Independent Predictor Of All-cause Death Research Articles

Relationship between systolic blood pressure and renal function on clinical outcomes in patients with atrial fibrillation: a report from the AF-GEN-UK registry

Abstract Background European guidelines on AF management recommend a systolic blood pressure (SBP) target of 120–129 mmHg as this level is associated with the lowest risk of poor outcomes. Elevated blood pressure and AF both negatively affect renal function, but the interactions between SBP and renal function in patients with AF remains unclear. In the UK extension of the EURObservational Research Programme (EORP) Long-term Registry of patients with atrial fibrillation (AF) [AF-GEN-UK study], we assessed the combined impact of BP levels and renal (dys)function on mortality, thromboembolic and haemorrhagic events. Methods 1580 patients (60.1% males, mean (SD) age 70.6 (11.2) years) from the AF-GEN-UK registry had SBP available at baseline and were stratified into groups based on SBP: 120–129 mmHg (reference group, n=289), <100 mmHg (n=165), 110–119 mmHg, (n=254), 130–139 mmHg (n=321), 140–159 mmHg (n=385), and ≥160 mmHg (n=166). Impact of SBP, renal function and their interaction on 1-year outcomes were assessed using Cox regression analysis, adjusted for age, oral anticoagulation (OAC) use and CHA2DS2-VASc score. SBP groups were compared by ANOVA (continuous data) and Chi-square test (categories) with two tailed p<0.05 deemed significant (STATA Corp, version 13). Results Overall OAC use was 84% and was similar between all SBP groups. Renal function (eGFR), was preserved across SBP groups; those with SBP 110–119 mmHg had the lowest level. Prevalence of heart failure was highest in those with SBP <110 mmHg. Patients with uncontrolled SBP (>140 mmHg) were older, more likely female and higher rates of hypertension, with correspondingly higher CHA2DS2VASc scores. SBP <100 mmHg (Hazard Ratio (HR) 2.36; 95% confidence intervals (CI) 1.20–4.64) and lower eGFR (HR 0.99; 95% CI 0.98–0.996) were associated with all cause-death in univariate analyses. Adjusted Cox regression revealed that SBP <100 mmHg and OAC use were independent predictors of all-cause death (Table). No interaction between BP groups and eGFR was evident. OAC use (aHR 0.31; 95% CI 0.11–0.92) was associated with a reduced risk of thromboembolic events. Conclusion In anticoagulated patients with AF, SBP <110 mmHg was independently predicted of all-cause death, with no interaction with kidney function. No independent association of SBP groups with haemorrhagic and thromboembolic events was evident. OAC therapy was associated with a significant reduction in all-cause death and thromboembolic events. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): This project was supported by the BMS/Pfizer European Thrombosis Investigator Initiated Research Program

Prognostic value of rest B-lines with the simplified 4-site scan for predicting survival: incremental value over transthoracic echocardiography

Abstract Background Lung ultrasound (LUS) detects pulmonary congestion as B-lines at rest. Methods After preliminary exclusion of 154 patients lost to follow-up, we analyzed transthoracic echocardiography (TTE) plus LUS (4-site simplified scan) data in 5165 subjects (age 64±11 years) referred to 19 certified centers of 9 countries for known or suspected coronary artery disease (n=3891, 75%), dyspnea (n=591, 12%), or screening in asymptomatic patients with risk factors (n=667, 13%). We analyzed the anterior and lateral hemi-thoraces, scanning from mid-axillary to mid-clavicular lines on the third intercostal space. B-lines score ranged from 0 (normal) to 40 (severely abnormal). By selection, follow-up information was available in all. All-cause death was the predetermined end-point. Results Feasibility of B-lines was 100% in all subjects. B-lines (median) were 0.1 [0–1]. Rest B-lines (≥2) were present in 863 patients (16.7%). Ejection fraction was 61±10%. After a median follow-up of 690 (Interquartile range 420–1065) days, 96 all-cause deaths occurred. Two-year mortality was 3.6% in patients with and 1.5% in patients without B-lines (p<0.001) and increased progressively with the increasing number of B-lines, from 2.4% in mild (2–4, n=630), 5.0% in moderate (5–9, n=160) and 8.2% in patients with severe (≥10, n=73) B-lines (see figure). At multivariable analysis, rest B lines (HR 1.812, 95% CI: 1.165–2.916, p=0.008) and ejection fraction (HR 0.987, 95% CI: 0.976–0.998, p=0.020) were independent predictors of all-cause death, in addition to age (HR 1.045, 95% CI: 1.023–01.067, p<0.001) and diabetes (HR 1.643, 95% CI: 1.079–2.503, p=0.021). Conclusion In all-comers referred for TTE, resting B-lines assessed by focused LUS with the simplified 4-site scan are detected in 1 out of 4 patients with symptos or coronary risk factors and are associated with worse survival. The severity of pulmonary congestion predicts the severity of outcomes. The prognostic value of resting B-lines is independent and additive over standard clinical and TTE predictors such as diabetes and ejection fraction. Focused LUS for pulmonary congestion can easily be incorporated in standard TTE examination. Funding Acknowledgement Type of funding sources: None.

