Independent Predictor Of All-cause Death Research Articles

Prognostic impact of non-ischaemic late gadolinium enhancement in patients with ischaemic cardiomyopathy

Abstract Background Although the presence and extent of ischaemic late gadolinium enhancement (LGE) as assessed by cardiovascular magnetic resonance (CMR) have emerged as robust predictors of outcomes in patients with ischaemic cardiomyopathy (ICM), the prognostic significance of non-ischaemic LGE is not well established. Objective To assess the prognostic impact of the presence of non-ischaemic LGE in a large cohort of patients with ICM with reduced left ventricular ejection fraction (LVEF) undergoing CMR for myocardial viability. Methods Between 2008 and 2022, all consecutive patients referred for myocardial viability assessment using CMR with a history of ICM (≥70% stenosis in ≥1 epicardial coronary vessel on angiography and/or history of myocardial infarction and/or coronary revascularisation) and LVEF <50% were included. Non-ischaemic was defined as midwall-LGE corresponding to non-specific myocardial fibrosis. Patients with a history of acute myocarditis and/or sub-epicardial LGE were excluded. The primary outcome was all-cause mortality using the National Registry of Death. Nested Cox proportional hazard models were used to assess the additional prognostic value of the presence of non-ischaemic LGE, including its location (lateral and/or septal and other locations) and its extent (1 or ≥2 segments), beyond the presence of ischaemic-LGE and traditional prognostic factors. The incremental prognostic value of non-ischaemic LGE extent and location was assessed by the C-statistic increment. Results Among the 6,082 patients (average age 65±12 years, 73% male), 702 (12%) had additional midwall-LGE. Over a median follow-up of 9 years (IQR 7-12), 652 (11%) patients died. Non-ischaemic LGE alone was associated with a higher risk of mortality (HR: 2.9; 95% CI: 2.4-3.4, p<0.001). Figure 1 shows an increased all-cause mortality rate, regardless of ischaemic-LGE extent and transmurality. In patients with non-ischaemic LGE (N=702), survival curves indicated higher risk for lateral and/or septal locations, larger extent, and the presence of ischaemic-LGE (all p<0.001, Figure 2). After adjustment for traditional prognosticators and ischaemic-LGE extent, non-ischaemic LGE in septal and/or lateral locations (adjusted HR: 2.6; 95% CI: 1.8-3.6) and extent ≥2 segments (adjusted HR: 2.6; 95% CI: 1.8-3.7, both p<0.001) were independently associated with mortality. A comprehensive LGE model including all non-ischaemic LGE characteristics improved reclassification compared to traditional factors with and without ischaemic-LGE (C-statistic improvement: 0.13 and 0.05, all p<0.001). Conclusion In a large cohort of ICM patients, the presence of non-ischaemic LGE is an independent predictor of all-cause death, particularly for larger extent or in the septal and/or lateral segments. All-cause mortality rates Prognostic impact of non-ischaemic LGE

Clinical Outcomes in Atrial Fibrillation Patients Undergoing Transcatheter Aortic Valve Replacement With Contemporary Devices.

Atrial fibrillation (AF) has been identified as a marker of advanced cardiac damage in aortic stenosis patients. However, the factors associated with poorer outcomes among AF patients in contemporary TAVR practice, particularly regarding mortality and heart failure (HF)-related hospitalizations, remain largely unknown. Multicenter study including consecutive patients with a history of AF, evaluating the clinical outcomes and predictors of mortality, and HF-related hospitalization, who underwent TAVR with newer-generation devices using balloon or self-expandable valves. A total of 3,476 patients were included. After a median follow-up of 2 (1-4) years, 36.4% had died, with 51.5% of deaths being cardiovascular-related, including 15.6% from HF. HF-related hospitalizations post-TAVR accounted for 34.8% of all hospitalizations and exhibited a significantly higher mortality risk (HR:1.54;95%CI:1.32-1.81;P<0.001). Permanent AF emerged as an independent predictor of all-cause death or HF-related hospitalizations (HR:1.25; 95%CI:1.10-1.40;P<0.001), as did other baseline characteristics, including chronic kidney disease (HR:1.23;95%CI:1.09-1.38;P=0.001), anemia (HR:1.21; 95%CI:1.07-1.36;P=0.002), and New York Heart Association class III or IV (HR:1.13; 95%CI:1.01-1.27;P=0.045). Additionally, early post-procedural complications, including stroke and bleeding also significantly increased the risk of mortality and HF-related hospitalizations (HR:5.52;95%CI:3.12-9.79;P<0.001 & HR:1.17;95%CI:1.03-1.33;P=0.014, respectively). AF patients exhibited a high risk of HF-related hospitalizations in a contemporary TAVR cohort. Several baseline co-morbidities and periprocedural complications, along with permanent (vs. paroxysmal) AF were associated with poorer outcomes. These findings confirm the negative impact of AF despite the continued improvements in TAVR technology and underscore the importance of early intervention and optimization of HF management to improve outcomes in this high-risk population.

Prognostic importance of extensive coronary calcium on lung cancer screening chest computed tomography.

