Independent Predictor Of All-cause Death Research Articles

P671Impacts of echocardiography-defined pulmonary hypertension on clinical outcome in patients with multiple myeloma

Abstract Background Pulmonary hypertension (PH) is a rarely reported complication of multiple myeloma (MM). PH of MM is usually mild to moderate and can be secondary to a variety of conditions, including left ventricular dysfunction, diastolic dysfunction, chronic heart failure, treatment-related toxicity, thrombophilic condition and precapillary involvement. However, only few reports regarding PH in MM incidence and prognosis exist up to now. Purpose The purpose of this study was to investigate the risk factors of transthoracic echocardiography-defined PH and its impact on clinical outcome in patients with MM. Methods A total of 277 MM patients was included and divided into 2 groups–those non-pulmonary hypertension (PH) or those with PH, based on the results of the transthoracic echocardiography (TTE); PH group (n=143, 60.9±9.2 years, 68 males) versus non-PH group (n=134, 55.9±11.5 years, 72 males). We analyzed propensity score matching and multiple imputation method were used to deal with the missing data in echocardiographic characteristics. Results During the follow-up period (median 618 days), all-cause death occurred in 79 (28.5%) patients and 41 patients (14.8%) died from cardiovascular causes (including acute decompensated heart failure, fatal MI, sudden cardiac arrest). In the Kaplan-Meier survival analysis of crude population and propensity-matched population, cumulative overall survival and cardiovascular death (CVD)-free survival were significantly lower in the PH group than in the non-PH group (p<0.001). In propensity-matched population, estimated pulmonary artery pressure >35mmHg in TTE, congestive heart failure, and DM were significant independent predictors of all-cause death. KM curves in MM stratified by PH Conclusion This study demonstrates that the presence of PH, congestive heart failure, and DM is an independent prognostic factor for all-cause death in MM patients with MM. These results highlight the risk associated cardiovascular disease in MM patients and emphasize that management strategies that prevent deterioration of cardiac function are essential.

Stromal cell derived factor-1 and long-term prognosis in acute coronary syndrome.

Aim: To explore long-term prognostic value of SDF-1 in acute coronary syndrome (ACS). Materials & methods: We included 254 patients with ACS. Plasma SDF-1 was measured and patients were classified into tertiles of SDF-1. Results: Multivariate analysis showed third tertile of SDF-1 as an independent predictor of all-cause death (HR: 2.5; 95% CI: 1.2-5.2; p = 0.011) and the composite of major adverse cardiovascular and cerebrovascular events (HR: 1.8; 95% CI: 1.1-3.1; p = 0.031). SDF-1 added to a clinical model can improve all-cause death prediction (net reclassification improvement 0.362; 95% CI: 0.423-0.681; p = 0.027). Conclusion: SDF-1 is an independent predictor of all-cause mortality and major adverse cardiovascular and cerebrovascular events in long-term follow-up of patients with ACS and adds prognostic information beyond traditional cardiovascular risks factors.

Progression of right ventricular dysfunction and predictors of mortality in patients with idiopathic interstitial pneumonias

BackgroundFew studies have examined the relationship between echocardiographic indices of right ventricular (RV) function and the severity of pulmonary disease, or their prognostic impact. We evaluated the RV function in patients with interstitial pneumonia and its prognostic impact at each stage of disease severity. MethodA total of 176 patients with idiopathic interstitial pneumonias (IIPs) were retrospectively enrolled and we evaluated RV function by transthoracic echocardiography. The severity of IIPs was graded according to the Goh score. The primary outcome was all-cause death. ResultsThere were 55 patients in mild group (31%), 66 in moderate group (38%), and 55 in severe group (31%). Regarding RV function, RV free wall longitudinal strain and tricuspid annular plane systolic excursion (TAPSE) deteriorated with increasing severity of IIPs, but fractional area change (FAC) decreased significantly only in severe group. There were 64 all-cause deaths during the follow-up period (median 908 days). In moderate group, TAPSE [hazard ratio (HR): 0.85, 95% confidence interval (CI): 0.74–0.97, p=0.017], FAC (HR: 0.89, 95% CI: 0.83–0.96, p=0.001), and mean pulmonary artery pressure (PAP)/cardiac output (HR: 1.50, 95% CI: 1.08–2.09, p=0.015) were independent predictors of all-cause death, even after adjusting for age and log brain natriuretic peptide (BNP). On the other hand, not RV function or PAP but male sex and BNP level were associated with mortality in severe group. ConclusionsAmong patients with IIPs, RV longitudinal function deteriorated with increasing severity of IIPs. Echocardiographic indices of RV function were independently associated with mortality in moderate-stage IIPs.