Clinical and prognostic significance of left ventricular outflow tract velocity time integral (LVOT-VTI) in patients with chronic heart failure

Abstract Background The echocardiographic evaluation of cardiac output relies on the product of the flow across the left ventricular outflow tract (LVOT), estimated through its velocity time integral (LVOT-VTI), and its cross-sectional area, estimated through the formula πr2. Considering the geometrical assumption behind such formula, LVOT-VTI has been proposed as a more reproducible surrogate of cardiac systolic function and showed prognostic value in the critical care setting. However, the role of such measure in patients with chronic heart failure (HF) remains unexplored. Objective To assess the clinical and prognostic significance of LVOT-VTI in a contemporary cohort of patients with chronic HF. Methods Outpatients with chronic HF with a LV ejection fraction <50% were prospectively enrolled to undergo a clinical, echocardiographic, and biohumoral assessment, and were followed-up for the endpoint of all-cause death. Results Finally, 971 patients were enrolled (71±12 years, 72% men, 50% ischemic etiology, LVEF 35±9%). Most patients showed a NYHA class I-II (74%) and were treated with ACE-inhibitors/ARBs or ARNI (81%), beta-blockers (95%), and mineralocorticoid receptor antagonists (71%). Patients were distinguished in three subgroups according to LVOT-VTI tertiles <19 (n=324), 19–24 (n=324), or ≥24 (n=323). Compared with the other two subgroups, patients with LVOT-VTI <19 showed worse NYHA class, lower LVEF and tricuspid annular plane systolic excursion (TAPSE), and higher E/e', left atrial volume index (LAVi), estimated systolic pulmonary arterial pressure (sPAP), and NT-proBNP concentration (all p<0.001). No differences were observed as for patients' age, HF etiology, and therapies (all p>0.05). Over a median follow-up of 22 (9–34) months, 103 (11%) patients met the primary endpoint. LVOT-VTI significantly stratified the risk of death, observing 65 (20%), 21 (7%), and 17 (5%) events across the subgroups with values <19, 19–24, or ≥24 (log-rank 33, p<0.001). At multivariable regression analysis, LVOT-VTI <19 (HR 2.06 [95% 1.21–3.49], p=0.008), but not LVEF <30% (p=0.614) was an independent predictor of all-cause death in a model adjusted for age, sex, ischemic etiology, renal function, hemoglobin, E/e', LAVi, TAPSE, sPAP, and NT-proBNP. Conclusion LVOT-VTI is associated with disease severity and is a strong predictor of all-cause death in patients with chronic HF. Funding Acknowledgement Type of funding sources: None.

Reduced Left Ventricular Ejection Fraction Is a Risk for Sudden Cardiac Death in the Early Period After Hospital Discharge in Patients With Acute Myocardial Infarction.

The incidence of sudden cardiac death (SCD) after discharge in Japanese acute myocardial infarction (AMI) patients with reduced left ventricular ejection fraction (LVEF) treated with primary percutaneous coronary intervention (PCI) remains unknown.Methods and Results:The study population included 1,429 AMI patients (199 with LVEF ≤35% and 1,230 with LVEF >35%) admitted to the Hirosaki University Hospital, treated with primary PCI within 12 h after onset, and survived to discharge. LVEF was evaluated in all patients before discharge, and the patients were followed up for a mean of 2.6±0.8 years. The Kaplan-Meier survival curves revealed LVEF ≤35% was associated with all-cause death and SCD. The incidence of SCD was 2.6% at 1 year and 3.1% at 3 years in patients with LVEF ≤35%, whereas it was 0.1% at 1 year and 0.3% at 3 years in patients with LVEF >35%. Sixty-seven percent of SCDs in patients with LVEF ≤35% occurred within 4 months after discharge, and the events became less frequent after this period. A Cox proportional hazard model indicated LVEF ≤35% as an independent predictor for all-cause death and SCD. The incidence of SCD was relatively low in Japanese AMI patients treated with primary PCI, even in patients with LVEF ≤35% upon discharge. Careful management of patients with reduced LVEF is required to prevent SCD, especially in the early phase after discharge.

FT3/FT4 ratio is correlated with all-cause mortality, cardiovascular mortality, and cardiovascular disease risk: NHANES 2007-2012.