Low-dose chest computed tomography (CT) is used for lung cancer screening, but can also detect coronary artery disease as coronary artery calcium. We sought to determine the prevalence and prognostic utility of coronary artery calcium in a population at high risk of cancer. We reviewed CT scans from consecutive participants screened for lung cancer between March 2017 and November 2018 as part of the Ontario Health Lung Cancer Screening Pilot for People at High Risk. We quantified coronary artery calcium using an estimated Agatston score. We identified the composite primary outcome of all-cause death and cardiovascular events using linked electronic medical record data from The Ottawa Hospital to December 2023. Among 1486 people who underwent screening CT, coronary artery calcium was detected in 1232 (82.9%) and was extensive in 439 (29.5%). On multivariable analysis, extensive coronary artery calcium was associated with the composite primary outcome (hazard ratio [HR] 2.13, 95% confidence interval [CI] 1.35-3.38), all-cause death (HR 2.39, 95% CI 1.34-4.27), and cardiovascular events (HR 2.06, 95% CI 1.13-3.77). Extensive coronary artery calcium remained predictive of cardiovascular events after we adjusted for noncardiovascular death as a competing risk (HR 2.05, 95% CI 1.09-3.85). Among people undergoing low-dose chest CT for lung cancer screening, extensive coronary artery calcium was an independent predictor of all-cause death and cardiovascular events, even after adjustment for noncardiovascular death. The opportunity to identify and reduce risks from coronary artery disease may represent an additional benefit of lung cancer screening.

Abstract 4138417: A Novel Echocardiography Risk Score Predicted Mortality In Patients With Heart Failure With Preserved Ejection Fraction.

Introduction: Patients with heart failure with preserved ejection fraction (HFpEF) exhibit several echocardiographic abnormalities, including diastolic dysfunction, left ventricular (LV) hypertrophy, left atrial enlargement or pulmonary hypertrophy. It is not fully understood how these abnormalities are related with prognosis in HFpEF patients. Hypothesis: A combination of echocardiography parameters can predict clinical outcome in patients with HFpEF. Aims: This study aimed to develop a model to predict all-cause mortality in patients with HFpEF using echocardiography parameters. Methods: We analyzed data from 952 patients (81±9 years, 43% male) registered in the PURSUIT-HFpEF (Prospective, Multicenter, Observational Study of Patients with Heart Failure with Preserved Ejection Fraction) study, a multicenter registry of patients hospitalized for acute decompensated HFpEF. Comprehensive echocardiography was performed before discharge. Patients were randomly assigned to the derivation and validation cohorts (2:1 ratio). Stepwise model selection was performed on age, sex and 26 echocardiography parameters to identify independent predictors of mortality. These predictors were used to construct a risk model for mortality. The accuracy of the risk score was validated using time-dependent ROC curves in both the derivation cohort (n=629) and in the validation cohort (n=323). Results: During the follow-up period (720 days, IQR: 376, 1100 days), all-cause death was observed in 248 patients (26.1%). Age, sex, diastolic (DWS), E/e’ ratio, LV mass index, LV posterior wall thickness (PWth), relative wall thickness (RWT), tricuspid regurgitant pressure gradient (TRPG) were selected as independent predictors of all-cause death. The score shown in the Table was applied to each factor, and the sum of the scores was calculated as the risk score. The AUC of the risk score for predicting 1-year mortality in the derivation cohort was 0.71 and the optimal cut-off value of 4.5 provided a sensitivity and specificity of 62.8% and 69.1%, respectively. The AUC for 1-year mortality in the validation cohort was 0.67. Conclusions: The novel echocardiography score effectively predicted mortality in HFpEF. This model could be a valuable tool for risk stratification.

Abstract 4145876: Prognostic significance of somatic mutations in myeloid cells of men with chronic heart failure – interaction between loss of Y chromosome and clonal hematopoiesis

Introduction: Age-associated clonal hematopoiesis of indeterminate potential (CHIP) has been associated with increased incidence and worse prognosis of chronic heart failure. CHIP is driven by somatic mutations in hematopoietic stem and progenitor cells (HSPC). Mosaic loss of the Y chromosome (LOY), the most common somatic mutation in blood cells of men, also correlates with clonal expansion of myeloid cells, increases with age and was experimentally shown to lead to diffuse cardiac fibrosis and subsequent heart failure in mice. However, the prognostic significance of LOY as well as its potential interaction with CHIP in patients with chronic heart failure is unknown. Aims/Methods: We investigated the prevalence and prognostic significance of the extent of LOY and the two most common CHIP-driver mutations DNMT3A and TET2 in 705 male patients with established chronic heart failure across the entire spectrum of left ventricular ejection fraction. Results: Both, LOY and DNMT3A/TET2 mutations, increased with age, and LOY co-occurred with DNMT3A/TET2 mutations in 27.1% of men at age &gt; 70 years. LOY was an independent predictor of death during 3-years of follow-up across the entire spectrum of left ventricular ejection fraction. The co-occurrence of harboring LOY and DNMT3A/TET2 mutations significantly contributed to the observed increased mortality observed in carriers of DNMT3A/TET2 mutations. The detrimental effect of LOY on prognosis was confirmed in a validation cohort of patients with ischemic heart disease.scRNA sequencing of peripheral blood cells in patients with chronic ischemic heart failure showed increased profibrotic signaling in LOY monocytes with elevated markers of monocyte mediated inflammation and profibrotic cardiac remodeling (S100A8, TLR2, CLEC4D) and reduced expression of TGF-b inhibiting genes (SMAD7, TGIF2). The proinflammatory phenotype of LOY monocytes was further amplified in LOY monocytes of patients simultaneously harboring DNMT3A mutations, who displayed heightened expression of alarmins (S100A8, HMGB2) and interferon signaling related genes (IFNGR1, TRIM56, CD84) compared to patients without CHIP mutations. Conclusion: The age-associated acquisition of somatic mutations in blood cells of men with chronic heart failure is associated with increased mortality, with loss of Y chromosome emerging as an independent predictor of all-cause death across the entire spectrum of left ventricular function.

