (aHR = 3.43; 95% CI, 1.76–6.71), “underwent cardiopulmonary resuscitation” (aHR = 4.59; 95% CI, 1.76–6.71), and without “angiotensin-converting enzyme inhibitors/angiotensin receptor blocker” (aHR = 0.41; 95% CI, 1.86–11.31) (all p <0.001). “Plasma NT-pro BNP level ≧11,755 ng/L” was demonstrated as an independent predictor in 1-month (aHR = 2.37; 95% CI, 1.10–5.11; p = 0.028) and 3-month mortality (aHR = 1.98; 95% CI, 1.02–3.86; p = 0.045) but not in more extended follow-up. The outcome predictivity of plasma NT-proBNP levels diminished in a longer follow-up period in hospitalized acute HF patients. In conclusion, these findings remind physicians to act with caution when using a single plasma level of NT-proBNP to predict patient outcomes with a longer follow-up period.

Quality of life measures predict mortality in patients with cirrhosis and severe ascites.

Severe ascites is associated with both a poor health-related quality of life (HRQL) and a mortality in excess of that captured by current prognostic clinical scores. To determine the association between HRQL and mortality in patients with severe ascites. The HRQL data from previously published randomised controlled trials examining the efficacy of satavaptan in ascites were retrospectively evaluated. Of the 496 patients randomised who completed the SF-36, 405 patients had complete datasets and were included in the analysis (difficult-to-treat ascites, n=164 or refractory ascites, n=241). Overall, patients reported poor HRQL, in particular the physical component score (PCS) of SF-36. The physical component score (PCS) correlated with the mental component score (MCS) of SF-36 (Spearman rank correlation=0.68) but not with markers of severity of liver disease. The PCS, but not the MCS, was significantly lower in patients who died (P=0.01 and P=0.84, respectively). After confounder-adjustment, the hazard ratio for a 10-point increase in the physical component score was 0.83 (95% CI; 0.72-0.97) for all-cause mortality and 0.84 (95% CI; 0.71-0.99) for cirrhosis-related deaths only, indicating that patients with better physical HRQL live longer on average. Poor physical component score (PCS) of SF-36 is an independent predictor of 12-month mortality in patients with severe ascites independent of current prognostic clinical scores. It holds promise not only in prognostic modelling but also as an endpoint in the evaluation of therapies targeting ascites.

Impact of prior revascularization on the outcomes of patients presenting with ST-elevation myocardial infarction and cardiogenic shock.

Patient presenting with ST-elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS) have extremely high mortality rates. We sought to assess the impact of prior revascularization by either coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention (PCI) on the in-hospital and 12-month outcomes and compare them with revascularization-naïve patients. Between 1/2010 and 5/2017, a total of 241 consecutive patients were admitted to our institution with STEMI and CS as defined by New York State Percutaneous Coronary Interventions Reporting System (PCIRS) and underwent primary PCI. Baseline clinical, angiographic and procedural characteristics, as well as in-hospital outcomes were prospectively collected among all patients undergoing primary PCI as part of the New York State PCIRS data collection. Patients with a history of prior bypass graft surgery were older and had a history of heart failure, hypertension, dyslipidemia, and diabetes. The left anterior descending coronary artery was usually the culprit vessel in post PCI and revascularization naïve patients, whereas it was a vein graft in patients with a prior history of surgical bypass. In-hospital mortality rates were different in the three groups and there was no significant difference in major adverse cardiac and cerebrovascular events rates among the three groups (p = 0.87). Notably, revascularization-naïve patients had higher rates of major bleeding complications (p = 0.006). By multivariable analysis, only age (OR 1.03; CI = 1.0-1.06), a prior history of congestive heart failure (OR 4.36, CI = 1.04-18.38) and dyslipidemia (OR 0.32 CI = 0.15-0.64) were independent predictors of 12-month mortality. Prior revascularization had no impact on rates of stroke, death or MACCE. Patients with acute STEMI and CS had similar in-hospital and one year mortality, stroke or major adverse cardiac and cerebrovascular events rates irrespective of their prior revascularization status.

Pretreatment with dual antiplatelet therapy in patients with ST-elevation myocardial infarction.