BackgroundThyroid hormones play a vital role in maintaining the homeostasis of the cardiovascular system. The FT3/FT4 ratio can be used to evaluate the rate of T4-to-T3 conversion, reflecting the peripheral sensitivity of thyroid hormones. There is no study to investigate its relationship with death and cardiovascular disease (CVD) in the general population.MethodsThis retrospective cohort study involved 8,018 participants with measured thyroid function and no prior thyroid disease who participated in the National Health and Nutrition Examination Survey (NHANES) from 2007 to 2012. Mortality status was determined by routine follow-up using the National Death Index through December 31, 2015.ResultsDuring a median of 87 months of follow-up, we observed 699 all-cause deaths, including 116 cardiovascular deaths. In multivariate adjusted models, higher free thyroxine (FT4) was linked to increased all-cause mortality (HR, 1.15 per SD; 95% CI, 1.09-1.22), cardiovascular mortality (HR, 1.18 per SD; 95% CI, 1.01-1.39), and CVD risk (HR, 1.17 per SD; 95% CI, 1.08-1.27). Higher free triiodothyronine (FT3) was linked to decreased all-cause mortality (HR 0.81 per SD; 95% CI, 0.70-0.93). Higher FT3/FT4 ratio was linked to decreased all-cause mortality (HR, 0.77 per SD; 95% CI, 0.69-0.85), cardiovascular mortality (HR, 0.79 per SD; 95% CI, 0.62-1.00), and CVD risk (HR, 0.82 per SD; 95% CI, 0.74-0.92). The FT3/FT4 ratio stratified findings were broadly consistent with the overall results.ConclusionsFT3, FT4, and the FT3/FT4 ratio were all independent predictors of all-cause death. FT4 and the FT3/FT4 ratio, but not FT3, were independent predictors of cardiovascular mortality and CVD risk. Along with FT3 and FT4, we should pay equal attention to the FT3/FT4 ratio in the general population.

Polypharmacy and Major Adverse Events in Atrial Fibrillation.

Patients with atrial fibrillation (AF) often receive multiple medications daily. The purpose of this study was to examine the prognostic implications of polypharmacy in patients with AF. This is a retrospective post hoc analysis of 1113 AF patients, enrolled in a randomized trial during an acute hospitalization (MISOAC-AF, NCT02941978). The presence of polypharmacy (use of >4 drugs daily) was assessed at hospital discharge. Regression analyses were performed to identify clinical predictors of polypharmacy and compare the outcomes of patients with or without confirmed polypharmacy. The coprimary outcomes were all-cause and cardiovascular (CV) mortality. Among patients with polypharmacy, the difference in the risk of mortality was also assessed per each added drug as a numeric variable. Polypharmacy was found in 36.9% of participants. Dyslipidemia, coronary artery disease, lower left ventricular ejection fraction, and higher glomerular filtration rates were independent predictors of polypharmacy. Polypharmacy was an independent predictor for all-cause death (adjusted hazard ratio [aHR]: 1.29, 95% confidence interval [CI]: 1.01-1.64) and CV death (aHR: 1.39, 95% CI: 1.05-1.84). Among patients with polypharmacy, each additional concomitant medication was independently associated with a 4% increased risk of all-cause mortality (aHR = 1.04, 95% CI: 1.00-1.08) and a 5% increased risk of CV mortality (aHR = 1.05, 95% CI: 1.00-1.10). Polypharmacy was common among patients with AF hospitalized in a tertiary hospital and was incrementally associated with higher rates of mortality.

Short-Term Prognostic Efficacy of mGPS and LCS in Patients With Acute Heart Failure.

AimSystemic inflammation plays an important role in the occurrence and development of acute heart failure. The modified Glasgow Prognostic Score (mGPS) and “lymphocyte C-reactive protein score” (LCS) are used to assess the inflammation levels in cancer patients. The purpose of this study was to assess the prognostic value of these two inflammation-related scoring systems in patients with acute heart failure.MethodsTwo hundred and fifty patients with acute heart failure were enrolled in this study. The mGPS and LCS scores were recorded after admission. All patients were divided into 2 groups: the death group and the survival group according to the 3-month follow-up results. The predictive values of mGPS and LCS were assessed using receiver-operating characteristic (ROC) analyses. Univariate and multivariate logistic analyses were used to evaluate the relationships between variables and endpoint.ResultsThe levels of mGPS and LCS in the death group were significantly higher than those in the survival group (P < 0.05). The areas under the ROC curve of the mGPS and LCS for predicting death were 0.695 (95%CI: 0.567~0.823) and 0.736 (95%CI: 0.616~0.856), respectively. Multivariate analysis demonstrated that both LCS, LVEF and serum direct bilirubin were independent predictors of all-cause death, excluding mGPS.ConclusionsCompared with mGPS, LCS is independently associated with short-term outcomes in patients with acute heart failure. LCS was a clinically promising and feasible prognostic scoring system for patients with acute heart failure.

Effects of chronic obstructive pulmonary disease on long-term prognosis of patients with coronary heart disease post-percutaneous coronary intervention.