Mini nutritional assessment is a predictor of mortality and morbidity in patients with pulmonary arterial hypertension

Abstract Background Malnutrition has been demonstrated as a predictor for unfavorable clinical outcomes in chronic heart failure, and may affect patients with pulmonary arterial hypertension (PAH). The Mini Nutritional Assessment (MNA) is a reliable indicator for nutritional status assessment, but its relationship with mortality risk and hospitalization in PAH patients has not yet been investigated. Purpose The study aimed to determine whether the MNA has prognostic value in stable patients with PAH. Methods A prospective multicenter study was performed. All patients completed the MNA at study entry in outpatient clinic or during planned hospitalization. The primary endpoint was all-cause mortality. Secondary end-point was the composite end-point of all cause death or PAH-related hospitalizations. Patients with malnutrition (MNA ≤17 points) or at risk of malnutrition (MNA 18-23,5 points) were considered as having abnormal nutritional status for statistical analysis. Results 182 PAH patients were included to the study (mean age 60 ± 17 years; 73% females; 57% idiopathic PAH). Abnormal nutritional status was identified in 68 (37%) patients. Median and the range of follow up period was 23 months and 0–32 months, respectively. 34 (18.7%) patients died, 53 (29.1%) were hospitalized due to PH, and 57 (31.3%) achieved the composite secondary end-point. Kaplan-Meier survival curves revealed significant differences in overall survival between patients with abnormal MNA and normal MNA, p &amp;lt;0.0001, and significant differences in composite risk of death and PAH-related hospitalization, p=0.02. In the multivariate Cox regression analysis including age, sex, and main risk factors (COMPERA 2.0 score, TAPSE/PASP, right atrial pressure, cardiac index, mix oxygen saturation), abnormal MNA remained significantly associated with all-cause mortality (HR 2.86 [95%CI: 1.29–6.38], p=0.01) and the composite end-point HR 2.39 [95% CI: 1.05–5.42], p=0.04) in PAH patients. Conclusions Using MNA as a routine screening tool allowed the detection of abnormal nutritional status in more than one third of PAH patients. Nutritional status assessed by the MNA was an independent predictor of all-cause death and the composite end-point of all-cause death and PAH-related hospitalization in patients with PAH.

A novel risk score incorporating frailty or congestion status predicted mortality in patients with heart failure with preserved ejection fraction.

Abstract Introduction In patients with heart failure (HF), frailty or congestion is strongly associated with clinical outcomes. However, existing risk prediction models for HF prognosis do not incorporate these important clinical factors. The estimated plasma volume status (ePVS) is an easy-to-calculate index to estimate plasma volume. which is associated with the prognosis in HF patients. Purpose This study intends to construct an inclusive risk prediction model for all-cause mortality in patients with HF with preserved ejection fraction (HFpEF), incorporating evaluations of frailty and congestion alongside traditional risk factors. Methods We analyzed data from 1212 patients (81±9 years, 55% female) registered in the PURSUIT-HFpEF (Prospective, Multicenter, Observational Study of Patients with Heart Failure with Preserved Ejection Fraction) study, a multicenter registry of patients hospitalized for acute decompensated HFpEF. We evaluated clinical factors including Clinical Frailty Scale (CFS) and blood test results collected before discharge. We calculated ePVS at discharge using the Duarte formula as ePVS (mL/g)=100×(1-hematocrit)/hemoglobin (g/dL). Patients were followed for median of 713 days (IQR 369-1088 days) to observe all-cause death. Patients were randomly assigned to the derivation and validation cohorts (2:1 ratio). Using the Bayesian Information Criterion (BIC), a stepwise model selection was executed on 51 clinical parameters, including CFS and ePVS, to identify independent predictors of mortality. A risk model for mortality was constructed based on these predictors and their coefficients. The accuracy of the risk score was validated using time-dependent ROC curves both in the derivation cohort (n=801) and in the validation cohort (n=411). Results During the follow-up period, all-cause death was observed in 315 patients (25.9%). Age, sex, CFS, NT-proBNP and ePVS were selected as independent predictors of all-cause death. The score shown in the Table was applied to each factor, and the sum of the scores was calculated as the risk score. The AUC of the risk score for predicting 1-year mortality in the derivation cohort was 0.79 (95% CI 0.74, 0.85). The optimal cut-off value of 6 provided a sensitivity and specificity of 74.9% and 74.4%, respectively. The AUC for 1-year mortality in the validation cohort was 0.70 (95% CI 0.63, 0.77). Conclusions The novel risk prediction model incorporating CFS and ePVS effectively predicted mortality in HFpEF. This model could be a valuable tool for risk stratification.Table