The optimal time to administer P2Y12 inhibitors in patients with ST-elevation myocardial infarction (STEMI) remains to be defined. We sought to assess whether a pretreatment strategy was associated with improved coronary reperfusion and clinical outcomes. Consecutive patients from the Melbourne Interventional Group registry (2005-2014) who presented with STEMI and underwent primary PCI were included. Those who received any P2Y12 inhibitor prior to arrival in the cardiac catheterisation laboratory were included in the pretreatment group. The primary endpoints were the proportion of patients with initial TIMI flow grade <3 and in-hospital bleeding. The secondary endpoints were 12-month mortality and major adverse cardiovascular events (MACE). Of the 2,807 patients included, 892(31.8%) received pretreatment. Clopidogrel was the most common P2Y12 inhibitor used (79.6%). Pretreatment was associated with less thromboaspiration and GPIIb/IIIa inhibitor use (both P < 0.01). Pretreatment was not associated with lower rates of TIMI flow <3 on initial angiogram (78.0% vs. 80.7%, P = 0.18) nor with increased in-hospital bleeding (3.6% vs. 3.9%, P = 0.67). Pretreatment was associated with lower 12-month mortality (4.7% vs. 7.0%, P = 0.02) but similar MACE rate (13.0% vs. 14.1%, P = 0.43). Multivariate analysis revealed pretreatment was not an independent predictor of 12-month mortality (OR 0.79; 95% CI 0.5-1.3, P = 0.32). Pretreatment with a P2Y12 inhibitor in patients with STEMI was not routine practice in our Australian cohort and was not associated with improved coronary reperfusion or clinical outcomes. Larger studies are required to definitively ascertain the risk/benefit ratio of dual antiplatelet therapy pretreatment in STEMI.

Relation of Renal Function with Left Ventricular Systolic Function and NT-proBNP Level and Its Prognostic Implication in Heart Failure with Preserved versus Reduced Ejection Fraction: an analysis from the Korean Heart Failure (KorHF) Registry.

Background and ObjectivesThe relationship between ejection fraction (EF), N-terminal pro-brain natriuretic peptide (NT-proBNP) levels and renal function is unknown as stratified by heart failure (HF) type. We investigated their relation and the prognostic value of renal function in heart failure with preserved ejection fraction (HFpEF) vs. reduced ejection fraction (HFrEF).Materials and MethodsNT-proBNP, glomerular filtration rate (GFR), and EF were obtained in 1,932 acute heart failure (AHF) patients. HFrEF was defined as EF<50%, and renal dysfunction as GFR<60 mL/min/1.73 m2 (mild renal dysfunction: 30≤GFR<60 mL/min/1.73 m2; severe renal dysfunction: GFR<30 mL/min/1.73 m2). The primary outcome was 12-month all-cause death.ResultsThere was an inverse correlation between GFR and log NT-proBNP level (r=−0.298, p<0.001), and between EF and log NT-proBNP (r=−0.238, p<0.001), but no correlation between EF and GFR (r=0.017, p=0.458). Interestingly, the prevalence of renal dysfunction did not differ between HFpEF and HFrEF (49% vs. 52%, p=0.210). Patients with renal dysfunction had higher 12-month mortality in both HFpEF (7.9% vs. 15.2%, log-rank p=0.008) and HFrEF (8.6% vs. 16.8%, log-rank p<0.001). Multivariate analysis showed severe renal dysfunction was an independent predictor of 12-month mortality (hazard ratio [HR], 2.08; 95% confidence interval [CI], 1.40–3.11). When stratified according to EF: the prognostic value of severe renal dysfunction was attenuated in HFpEF patients (HR, 1.46; 95% CI, 0.66–3.21) contrary to HFrEF patients (HR, 2.43; 95% CI, 1.52–3.89).ConclusionIn AHF patients, the prevalence of renal dysfunction did not differ between HFpEF and HFrEF patients. However, the prognostic value of renal dysfunction was attenuated in HFpEF patients.

Hyponatremia at discharge as a predictor of 12-month clinical outcomes in hospital survivors after acute myocardial infarction.

Hyponatremia in the early phase of acute myocardial infarction (AMI) is a well-known predictor of poor prognosis. However, little is known about the clinical implication of sodium levels at discharge in hospital survivors after AMI. The study included 1290 consecutive patients (64±12years; 877 men) who survived the index hospitalization after AMI. We determined the 12-month mortality rates of these patients. Patients who died during the 12-month follow-up had lower sodium levels at discharge than those who had survived (137±6 vs. 139±4mmol/L; P<0.014). Hyponatremia at discharge, defined as a serum sodium level ≤135mmol/L, was present in 210 patients (16.3%). In the Cox-proportional hazard model, hyponatremia at discharge (hazard ratio, 2.264; 95% confidence interval, 1.119-4.579; P=0.023) was an independent predictor of 12-month mortality. Moreover, hyponatremia at discharge had an incremental prognostic value over conventional risk factors (χ 2=7, P=0.007), and conventional risk factors and log N-terminal Pro-B-type natriuretic peptide combined (χ 2=5, P=0.021). In the subgroup analysis, the 12-month mortality of patients with hyponatremia at discharge was significantly higher than in those without, irrespective of age, Killip class, left ventricular ejection fraction, percutaneous coronary intervention at index hospitalization, and prescription of diuretics at discharge. Hyponatremia at discharge is an independent predictor of 12-month mortality in hospital survivors after AMI.

Impact of malnutrition on 12-month mortality following acute hip fracture.