BACKGROUNDChronic obstructive pulmonary disease (COPD) and cardiovascular diseases are often comorbid conditions, their co-occurrence yields worse outcomes than either condition alone. This study aimed to investigate COPD impacts on the five-year prognosis of patients with coronary heart disease (CHD) after percutaneous coronary intervention (PCI).METHODSPatients with CHD who underwent PCI in 2013 were recruited, and divided into COPD group and non-COPD group. Adverse events occurring among those groups were recorded during the five-year follow-up period after PCI, including all-cause death and cardiogenic death, myocardial infarction, repeated revascularization, as well as stroke and bleeding events. Major adverse cardiac and cerebral events were a composite of all-cause death, myocardial infarction, repeated revascularization and stroke.RESULTSA total of 9843 patients were consecutively enrolled, of which 229 patients (2.3%) had COPD. Compared to non-COPD patients, COPD patients were older, along with poorer estimated glomerular filtration rate and lower left ventricular ejection fraction. Five-year follow-up results showed that incidences of all-cause death and cardiogenic death, as well as major adverse cardiac and cerebral events, for the COPD group were significantly higher than for non-COPD group (10.5% vs. 3.9%, 7.4% vs. 2.3%, and 30.1% vs. 22.6%, respectively). COPD was found under multivariate Cox regression analysis, adjusted for confounding factors, to be an independent predictor of all-cause death [odds ratio (OR) = 1.76, 95% CI: 1.15–2.70, P = 0.009] and cardiogenic death (OR = 2.02, 95% CI: 1.21–3.39, P = 0.007). CONCLUSIONSCOPD is an independent predictive factor for clinical mortality, in which CHD patients with COPD are associated with worse prognosis than CHD patients with non-COPD.

Impact of recurrent acute heart failure hospitalizations on prognosis of heart failure patients

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Hospitalizations for acute heart failure (AHF) are significant events for heart failure (HF) patients (pts) with each hospitalization portending a poor prognosis. Our aim was to compare pts with recurrent AHF admissions to those without and to study the impact of recurrent admissions on overall mortality. Methods Single centre retrospective study that included all pts followed at the HF Clinic of the Cardiology Department that had at least one visit during 2018. All data since their initial follow-up on HF Clinic was considered. Recurrent admissions were defined as 2 or more admissions for AHF in the same year, during the follow-up. Results A total of 138 pts were included (83% male, mean age 61±11years). Dilated cardiomyopathy (65;47%) and ischemic cardiomyopathy (62;45%) were the most frequent aetiologies and most pts had HF with reduced ejection fraction (131;95%). Mean left ventricular ejection fraction (LVEF) was 26±9% and right ventricular dysfunction was present in 27% of the cases. The majority of patients was on NYHA class II (80, 58%). A total of 84 (61%) pts was medicated with inhibitors of the renin-angiotensin system (iRAS), 45 (33%) with angiotensin receptor-neprilysin inhibitor (ARNI), 127 (92%) with beta-blockers (BB) and 116 (84%) with mineralocorticoid receptor antagonists (MRA). Ninety-seven (70%) pts had a cardiac electronic device implanted (47 CRT, 50 ICD). During a median follow-up of 40 months (IQR 32-58), 41 (30%) pts had hospitalizations for AHF and 21 (15%) had recurrent admissions. The median time to the first hospitalization was 16 months (IQR 6-29). Pts with recurrent admissions had a similar comorbidity profile and HF aetiology in comparison to pts with one or none admissions. Considering baseline echocardiographic parameters on first visit, they had a higher mean E/E’ ratio (22±8 vs 14±6, p= .012) and pulmonary systolic artery pressures (52±20 vs 38±14 mmHg, p= .026). No differences were found in LVEF, left ventricular volumes, presence of right ventricular dysfunction or mitral regurgitation. They were less frequently medicated with iRAS or ARNI (81% vs 96%, p=.012) and BB (81% vs 94%, p= .043) and had a higher mean diuretic dosage (87±47 vs 63±43 mg). During the follow-up a total of 31 (22%) pts died, 14 (10%) for cardiovascular reasons. Pts with recurrent AHF admissions were more likely to die from any cause (log rank =.01). On a multivariate analysis, recurrent AHF hospitalizations were an independent predictor of all-cause death (HR 2.4, IC95% 1.1-5.2, p=.03). Conclusion Recurrent AHF hospitalizations are associated with a worse long-term outcome of HF pts. Efforts should be made for an earlier identification of these pts. A higher baseline pulmonary systolic artery pressure and mean E/E’ ratio may identify a higher risk group who benefits from a closer follow-up.

Pulmonary Congestion During Exercise Stress Echocardiography in Ischemic and Heart Failure Patients.

Lung ultrasound detects pulmonary congestion as B-lines at rest, and more frequently, during exercise stress echocardiography (ESE). We performed ESE plus lung ultrasound (4-site simplified scan) in 4392 subjects referred for semi-supine bike ESE in 24 certified centers in 9 countries. B-line score ranged from 0 (normal) to 40 (severely abnormal). Five different populations were evaluated: control subjects (n=103); chronic coronary syndromes (n=3701); heart failure with reduced ejection fraction (n=395); heart failure with preserved ejection fraction (n=70); ischemic mitral regurgitation ≥ moderate at rest (n=123). In a subset of 2478 patients, follow-up information was available. During ESE, B-lines increased in all study groups except controls. Age, hypertension, abnormal ejection fraction, peak wall motion score index, and abnormal heart rate reserve were associated with B-lines in multivariable regression analysis. Stress B lines (hazard ratio, 2.179 [95% CI, 1.015-4.680]; P=0.046) and ejection fraction <50% (hazard ratio, 2.942 [95% CI, 1.268-6.822]; P=0.012) were independent predictors of all-cause death (n=29 after a median follow-up of 29 months). B-lines identify the pulmonary congestion phenotype at rest, and more frequently, during ESE in ischemic and heart failure patients. Stress B-lines may help to refine risk stratification in these patients. URL: https://www. gov; Unique identifier: NCT03049995.