Exploring the long-term effects of dapagliflozin in patients with stable acute myocardial infarction and preserved ejection fraction through a propensity score matching study

Abstract Background and Aims The recent Emmy trial underscored notable improvements in cardiac structure and function among post-acute myocardial infarction (AMI) patients treated with Empagliflozin, compared to those receiving a placebo. However, limitations such as a small sample size and a short follow-up period hindered the assessment of potential differences in actual clinical events between the groups. Consequently, our study aimed to evaluate the long-term outcomes, survival rates, rates of major adverse cardiovascular events (MACE), and heart failure (HF) incidence in patients with preserved ejection fraction (EF) who experienced AMI and underwent successful percutaneous coronary intervention (PCI), comparing those who received early initiation of Dapagliflozin with those who did not. Methods Data from the Taipei Medical University Research Database in Taiwan identified 7,081 inpatients who met the criteria of AMI status post successful PCI, with a left ventricular ejection fraction (LVEF) greater than 50% and absence of clinical symptoms indicative of heart failure. Exclusion criteria included individuals with a pre-existing diagnosis of heart failure before the index AMI episode and those with an LVEF below 50%, resulting in the exclusion of 357 patients from our study. The study subjects were then divided into two groups: those treated with Dapagliflozin and those not treated with Dapagliflozin, with matching for age, diabetes mellitus, and chronic kidney disease in a 1:2 ratio. Results The cohort study included of 756 patients who met the criteria of this study, among whom 252 were Dapagliflozin users and 504 were not. Over a 7-year follow-up period, Kaplan-Meier survival analyses revealed a significant reduction in cardiovascular mortality and all-cause mortality among Dapagliflozin users compared to non-users (p &amp;lt; 0.01). However, no significant differences were observed in heart failure, recurrent AMI, or stroke during the follow-up. Multivariate Cox analysis indicated the use of Dapagliflozin (hazard ratio = 0.310, 95% confidence interval = 0.188-0.510, p &amp;lt; 0.001) and age of diagnosis (hazard ratio = 1.063, 95% confidence interval =1.045-1.081, p &amp;lt; 0.001) were both independent predictors of all cause death. Conclusions In patients with stabilized AMI, the use of Dapagliflozin was associated with a decreased risk of all-cause death, especially cardiovascular mortality. However, there were no significant differences observed in the rates of heart failure, recurrent AMI, or stroke over the seven-year follow-up period.Baseline characteristicsKaplan–Meier curves of all cause death

LDL-C and hs-CRP Jointly Modify the Effect of Lp(a) on 5-Year Death in Patients With Percutaneous Coronary Intervention.

Recent studies have suggested that adverse events associated with lipoprotein(a) [Lp(a)] might be modified by low-density lipoprotein cholesterol (LDL-C) or high-sensitivity C-reactive protein (hs-CRP) levels, but whether LDL-C and hs-CRP jointly mediate the outcome of Lp(a) remains unknown in patients with coronary artery disease. A prospective study was conducted, enrolling consecutive 10 724 patients with percutaneous coronary intervention (PCI) in 2013. The endpoint event was all-cause death. A total of 10 000 patients with complete baseline data were finally included. During a median follow-up of 5.1 years, Lp(a) ≥ 30 mg/dL was an independent risk factor of all-cause death in the overall population, LDL-C ≥ 70 mg/dL, and hs-CRP ≥ 2 mg/L population, respectively. According to concurrent LDL-C (70 mg/dL) and hs-CRP (2 mg/L) levels, further analysis revealed that when LDL-C < 70 mg/dL regardless of hs-CRP levels, Lp(a) ≥ 30 mg/dL was not an independent predictor of all-cause death. However, when LDL-C ≥ 70 mg/dL, Lp(a) ≥ 30 mg/dL was independently associated with a higher risk of all-cause death in hs-CRP ≥ 2 mg/L (HR: 1.488, 95% CI: 1.059‒2.092), but not in hs-CRP < 2 mg/L (HR: 1.303, 95% CI: 0.914‒1.856). Among PCI patients, Lp(a)-associated outcome was jointly affected by LDL-C and hs-CRP. As long as LDL-C is well controlled, the adverse effects of increased Lp(a) on cardiovascular risk seem to be weakened, and only when LDL-C and hs-CRP increase at the same time, elevated Lp(a) is associated with poorer long-term outcome.

IL-2Rα is a potential biomarker for heart failure diagnosis of patients with end-stage renal disease and haemodialysis.