192 Interleukin-6 and C-Reactive Protein Predict all Cause Death and Poor Functional Outcome after Non-Severe Stroke and Transient Ischaemic Attack

Abstract Background Inflammation plays a role in the development of ischaemic cerebrovascular events. High sensitivity C-reactive protein (CRP) is known to predict recurrent events. Little data exists for more upstream serum markers of inflammation. Methods BIO-STROKE and BIO-TIA were multicentre prospective biomarker and imaging studies of patients with non-severe stroke, TIA and controls. Exclusion criteria were malignancy, infection, recent trauma / surgery, recurrent stroke before phlebotomy/MRI. Serum biomarkers analysed included Interleukin (IL) – 6, CRP, IL-1, IL-8, IL10, IL12p70, IFN and TNF.Plasma CRP and IL-6 were measured by mass spectrometry. Additional biomarkers were measured using ELISA. Follow up was performed at 7, 28, 90 days and 1 year. Results 680 patients (439 strokes, 241 TIAs) and 68 controls were included in the analysis. The median age was 70 for cases. Carotid stenosis was present in 23.6% of cases. Median CRP was 3.75mg/L, 2.36mg/l and 1.87mg/L in the stroke, TIA and control groups (p=<0.001). Median IL-6 was 5.86pg/ml (stroke), 4.25pg/ml (TIA), 3.06pg/ml (control) (p=<0.001). On multivariate cox regression analysis baseline IL6 and CRP were independent predictors of all cause death at 1 year with a HR of 1.005 (95% CI 1.002-1.007, p<0.001).and 1.005(95% CI 1.002-1.007, p<0.001) per unit increase. Both IL6 and CRP were associated with vascular death at 1 year. In adjusted analyses, IL6 and CRP were associated with poor functional outcome at 1 year (OR of 1.02(CI 1.01 -1.03) and 1.02(CI 1.01-1.03) per unit increase, for IL6 and CRP respectively). On adjusted analysis, when IL6 was analysed as quartiles, there was a strong association with death at 1 year with an OR 1.87 (95% CI 1.19-2.93).CRP, analysed as quartiles, demonstrated an OR for death at 1 year of 1.64 (1.10-2.46). Conclusion IL-6 and CRP may be a useful prognostic factor for the prediction of outcome and death after stroke at 1 year follow up.

Contemporary management of stent thrombosis: Predictors of mortality and the role of new‐generation drug‐eluting stents

We sought to evaluate mortality predictors and the role of new-generation drug-eluting stents (NG-DES) in stent thrombosis (ST) management. No data are available regarding the outcome of patients with ST after interventional management that includes exclusively NG-DES. Patients with definite ST of DES or BMS who underwent urgent/emergent angiography between 2015 and 2018 at our institution were considered for the study. After excluding patients who achieved TIMI-flow<2 after intervention or received an old-generation stent, 131 patients were included. Management classification was stent or non-stent treatment (medical management, thromboaspiration, balloon-angioplasty). Follow-up was performed to document all-cause death (ACD) and target-lesion-revascularization (TLR) that was used for censorship. Mode of presentation was STEMI in 88% and UA/NSTEMI in 12%. Type of ST was early, late, and very late in 11, 4, and 85%, respectively. Eighty four patients received stent and 47 non-stent treatment. After 926 ± 34 days, 21 ACDs, 7 TLRs and no cases of definite, recurrent ST were observed. Univariate predictors of in-hospital mortality were LVEF and presentation with shock or cardiac arrest. For patients discharged alive, non-stent treatment (HR 4.2, p = .01), TIMI-2 flow (HR 7.4, p = .002) and GFR < 60 mL/min (HR 3.8, p = .01) were independent predictors of ACD. The stent-treatment group had significantly better ACD-free survival after discharge, both unadjusted (p = .022) and adjusted (p = .018). After ST management, different predictors were observed for in-hospital mortality and mortality in patients discharged alive. The better outcome with NG-DES treatment is a novel observation, warranting further studies to elucidate if it is associated with stent-related or patient-related factors.

CHA2DS2VASc score and adverse outcomes in middle-aged individuals without atrial fibrillation.