Studies investigating the relationship between malnutrition and post-discharge mortality following acute hip fracture yield conflicting results. This study aimed to determine whether malnutrition independently predicted 12-month post-fracture mortality after adjusting for clinically relevant covariates. An ethics approved, prospective, consecutive audit was undertaken for all surgically treated hip fracture inpatients admitted to a dedicated orthogeriatric unit (November 2010-October 2011). The 12-month mortality data were obtained by a dual search of the mortality registry and Queensland Health database. Malnutrition was evaluated using the Subjective Global Assessment. Demographic (age, gender, admission residence) and clinical covariates included fracture type, time to surgery, anaesthesia type, type of surgery, post-surgery time to mobilize and post-operative complications (delirium, pulmonary and deep vein thrombosis, cardiac complications, infections). The Charlson Comorbidity Index was retrospectively applied. All diagnoses were confirmed by the treating orthogeriatrician. A total of 322 of 346 patients were available for audit. Increased age (P = 0.004), admission from residential care (P < 0.001), Charlson Comorbidity Index (P = 0.007), malnutrition (P < 0.001), time to mobilize >48 h (P < 0.001), delirium (P = 0.003), pulmonary embolism (P = 0.029) and cardiovascular complication (P = 0.04) were associated with 12-month mortality. Logistic regression analysis demonstrated that malnutrition (odds ratio (OR) 2.4 (95% confidence interval (CI) 1.3-4.7, P = 0.007)), in addition to admission from residential care (OR 2.6 (95% CI 1.3-5.3, P = 0.005)) and pulmonary embolism (OR 11.0 (95% CI 1.5-78.7, P = 0.017)), independently predicted 12-month mortality. Findings substantiate malnutrition as an independent predictor of 12-month mortality in a representative sample of hip fracture inpatients. Effective strategies to identify and treat malnutrition in hip fracture should be prioritized.

Prognostic Value of C-Reactive Protein as an Inflammatory and N-Terminal Probrain Natriuretic Peptide as a Neurohumoral Marker in Acute Heart Failure (from the Korean Heart Failure Registry)

The neurohumoral and inflammatory pathways are regarded as the main mechanisms for the progression of heart failure. We sought to investigate the prognostic value of high-sensitivity C-reactive protein (hs-CRP) and N-terminal probrain natriuretic peptide (NT-proBNP) by evaluating their relation with 12-month mortality rate in this prospective cohort study from 24 academic hospitals in Korea. In 1,608 patients with acute heart failure (AHF), the median hs-CRP and NT-proBNP values were 0.77 mg/dl (interquartile range 0.29 to 2.84) and 4,638 pg/ml (interquartile range 1,945 to 10,852), respectively. During the 12-month follow-up, 213 patients (13.3%) died. The mortality rate increased from the lowest to the highest hs-CRP quartiles (Q1 7.4%, Q2 9.5%, Q3 16.9%, Q4 19.3%, p <0.001) and NT-proBNP quartiles (Q1 7.0%, Q2 13.4%, Q3 11.6%, Q4 20.4%, p <0.001). After adjustment, both hs-CRP (hazard ratio [HR] 1.811, 95% confidence interval [CI] 1.138 to 2.882) and NT-proBNP (HR 1.971, 95% CI 1.219 to 3.187) were independent predictors of 12-month mortality among others. When combining both hs-CRP and NT-proBNP and stratifying the patients according to their median values, patients with elevation of both hs-CRP and NT-proBNP values had 2.4-fold increased hazards (HR 2.382, 95% CI 1.509 to 3.761) compared with those without elevation of both markers. In Korean patients with AHF, patients with increased levels of both hs-CRP and NT-proBNP had worse clinical outcomes. The combination of the neurohumoral and inflammatory markers may provide a better strategy for risk stratification of Asian patients with AHF.

Predicting 12-Month Mortality for Peritoneal Dialysis Patients Using the “Surprise” Question

Studies in hemodialysis patients suggest that the "surprise" question can help to identify a group of patients with a high mortality risk who should receive priority for palliative care interventions. However, the same instrument has not been tested in peritoneal dialysis (PD) patients. We studied 367 prevalent PD patients from a single dialysis center. Three clinicians independently answered the "surprise" question (Would I be surprised if this patient died within the next 12 months?) according to their clinical impression of the individual patient. Patients are then classified into "yes" (yes, surprised) and "no" (no, not surprised) groups. All patients were followed for 12 months. In this cohort, 109 patients (29.7%) were allocated to the "no" group, and 258 (70.3%), to the "yes" group. Patients in the "no" group were older and had high prevalences of pre-existing ischemic heart disease, cerebrovascular disease, and peripheral vascular disease. The "no" group had a higher score on the Charlson comorbidity index and a higher malnutrition-inflammation score. At 12 months, 44 patients had died. Mortality was 24.8% in the "no" group and 6.6% in the "yes" group. Multivariate analysis showed that an opinion of "Not surprised if dies in the next 12 months" was an independent predictor of 12-month mortality, with an associated 3.594 excess mortality risk (95% confidence interval: 1.411 to 9.151; p = 0.007). The positive predictive value of this opinion was 24.8%, and its negative predictive value was 93.4%. The "surprise" question has the potential to help identify a group of PD patients with high short-term mortality. Its use may contribute to a decision to refer PD patients for early palliative care assessment.