Heart failure (HF) is a leading cause of mortality in patients with end-stage renal disease (ESRD) undergoing haemodialysis. Identifying novel predictors of HF is essential for improving diagnostic precision and enhancing patient outcomes. This study included 68 participants from the Haemodialysis Centre at the Second Hospital of Tianjin Medical University. Clinical characteristics and echocardiographic data were collected and analysed. We measured the plasma of 44 cytokines to investigate their correlation with cardiac function and their potential as HF biomarkers. In the HF with reduced ejection fraction (HFrEF) group, the levels of several cytokines, including stem cell growth factor-β (SCGF-β), C-X-C motif chemokine 10 (CXCL10), interleukin-1α (IL-1α), interleukin-6 (IL-6), interleukin-8 (IL-8), interleukin-16 (IL-16), interleukin-1 receptor antagonist protein (IL-1Ra), interferon-γ (IFN-γ), tumour necrosis factor-α (TNF-α), leukaemia inhibitory factor (LIF), C-C motif chemokine 3 (CCL3), interleukin-10 (IL-10), interleukin-2 receptor subunit alpha (IL-2Rα), tumour necrosis factor ligand superfamily member 10 (TNFSF10), macrophage colony-stimulating factor (M-CSF), granulocyte colony-stimulating factor (G-CSF) and stem cell factor (SCF), were significantly increased, while C-C motif chemokine 11 (CCL11)/eotaxin levels were decreased compared with those in the control group (P<0.05). Receiver operating characteristic (ROC) curve analysis highlighted TNF-α [area under the ROC curve (AUC)=0.85, odds ratio (OR)=1.080, 95% confidence interval (CI): 1.033-1.128, P=0.001], IFN-γ (AUC=0.84, OR=1.836, 95% CI: 1.289-2.615, P=0.003) and IL-2Rα (AUC=0.82, OR=1.022, 95% CI: 1.009-1.035, P=0.001) as excellent predictors for HFrEF in haemodialysis patients with ESRD, and they outperformed soluble suppression of tumourigenicity-2 (sST2) but slightly underperformed N-terminal pro-brain natriuretic peptide (NT-proBNP). IL-2Rα (AUC=0.77, OR=1.018, 95% CI: 1.007-1.030, P=0.001) demonstrated superior diagnostic capabilities when distinguishing patients with HF with left ventricular ejection fraction (LVEF) <50% from controls. IL-2Rα emerged as a robust biomarker for left ventricular HF, while TNF-α (AUC=0.89, OR=1.140, 95% CI: 1.039-1.250, P=0.005) showed promise in assessing HF severity in patients with ESRD. IL-2Rα (AUC=0.80, OR=1.017, 95% CI: 1.007-1.027, P=0.001) also significantly predicted right ventricular systolic dysfunction. During a median follow-up of 14months, 10 patients (14.7%) experienced all-cause mortality. Multivariate Cox regression analysis confirmed that plasma IL-2Rα was an independent predictor of all-cause death [hazard ratio (HR): 1.010, 95% CI: 1.001-1.020, P=0.039] after adjusting for other variables. This study underscores the potential of IL-2Rα as a valuable biomarker for HF diagnosis and management in haemodialysis patients with ESRD and contributes to our understanding of this high-risk population.

Long-term outcomes of transcatheter aortic valve implantation: a single-center observational study

Aim. To evaluate remote outcomes of transcatheter aortic valve implantation (TAVI), including overall survival, freedom from cardiovascular death, permanent pacemaker implantation, and repeat valve replacement.Material and methods. This retrospective observational study included 535 patients who underwent TAVI from April 2015 to January 2024. Patients who underwent TAVI for moderate aortic stenosis or severe aortic valve regurgitation (n=35) were excluded from the analysis. A total of 500 patients were included in the final analysis. Males accounted for 40,8%. Most patients had intermediate EuroSCORE II risk (5,2%), as well as low STS-PROM score risk (2,9%). The median follow-up period was 2,2 (0,6;4,1) years.Results. Overall patient survival was 94%, 88%, 86%, and 58% at 1, 3, 5, and 8 years, respectively. Freedom from cardiovascular death was 97%, 90%, 78%, and 61% at 1, 3, 5, and 8 years, respectively. The cumulative freedom from permanent pacemaker implantation over the entire follow-up period was 89,4%, and from repeat pacemaker replacement — 98,8%. The factors influencing the long-term all-cause mortality were male sex, smoking, cancer, and left ventricular mass index. The only independent predictor of cardiovascular death was the STS-PROM score.Conclusion. Our experience demonstrates satisfactory long-term outcomes of transcatheter aortic valve implantation in patients with severe aortic stenosis in terms of overall survival, cardiovascular death, permanent pacemaker implantation, and repeat pacemaker replacement. Independent predictors of all-cause death were male sex, smoking, cancer, and left ventricular mass index. The only independent predictor of cardiovascular death in the long-term period was the STS-PROM score.

Post-dialysis fatigue predicts all-cause mortality in patients on chronic hemodialysis.

Fatigue is reportedly associated with a poor prognosis in dialysis patients. The aim of the present study was to investigate whether fatigue on dialysis days or non-dialysis days is associated with mortality in patients on chronic hemodialysis. This was a prospective study of 134 hemodialysis patients. The level of fatigue was evaluated using a visual analog scale (VAS). The association between high fatigue evaluated by the highest quartile of the VAS value and all-cause death was investigated. The fatigue scale score was significantly higher on dialysis than on non-dialysis days. During the follow-up period (median 6.8 years), 42 patients died. Patients with high post-dialysis fatigue in the higher quartiles died more frequently compared to those with in the lower quartiles (p = 0.012). Multivariate Cox regression analysis showed that high post-dialysis fatigue was an independent predictor of all-cause death (adjusted hazard ratio 2.12, 95% confidence interval 1.10-4.07). Higher post-dialysis fatigue is related to increased mortality.