The CHA2DS2VASc score is used to evaluate the risk of thromboembolic events in patients with non-valvular atrial fibrillation. We assessed the prognostic yield of CHA2DS2VASc for new-onset atrial fibrillation, cardiovascular morbidity and mortality in a non-atrial fibrillation population. We analysed a population-based cohort of 22,179 middle-aged individuals with (n = 3542) and without (n = 18,367) a history of atrial fibrillation; we grouped the population into five CHA2DS2VASc strata (0-1-2-3-≥4), and compared the risk of major adverse cerebro-cardiovascular events and mortality. Furthermore, we analysed the annual incidence of atrial fibrillation across different CHA2DS2VASc strata. Over a median follow-up of 15 years, 1572 patients (6.9%) had ischaemic strokes, 2162 (9.5%) coronary events and 5899 (26%) died. The cumulative incidence of ischaemic stroke in CHA2DS2VASc ≥ 4 subjects without atrial fibrillation was similar to patients with atrial fibrillation and CHA2DS2VASc 2, with a 10-year crude incidence rate of 0.91 (95% confidence interval (CI) 0.68-1.19) and 1.13 (95% CI 0.93-1.36) ischaemic strokes per 100 patient-years, respectively. CHA2DS2VASc in a non-atrial fibrillation population showed higher predictive accuracy for ischaemic stroke compared with an atrial fibrillation population (area under the curve 0.60 vs. 0.56; P = 0.001). In multivariable Cox regression analysis, CHA2DS2VASc ≥ 2 was an independent predictor of all-cause death (adjusted hazard ratio (aHR) 2.58; 95% CI 2.42-2.76), cardiovascular death (aHR 3.40; 95% CI 2.98-3.89), ischaemic stroke (aHR 2.20; 95% CI 1.92-2.53) and coronary events (aHR 1.83; 95% CI 1.63-2.04). The cumulative incidence of atrial fibrillation was greater with increasing CHA2DS2VASc strata, with an absolute annual incidence of more than 2% per year if CHA2DS2VASc ≥ 4. The CHA2DS2VASc score is a sensitive tool for predicting new-onset atrial fibrillation and adverse outcomes in subjects both with and without atrial fibrillation.

Serum Uric Acid is an Independent Predictor for All-Cause Death and Rehospitalization in Patients with Acute Decompensated Heart Failure: Insights from KCHF Registry

Background Heart failure (HF) can be associated with higher serum uric acid (SUA) levels. Although higher SUA in stable chronic HF were reported to have worse outcomes, underlying pathophysiology and causal role of SUA in HF is unclear. The aim of this study was to test the hypothesis that SUA at admission or discharge could be an independent predictor for all-cause death and re-hospitalization in patients with acute decompensated heart failure (ADHF). Methods and Results This is post-hoc analysis from a prospective, observational, multicenter cohort study, enrolling consecutive 3,717 ADHF patients from 19 participating hospitals in Japan from October 2014 and March 2016. Patients were divided into tertile of SUA at discharge, which was stratified by sex. The mean SUA at discharge was 7.13±2.10 mg/dl in male and 6.98±2.26 mg/dl in female, respectively. During a mean follow-up of 1.1±0.7 years, there were 575 deaths and 662 HF hospitalization. Higher SUA at discharge was associated with worse outcomes, defined as a composite of all-cause death and HF rehospitalization in both male and female (Figure). After multivariable adjustment including age, body mass index, ischemic etiology, hypertension, diabetes mellitus, hyperlipidemia, prior stroke, COPD, smoking, reduce LVEF ( Conclusions Higher SUA both at admission and discharge were associated with worse outcomes in ADHF patients. We should account for SUA as a predictor for all-cause death and HF rehospitalization in ADHF patients.

Prognostic Values of Serum Chloride and Sodium Levels in Patients with Three-vessel Disease

ObjectiveIdentification of new risk factors is needed to improve prediction of adverse outcomes in patients with three-vessel disease (TVD). The present study aimed to evaluate the prognostic values of serum chloride and sodium levels in patients with TVD. MethodsWe used data from a prospective cohort of consecutive patients with angiographically confirmed TVD. The primary endpoint was all-cause death. Cox proportional hazard regression was used to analyze the relationship of serum chloride and sodium levels with long-term outcomes of TVD patients. ResultsA total of 8,318 participants with available serum chloride and sodium data were included in this analysis. At baseline, patients in the low tertiles group of serum chloride level (≤ 102.0 mmol/L) or serum sodium level (≤ 139.0 mmol/L) had more severe disease conditions. During a median follow-up of 7.5-year, both low serum chloride level and low serum sodium level were found to be associated with an increased risk for mortality in univariate analysis. However, when both parameters were incorporated into a multivariate model, only low serum sodium level remained to be an independent predictor of all-cause death (hazard ratio: 1.16, 95% confidence interval: 1.01-1.34, P = 0.041). Modest but significant improvement of discrimination was observed after incorporating serum sodium level into the Synergy between percutaneous coronary intervention (PCI) with Taxus and Cardiac Surgery score. ConclusionSerum sodium level is more strongly associated with long-term outcomes of TVD patients compared with serum chloride level. Low serum sodium level is an independent risk factor for mortality, but only provides modest prognostic information beyond an established risk model.