Incremental Prognostic Value of Left Ventricular Global Longitudinal Strain in Patients with Preserved Ejection Fraction Undergoing Transcatheter Aortic Valve Implantation

Evaluation of left ventricular global longitudinal strain (LVGLS) has allowed better characterization than left ventricular ejection fraction (LVEF) of subtle differences in left ventricular performance. The aim of this study was to determine whether LVGLS has prognostic value in patients with severe aortic stenosis and preserved LVEF undergoing transcatheter aortic valve implantation(TAVI). Among 412 consecutive patients who underwent TAVI, 344 patients (mean age, 78.9±5.0years; 161 men) with preserved LVEF (≥50%) at baseline were analyzed. Patients with low LVEF (<50%) were used as a comparison group in the survival analysis. The primary and secondary end points were all-cause death and a composite of cardiovascular death and heart failure hospitalization, respectively. The mean LVGLS and LVEF were -17.1±2.7% and 63±5%, respectively. Impaired LVGLS was defined as >-16%, which was the first LVGLS quartile (cutoff value, -16%). The estimated actuarial 5-year survival rate was 81.7±4.2% in the normal LVGLS group and 66.8±7.5% in the impaired LVGLS group (P=.005). In the multivariable analysis, impaired LVGLS was an independent predictor of all-cause death (adjusted hazard ratio, 2.26; 95% CI, 1.11-4.60) and the composite outcome (adjusted hazard ratio, 3.03; 95% CI, 1.45-6.33). Moreover, the impaired LVGLS group had a poor prognosis, similar to the impaired LVEF group (<50%). The addition of the absolute value of LVGLS to the clinical parameters and LVEF led to significant improvement in the prediction of all-cause mortality. In patients with severe aortic stenosis and preserved LVEF undergoing TAVI, subclinical LV dysfunction defined by impaired LVGLS is independently associated with poor clinical outcomes. LVGLS measurement provides incremental prognostic value above the established clinical and echocardiographic parameters.

Death and cardiovascular outcomes in end-stage renal failure patients on different modalities of dialysis

Cardiovascular morbidity and mortality in end-stage renal failure (ESRF) patients are high. We examined the incidence and predictors of death and acute myocardial infarction (AMI) in ESRF patients on different modalities of dialysis. Data were obtained from a population-based database (National Registry Disease Offices) in Singapore. The study cohort comprised all adult patients initiated on dialysis between 2007 and 2012 who were closely followed for the development of death and AMI until September 2014. Cox regression methods were used to identify predictors of death and AMI. Of 5,309 patients, 4,449 were on haemodialysis and 860 on peritoneal dialysis (PD). Mean age of the cohort was 61 (±13) years (44% women), of Chinese (67%), Malay (25%) and Indian (7%) ethnicities. By September 2014, the incidence of all-cause death was 34%; close to a third of the patients died from a cardiovascular cause. Age >60 years and the presence of ischaemic heart disease, diabetes, stroke, peripheral vascular disease and PD were identified as independent predictors of all-cause death. PD patients had lower odds of survival compared to patients on haemodialysis (hazard ratio 1.51, 95% confidence interval 1.35-1.70, P<0.0001). Predictors of AMI in this cohort were older age (>60 years) and the presence of ischaemic heart disease, diabetes, stroke, peripheral vascular disease and current/ex-smokers. There were no significant differences in the incidence of AMI between patients on PD and haemodialysis. The short-term incidence of death and AMI remains high in Singapore. Future studies should investigate the benefits of a tighter control of cardiovascular risk factors among ESRF patients on dialysis.

Soluble urokinase plasminogen activator receptor and functionally relevant coronary artery disease: a prospective cohort study