Timing and predictors of death during treatment in patients with multidrug/rifampin-resistant tuberculosis in South Korea.

This study aimed to investigate the timing and predictors of death during treatment among patients with multidrug/rifampin-resistant tuberculosis (MDR/RR-TB) in South Korea. This was a retrospective cohort study that included MDR/RR-TB cases notified between 2011 and 2017 in South Korea. Among 7,226 MDR/RR-TB cases, 699 (9.7%) died at a median of 167 days (IQR 51-358 d) from the initiation of MDR-TB treatment. The cumulative proportion of all-cause death was 35.5% at 90 days and 52.8% at 180 days from treatment initiation. TB-related deaths occurred at a median of 133 days (IQR 32-366 d), which was significantly earlier than the median of 184 days (IQR 68-356 d) for non-TB-related deaths (p = 0.002). In a multivariate analysis, older age was the factor most strongly associated with death, with those aged ≥ 75 years being 68 times more likely to die (aHR 68.11, 95% CI 21.75-213.26), compared those aged ≤ 24 years. In addition, male sex, comorbidities (cancer, human immunodeficiency virus, and end stage renal disease), the lowest household income class, and TB-specific factors (previous history of TB treatment, smear positivity, and fluoroquinolone resistance) were identified as independent predictors of all-cause death. This nationwide study highlights increased deaths during the intensive phase and identifies high-risk groups including older people and those with comorbidities or socioeconomic vulnerabilities. An integrated and comprehensive strategy is required to reduce mortality in patients with MDR/RR-TB, particularly focusing on the early stages of treatment and target populations.

Right ventricular systolic pressure is an independent risk factor of all-cause death and inappropriate therapies in patients with implanted CRT-D

Abstract Introduction Cardiac resynchronization therapy-defibrillators (CRT-D) are implanted mostly in patients with low left ventricular ejection fraction (LVEF) and wide QRS. In such subjects, there is often a concomitant right ventricular (RV) dysfunction, which has been associated with higher long-term mortality. However, data on the association between RV dysfunction and arrhythmic outcomes in patients with CRT-D are scarce. Purpose To define whether there is any association between right ventricular dysfunction and antiarrhythmic therapies or all-cause mortality in patients with HF and CRT-D. Methods The clinical and demographic data of patients enrolled in this study were obtained from the single-centre COMMIT-HF registry. The parameters regarding right ventricular function, such as right ventricle dimension (RVD), tricuspid annular systolic plane systolic excursion (TAPSE) and right ventricular systolic pressure (RVSP) were obtained from electronic patients’ records. The data on the long-term hard endpoints were obtained from the national healthcare provider, while the data on the risk of arrhythmic events, CRT-D shocks and antitachycardia pacing (ATP) were obtained from investigator-initiated and -adjudicated single-centre remote monitoring database updated annually. Multivariable stepwise logistic regression was used to determine independent predictors of the study outcomes, being all-cause death, and the occurrence of appropriate and inappropriate CRT-D therapies. Results During the period between July, 2009 and November, 2019, 335 patients were enrolled at the RM programme after implantation of CRT-D. Of them, during the median (Q1-Q3) follow-up period of 5.3 (2.8-6.6) years, (113 (33.7%) died, 111 (33.1%) received appropriate and 37 (11%) inappropriate therapies. In the multivariable analysis, the independent predictors of all-cause death were reduction in LVEF and increase in RVSP. Lower age and increased LVEDD were independent predictors of appropriate therapies, while lower age and increased RVSP were independent predictors of inappropriate therapies. No association between TAPSE and RVD and outcomes was found. Conclusions Among right ventricular dysfunction parameters, RVSP is an independent predictor of inappropriate therapies and all-cause death, but not of appropriate therapies in patients with HF and CRT-D.

Prognostic value of geriatric nutritional risk index in patients with stable coronary artery disease undergoing percutaneous coronary intervention

BackgroundMalnutrition increases the risk of poor prognosis in patients with cardiovascular disease, and our current research was designed to assess the predictive performance of the Geriatric Nutrition Risk Index (GNRI) for the occurrence of poor prognosis after percutaneous coronary intervention (PCI) in patients with stable coronary artery disease (SCAD) and to explore possible thresholds for nutritional intervention.MethodsThis study retrospectively enrolled newly diagnosed SCAD patients treated with elective PCI from 2014 to 2017 at Shinonoi General Hospital, with all-cause death as the main follow-up endpoint. Cox regression analysis and restricted cubic spline (RCS) regression analysis were used to explore the association of GNRI with all-cause death risk and its shape. Receiver operating characteristic curve (ROC) analysis and piecewise linear regression analysis were used to evaluate the predictive performance of GNRI level at admission on all-cause death in SCAD patients after PCI and to explore possible nutritional intervention threshold points.ResultsThe incidence of all-cause death was 40.47/1000 person-years after a mean follow-up of 2.18 years for 204 subjects. Kaplan-Meier curves revealed that subjects at risk of malnutrition had a higher all-cause death risk. In multivariate Cox regression analysis, each unit increase in GNRI reduced the all-cause death risk by 14% (HR 0.86, 95% CI 0.77, 0.95), and subjects in the GNRI > 98 group had a significantly lower risk of death compared to those in the GNRI < 98 group (HR 0.04, 95% CI 0.00, 0.89). ROC analysis showed that the baseline GNRI had a very high predictive performance for all-cause death (AUC = 0.8844), and the predictive threshold was 98.62; additionally, in the RCS regression analysis and piecewise linear regression analysis we found that the threshold point for the GNRI-related all-cause death risk was 98.28 and the risk will be significantly reduced when the subjects' baseline GNRI was greater than 98.28.ConclusionsGNRI level at admission was an independent predictor of all-cause death in SCAD patients after PCI, and GNRI equal to 98.28 may be a useful threshold for nutritional intervention in SCAD patients treated with PCI.

Prognostic Implication of Right Ventricular Free Wall Longitudinal Strain and Right Atrial Pressure Estimated By Echocardiography in Patients With Severe Functional Tricuspid Regurgitation.

The interaction between right ventricular (RV) function and pulmonary hypertension is crucial for prognosis of patients with severe functional tricuspid regurgitation. RV free wall longitudinal strain (RVFWLS) has been reported to detect RV systolic dysfunction earlier than other conventional parameters. Although pulmonary artery systolic pressure measured by Doppler echocardiography is often underestimated in severe functional tricuspid regurgitation, right atrial pressure (RAP) estimated by echocardiography may be viewed as a prognostic factor. Impact of RAP and RVFWLS on outcome in patients with severe functional tricuspid regurgitation remains unclear. The aim of the present study was to investigate prognostic implication of RAP, RVFWLS, and their combination in this population. We retrospectively examined 377 patients with severe functional tricuspid regurgitation. RAP, pulmonary artery systolic pressure, RV fractional area change, and RVFWLS were analyzed. RAP of 15 mm Hg was classified as elevated RAP. All-cause death at 2-year follow-up was defined as the primary end point. RVFWLS provided better prognostic information than RV fractional area change by receiver operating characteristic curve analysis. In the multivariable Cox regression analysis, elevated RAP and RVFWLS of ≤18% were independent predictors of clinical outcome. Patients with RVFWLS of ≤18% had higher risk of all-cause death than those without by Kaplan-Meier curve analysis. Furthermore, when patients were stratified into 4 groups by RAP and RVFWLS, the group with elevated RAP and RVFWLS of ≤18% had the worst outcome. Elevated RAP and RVFWLS of ≤18% were independent predictors of all-cause death. The combination of elevated RAP and RVFWLS effectively stratified the all-cause death.

Aortic events and relative survival in patients with moderately dilated proximal thoracic aorta

Objectives. This study describes growth, local and remote aortic events, and survival in patients with proximal (root, ascending) aortic diameters just below threshold for operation. Methods. Patients with proximal aortic diameter of 4.5 to 5.4 cm at baseline, were followed with serial computed tomography studies and data collected retrospectively. Aortic growth rate was estimated using mixed effects modelling. Clinical and radiological features associated with outcomes (all-cause death, aortic death, local or remote aortic events (dissection, rupture, intramural hematoma, or intervention)) were assessed with Cox analysis. Survival and freedom from events were estimated using Kaplan-Meier methods. Results. 80 patients underwent 274 CT scans during 265 patient-years. Median proximal aortic growth was 0.2 cm in 3 years. 32 events occurred in 28 patients (35%). Eleven events were local, all elective proximal aortic surgery. Nine events were remote: 5 type B aortic dissections, 3 descending aneurysms undergoing elective repair, and one infrarenal aortic rupture. Twelve patients died, half of type B aortic dissection. Relative survival compared to a matched normal population was 82% (95% confidence limits 55–98%) at 10 years. In Cox analysis, increased descending aortic diameter was an independent predictor of all-cause death (hazard ratio [HR], 1.39) and aortic death (HR 1.96). Conclusions. Descending, but not proximal, aortic growth was predictive of lethal events. The decreased relative survival, the substantial number of remote aortic events and aortic deaths strongly suggest continuous serial CT surveillance of the entire aorta. Other indicators than proximal aortic diameter appear needed to improve management of this patient group.