Background Soluble urokinase plasminogen activator receptor (suPAR) is an emerging biomarker associated with anatomical CAD burden and cardiovascular outcomes including myocardial infarction (MI) and death. We aimed to validate previous findings of the prognostic value of suPAR and to evaluate its diagnostic potential for functional relevant CAD (fCAD). Methods Consecutive patients with suspected fCAD were enrolled. Adjudication of fCAD was performed blinded to suPAR concentrations by myocardial perfusion single-photon emission tomography (MPI-SPECT) and coronary angiography. Prognostic outcome measures included all-cause death, cardiovascular death, and incident MI during 2-year follow-up. Results Among consecutive 968 patients, suPAR concentrations were higher in patients with fCAD compared to those without (3.45 vs. 3.20 ng/mL, p = 0.007), but did not provide acceptable diagnostic accuracy (area under the curve [AUC]: 0.56, 95%CI 0.52–0.60). SuPAR correlated with high-sensitivity cardiac-troponin T (Spearman’s rho (ρ) 0.393, p < 0.001), NT-proBNP (ρ = 0.327, p < 0.001), age (ρ = 0.364, p < 0.001) and very weakly with coronary atherosclerosis (ρ = 0.123, p < 0.001). Prognostic discrimination of suPAR was moderate for cardiovascular death (AUC = 0.72, 95%CI 0.62–0.81) and all-cause death (AUC = 0.72, 95%CI 0.65–0.79) at 2-years. SuPAR remained a significant predictor for all-cause death in multivariable Cox regression (HR = 1.96, p = 0.001). Conclusions SuPAR was an independent predictor of all-cause death, without diagnostic utility for fCAD. Clinical trial registration NCT01838148

Prognostic value of Doppler coronary artery assessment in comparison with other echocardiographic prognostic parameters

Abstract Funding Acknowledgements Type of funding sources: None. Background Coronary artery Doppler assessment during routine echocardiography is an established diagnostic tool, that was proved by previous investigators. The prognostic value of impaired coronary flow in left coronary artery was also recently shown in pilot studies [1, 2]. A low feasibility and unknown prognostic value in comparison with other traditional echocardiographic parameters in non-selected population are considered as the main limitations of this method. Aim To evaluate feasibility and the prognostic value of coronary artery ultrasound assessment in a non-selected population in everyday clinical practice in comparison with other echocardiographic parameters. Methods: 581 non-selected patients were screened in prospective cohort study. Left coronary artery flow was scanned in addition to conventional echocardiography. Follow-up period was 12 months. All-cause mortality, myocardial infarction, revascularization, and hospitalization due to heart failure decompensation were defined as major adverse cardiac events (MACE). Results: Feasibility of coronary artery visualization and Doppler assessment was 89.8%. Follow-up was available in 92% of patients; during this period 22 deaths and 1 non-fatal MI occurred, 116 patients had MACE. In univariable analysis age, global longitudinal strain (GLS), left atrium index and maximal coronary velocity were predictors for all-cause death (p &amp;lt; 0.006-0.0001), but ejection fraction was not (p &amp;lt; 0.29). In multivariable analysis maximal coronary velocity (HR: 1.02, 95%, CI: 1.01-1.03, p &amp;lt; 0.0006), age (HR: 1.06, 95%, CI: 1.01-1.11, p &amp;lt; 0.02), and left atrium index (HR: 1.05, 95%, CI: 1.01-1.08, p &amp;lt; 0.007) were independent predictors for all-cause death. Maximal coronary velocity (HR: 1.02, 95%, CI: 1.01-1.03, p &amp;lt; 0.0001), age (HR: 1.03, 95%, CI: 1.01-1.05, p &amp;lt; 0.006), GLS (HR: 0.90, 95%, CI: 0.85-0.96, p &amp;lt; 0.0008) and left atrium index (HR: 1.02, 95%, CI: 1.01-1.04, p &amp;lt; 0.009) were independent predictors for MACE. Conclusion Doppler coronary flow velocity scanning during routine echocardiography is a feasible and valuable tool for assessment of short-term prognosis in non-selected patients. Its short-term prognostic value is better than prognostic value of ejection fraction and global longitudinal strain for the same patients. Abstract Figure. Coronary flow velocity

Prognostic Value of Age-Adjusted D-Dimer Cutoff Thresholds in Patients with Acute Coronary Syndrome Treated by Percutaneous Coronary Intervention.

BackgroundAssociations between D-dimer and outcomes of patients with acute coronary syndrome (ACS) remain controversial. Using age-adjusted D-dimer cutoff thresholds improve the diagnostic accuracy for thrombotic diseases. This study aimed to investigate the prognostic value of age-adjusted D-dimer in ACS patients treated by percutaneous coronary intervention (PCI).MethodsA total of 3972 consecutive patients with ACS treated by PCI were retrospectively recruited. The basal age-adjusted D-dimer threshold was 500 ng/mL and was calculated as age × 10 in patients older than 50 years. Cox regression was used for outcome analysis. C-index, net reclassification index (NRI), and integrated discrimination improvement (IDI) were calculated to assess the additional prognostic value of age-adjusted D-dimer when combined with established clinical risk factors. The primary outcome was all-cause death.ResultsDuring a median follow-up of 720 days, a total of 225 deaths occurred. High D-dimer level, as defined by age-adjusted thresholds, was an independent predictor for all-cause death (hazard ratio [HR]: 1.75, 95% confidence interval [CI]: 1.32–2.31, P < 0.001), cardiac death (HR: 1.84, 95% CI: 1.30–2.60, P = 0.001), and MACE (HR: 1.48, 95% CI: 1.19–1.83, P < 0.001). Sensitivity and subgroup analysis showed that high D-dimer levels were constantly associated with worse outcomes across common risk factors and comorbidities. Besides, age-adjusted elevation of D-dimer significantly improved the risk predictions for all-cause death when added to the model of established risk factors (C-index: 0.846 vs 0.838, Δ C-index: 0.008, 95% CI: 0.001–0.015, Pdifference = 0.027; NRI: 0.645, 95% CI: 0.464–0.826, P < 0.001; IDI: 0.008, 95% CI: 0.001–0.017, P = 0.048).ConclusionIn ACS patients treated by PCI, age-adjusted elevation of D-dimer was an independent predictor for adverse outcomes and improved the risk predictions for long-term mortality.