The WATCH-DM risk score estimates clinical outcomes in type 2 diabetic patients with heart failure with preserved ejection fraction

The coexistence of heart failure is frequent and associated with higher mortality in patients with type 2 diabetes (T2DM), and its management is a critical issue. The WATCH-DM risk score is a tool to predict heart failure in patients with type 2 diabetes mellitus (T2DM). We investigated whether it could estimate outcomes in T2DM patients with heart failure with preserved ejection fraction (HFpEF). The WATCH-DM risk score was calculated in 418 patients with T2DM hospitalized for HFpEF (male 49.5%, age 80 ± 9 years, HbA1c 6.8 ± 1.0%), and they were divided into the “average or lower” (≤ 10 points), “high” (11–13 points) and “very high” (≥ 14 points) risk groups. We followed patients to observe all-cause death for 386 days (median). We compared the area under the curve (AUC) of the WATCH-DM score for predicting 1-year mortality with that of the Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) score and of the Barcelona Bio-Heart Failure Risk (BCN Bio-HF). Among the study patients, 108 patients (25.8%) had average or lower risk scores, 147 patients (35.2%) had high risk scores, and 163 patients (39.0%) had very high risk scores. The Cox proportional hazard model selected the WATCH-DM score as an independent predictor of all-cause death (HR per unit 1.10, 95% CI 1.03 to 1.19), and the “average or lower” risk group had lower mortality than the other groups (p = 0.047 by log-rank test). The AUC of the WATCH-DM for 1-year mortality was 0.64 (95% CI 0.45 to 0.74), which was not different from that of the MAGGIC score (0.72, 95% CI 0.63 to 0.80, p = 0.08) or that of BCN Bio-HF (0.70, 0.61 to 0.80, p = 0.25). The WATCH-DM risk score can estimate prognosis in T2DM patients with HFpEF and can identify patients at higher risk of mortality.

Predictive Model of All-Cause Death in Patients with Heart Failure using Heart Rate Variability.

Central Illustration : Predictive Model of All-Cause Death in Patients with Heart Failure using Heart Rate Variability. Short and long-duration heart rate variability (HRV) data from Holter monitoring could identify predictors of all-cause death in heart failure (HF) patients. To build a predictive model of all-cause death in patients with HF using HRV. Retrospective study including patients with suspected or confirmed HF who were admitted for decompensated HF or syncope that underwent Holter monitoring. In analysis of augmented sympathetic tonus, we evaluated the lowest HRV in nonoverlapping 10-minutes periods throughout 24h continuous electrocardiographic signal recording (short HRV variables). Variables with p<0.01 were included in a multivariate Cox regression model to determine the occurrence of the all-cause death. Variables with statistical significance in Cox regression were chosen to build the predictive model. P<0.05 was considered significant. A total of 116 patients were included, mean age of 71.9±16.3 years, 45.7% men, mean follow-up of 2.83±1.27 years. Thirty-nine deaths occurred (33.6%). By comparing survivors vs. non-survivors, the variables that showed statistical significance were lowest SDNN, lowest rMSSD, age and left ventricular ejection fraction (LVEF). In Cox regression, independent predictors of all-cause death were: age>69 years (HR 3.95, 95%CI 1.64-9.52); LVEF≤57% (HR 4.70, 95%CI 2.38-9.28) and lowest rMSSD≤12ms (HR 5.54, 95%CI 2.04-15.08). An integer value was assigned to each variable. Score<3 showed AUC=0.802 (95%CI 0.72-0.87). In HF patients hospitalized for decompensated HF or syncope, independent long-term predictors of all-cause death were age, LVEF, and 10-minutes rMSSD. These findings indicate that even brief moments of high sympathetic tone can impact survival, specifically in the elderly and patients with HF with reduced ejection fraction.

Triglyceride glucose index, a novel marker of insulin resistance, predicts outcomes in patients with heart failure with preserved ejection fraction

Abstract Background Insulin resistance (IR) is a characteristic feature of heart failure (HF), and it is present both in diabetic- and non-diabetic patients with HF. It is observed in patients with HF with preserved ejection fraction (HFpEF) as well as in those with HF with reduced ejection fraction (HFrEF). It is still not fully understood how IR can affect the clinical outcome in patients with HFpEF. Triglyceride glucose index (TyG index) is a novel, simple marker of IR which is well correlated with HOMA-IR. Purpose To investigate the correlation between TyG index and clinical outcome in patients with hospitalized HFpEF. Methods We enrolled 1231 patients registered in the PURSUIT-HFpEF (Prospective, Multicenter, Observational Study of Patients with Heart Failure with Preserved Ejection Fraction) study, which is a multicenter registration of patients hospitalized for acute decompensated HFpEF, for the present study. TyG index was calculated as Ln(serum triglyceride [mg/dL] x fasting blood glucose [mg/dL]/2) using blood sample before discharge. We followed the study patients for median of 387 days (IQR 239-727 days) to observe all-cause death and the major adverse cardiovascular events (MACE; composite of death, heart failure hospitalization and stroke). Results We could calculate TyG index in 917 patients (81±9 year old, 55.3% female) with the mean value of 8.5±1.5. Diabetes was observed in 360 (39.3%) patients, and they had higher TyG index than non-diabetic patients (8.8±0.6 vs. 8.4±.05, p&amp;lt;0.0001). Cox proportional hazard model selected TyG index score as an independent predictor for all-cause death regardless of history of diabetes, hypertension and dyslipidemia (p=0.004). We divided patients into 4 groups based on TyG index. Kaplan-Meier curves indicated the difference in all-cause mortality among 4 groups (Figure Left, p=0.0003 by log-rank test). Incidence of MACE was also significantly different among 4 groups (Figure Right, p=0.007 by log-rank test). Conclusion TyG index predicted all-cause mortality and MACE in patients with HFpEF regardless of diabetic state.Kaplan-Meier curves for death and MACE