Patient Survival Between Hemodialysis and Peritoneal Dialysis Among End-Stage Renal Disease Patients Secondary to Myeloperoxidase-ANCA-Associated Vasculitis.

BackgroundA significant proportion of anti-neutrophil cytoplasmic antibody (ANCA) associated glomerulonephritis eventually progresses to end-stage renal disease (ESRD) thus requiring long-term dialysis. There is no consensus about which dialysis modality is more recommended for those patients with associated vasculitis (AAV-ESRD). The primary objective of this study was to compare patient survival in patients with AAV-ESRD treated with hemodialysis (HD) or peritoneal dialysis (PD).MethodsThis double-center retrospective cohort study included dialysis-dependent patients who were treated with HD or PD. Clinical data were collected under standard format. The Birmingham vasculitis activity score (BVAS) was used to evaluate disease activity at diagnosis and organ damage was assessed using the vasculitis damage index (VDI) at dialysis initiation.ResultsIn total, 85 patients were included: 64 with hemodialysis and 21 with peritoneal dialysis. The patients with AAV-PD were much younger than the AAV-HD patients (48 vs. 62, P < 0.01) and more were female (76.2 vs. 51.6%, P = 0.05). The laboratory data were almost similar. The comorbidities, VDI score, and immuno-suppressive therapy at dialysis initiation were almost no statistical difference. Patient survival rates between HD and PD at 1 year were 65.3 vs. 90% (P = 0.062), 3 year were 59.6 vs. 90% (P < 0.001), and 5 years were 59.6 vs. 67.5% (P = 0.569). The overall survival was no significant difference between the two groups (P = 0.086) and the dialysis modality (HD or PD) was not shown to be an independent predictor for all-cause death (hazard ratio (HR) 0.73; 95% confidence interval (CI) 0.31–1.7; P = 0.473). Cardio-cerebrovascular events were the main cause of death among AAV-HD patients while infection in patients with AAV-PD.ConclusionThese results provide real-world data that the use of either hemodialysis or peritoneal dialysis modality does not affect patient survival for patients with AAV-ESRD who need long-term dialysis.

Impact of comorbidities on older patients undergoing open heart surgery.

The number of elderly patients undergoing cardiac surgery is increasing. Age greater than 80 years has been identified as a strong independent risk factor for shortand long-term survival. The current study is aimed to identify the impact of preoperative comorbidities on early and late outcomes in older patients undergoing cardiac surgery. Baseline characteristics, procedurals and postoperative complications of all patients undergoing cardiac surgery at our institution are collected. The current analysis is focused on patients aged at least 80 years at the time of intervention and treated from January 2010 to December 2019. In-hospital mortality resulted as 6.3%. Redo intervention [odds ratio (OR) 2.49, 95% confidence interval (CI) 1.13-5.48], chronic obstructive pulmonary disease (COPD) (OR 2.99, 95% CI 1.75-5.12) and peripheral arterial disease (PAD) (OR 2.23, 95% CI 1.30-3.81) were independent baseline predictors of outcome in the multivariate analysis. Prolonged extracorporeal circulation time, need for transfusion and prolonged intubation time strongly and independently predicted in-hospital mortality. During a mean follow-up of 3.6 years 34.3% of patients died and unplanned admission (HR 1.33, 95% CI 1.05-1.67), NYHA class III-IV (HR 1.35, 95% CI 1.12-1.64), diabetes (HR 1.27, 95% CI 1.01-1.59), COPD (HR 1.60, 95% CI 1.25-2.04) and PAD (HR 1.32, 95% CI 1.03-1.71) resulted as independent predictors of all-cause death. Cardiac surgery is feasible in octogenarians, with an acceptable risk of mortality. Chronological age itself should not be the main determinant of choice while referring patients for cardiac surgical intervention. Comorbidities such as COPD, PAD and diabetes need to be taken into account for risk stratification.

Risk Factors for Prognosis after the Maze IV Procedure in Patients with Atrial Fibrillation Undergoing Valve Surgery

The present study evaluated risk factors related to persistent atrial fibrillation (AF) at discharge (AF-d) and recurrent atrial fibrillation (rAF) and all-cause death after the maze IV procedure. Two hundred nineteen patients (63 female, aged 52.5±8.8 years) with valve disease and persistent AF undergoing valve surgery and the maze IV procedure in our center between 2015 and 2016 were included. Baseline demographic and clinical data were obtained by review of medical records. The median follow-up period was 27 months (interquartile range 21–34 months) in our patient cohort. The primary end point was all-cause death. The secondary end point was AF-d or rAF. rAF is defined as AF recurrence at 3 months or later after the procedure. Twenty-eight patients (12.8%) died during follow-up. Multiple logistic regression analysis showed that thrombocytopenia, elevated serum total bilirubin level, a larger right atrium, AF-d, and rAF were independent determinants for all-cause death after the maze IV procedure after adjustment for age, sex, and clinical covariates, including New York Heart Association class III/IV disease, hypertension, and aortic regurgitation, while valvular disease duration and left atrial diameter greater than 80.5 mm were independent determinants for AF-d, and thrombocytopenia, elevated serum total bilirubin level, higher mean pulmonary artery pressure, and AF-d were independent predictors for rAF. In conclusion, thrombocytopenia, elevated serum total bilirubin level, an enlarged right atrium, AF-d, and rAF are independent predictors of all-cause death in patients undergoing the maze IV procedure.

The Prognostic Significance of Chronic Kidney Disease on the All-Cause Death of Ischemic Heart Failure in the Chinese Population: A Prospective Cohort Study

Objective: Our team tried to explore the impact of chronic kidney disease (CKD) on all-cause death among ischemic heart failure (IHF) patients. Methods: From December 2015 to June 2019, IHF patients were continuously recruited in the Department of Cardiology, Guangdong Provincial People’s Hospital. Participants were tracked through telephone interviews until October 15, 2020, or until the clinical endpoints appeared. The clinical endpoints were defined as all-cause death. The date of death or the last follow-up date minus the discharge date was used to calculate the follow-up time. Results: A total of 1568 IHF patients (mean age 63.5 ± 11.0 years old, 85.8% male) were included in this study. Using the estimated glomerular filtration rate (eGFR) of 60 mL/min/1.73 m² as the dividing line, IHF patients were divided into non-CKD group (n = 1,134) and CKD group (n = 434). After a median follow-up of 2.1 years, the all-cause death of non-CKD and CKD patients was 6.1/100 person-years and 13.7/100 person-years, respectively, and the incidence rate ratio was 2.24 (95% CI: 1.75–2.88; p value <0.001). The cumulative all-cause death of non-CKD and CKD patients were 19.4% and 40.7%, respectively (p value <0.001). CKD was an independent predictor of all-cause death in IHF patients (HR: 1.35, 95% CI: 1.03–1.76, p value = 0.029). Among IHF patients, in 8 subgroups, the all-cause death of CKD patients was consistently higher than that of non-CKD patients. Among IHF patients, the risk of all-cause death gradually increased when eGFR gradually decreased. Conclusion: Among IHF patients, CKD is a significant risk factor for all-cause death.

Early and mid-term results in patients undergoing primary CABG in comparison with patients with PCI prior to CABG

Aim: We evaluated the impact of prior percutaneous coronary intervention (PCI) on early and mid-term results in patients undergoing coronary artery bypass grafting (CABG). Methods: Between 2015 and 2020, 938 consecutive patients (mean age 67.4 ± 9.11 years) underwent CABG with prior PCI (n = 121) or primary CABG (n = 817). The mean follow-up was 37 ± 25 (median 36) months. Kaplan-Meier estimates were used to assess survival rates, while Logistic and Cox model analysis regressions assessed the risk of prior PCI and other variables. Results: Six-year survival including in-hospital mortality was 79% ± 6% in CABG with prior-PCI patients vs.88% ± 2% in primary CABG (P = 0.002). As compared with primary CABG, in prior-PCI patients, clinical presentation (acute coronary syndrome, reduced left ventricular ejection fraction, and previous myocardial infarction, P ≤ 0.01, for all comparisons) was worse, comorbidity increased (Euroscore-2, severe chronic renal dysfunction, P &lt; 0.01), and in-hospital mortality was higher (6.6% or 8 patients vs. 1.6% or 13 patients, P &lt; 0.001). Prior PCI was found to be an independent predictor of mortality (HR = 4.23; P = 0.01). Six-year freedom from late all-cause death and cardiac death were 84% ± 6% vs. 90% ± 2% (P = 0.2) and 96% ± 2% vs. 96% ± 1% (P = 0.5), respectively. Independent predictors of all-cause death were advanced age at the operation (P &lt; 0.0001), reduced left ventricular ejection fraction (P = 0.01), severe chronic renal dysfunction (P = 0.02), prior PCI (P = 0.03), and Euroscore-2 (P = 0.05). Prior PCI did not negatively affect late cardiac death (P = 0.5). Conclusion: Patients undergoing CABG after prior PCI have worse perioperative outcomes. Mid-term reduced survival in the prior-PCI patients is mainly due to the concomitant presence of worse clinical presentation and increased comorbidity. Freedom from cardiac death is comparable and satisfactory in both cohorts, highlighting the positive protective effect of CABG over time.