Relation of Systolic Blood Pressure on the Following Day with Post-Discharge Mortality in Hospitalized Heart Failure Patients with Preserved Ejection Fraction.

The clinical scenario, which is based on systolic blood pressure (SBP) upon admission, is useful for classifying and determining initial treatment for acute heart failure (HF). However, the prognostic significance of SBP following the initial treatment is unclear.The Japanese Heart Failure Syndrome with Preserved Ejection Fraction (JASPER) registry is a nationwide, observational, and prospective registration of consecutive Japanese patients hospitalized with HF with preserved ejection fraction (HFpEF) and left ventricular ejection fraction ≥ 50%. We divided 525 patients into three groups based on their SBP on the day following hospitalization: high (SBP > 140 mmHg, n = 72, 13.7%); normal (100 ≤ SBP ≤ 140 mmHg, n = 379, 72.2%); and low (SBP < 100 mmHg, n = 74, 14.1%) groups. This analysis had two primary endpoints: (1) all-cause death and (2) all-cause death or rehospitalization for HF. In the Kaplan-Meier analysis, both of the endpoints were the highest in the low group (Log-Rank < 0.05, respectively). Compared to the normal and high groups, the low group demonstrated a higher prevalence of atrial fibrillation (67.1%, 63.9%, and 47.8%, P = 0.026) and the lowest left ventricular outflow tract velocity time integral determined by echocardiography (16.4 cm, 19.4 cm, and 23.3 cm, P = 0.001). In the multivariable Cox proportional hazard analysis, low SBP on the day following hospitalization was an independent predictor of all-cause death (hazard ratio 1.868, 95% confidence interval 1.024-3.407, P = 0.042) and the composite endpoint (hazard ratio 1.660, 95% confidence interval 1.103-2.500, P = 0.015).Classification based on SBP on the day following initial treatment predicts post-discharge prognosis in hospitalized patients with HFpEF.

The MAGGIC risk score predicts mortality in patients undergoing transcatheter aortic valve replacement: sub-analysis of the OCEAN-TAVI registry

This study is aimed to evaluate the performance of MAGGIC risk score for predicting mortality by external validation using multicenter transcatheter aortic valve replacement (TAVR) registry. We assessed 1383 patients who underwent TAVR from October 2013 to April 2016. Patients were divided into 2 groups according to the median of MAGGIC score and we compared the incidence of all-cause death between high and low MAGGIC score. To assess whether the MAGGIC risk score add prognostic value on STS risk score, we also compared the incidence of all-cause death between the 2 groups according to low, intermediate, and high STS score. The median of MAGGIC score was 29 (interquartile range: 13-46). Within 2years, 147 cases of all-cause death were observed. The high MAGGIC (30-46) risk score was significantly associated with an increased risk of all-cause death as compared to low MAGGIC (11-29) risk score and this relationship was also observed in patients with high STS risk score. However, this relationship was not observed in patients with low and intermediate STS score. Multivariate analysis showed that the MAGGIC risk score was an independent predictor of all-cause death (hazard ratio, 1.07; 95% confidence interval, 1.03-1.11). Our results demonstrated that the MAGGIC score predicts all-cause death in TAVR population and provides better risk stratification, particularly in patients with high STS risk.

Gender Differences in Prognostic Markers of All-Cause Death in Patients with Acute Heart Failure: a Prospective 18-Month Follow-Up Study.

Acute heart failure (AHF) is a life-threatening condition with poor prognosis. Gender differences have been increasingly recognized in diverse cardiovascular diseases. The present study aimed to evaluate gender-specific prognostic markers of all-cause death in AHF patients based on a prospective 18-month follow-up study. Data were collected from 419 patients with AHF hospitalization who were followed up for 18months using all-cause death as primary endpoint. The mean age of all patients was 60.9 ± 15.7years old, 277 were males, and 142 were females. Females had higher rate of valvular heart disease (37.3%) and atrial fibrillation (45.8%) but lower rate of cardiomyopathy (30.3%) than males in this cohort. Based on multiple COX stepwise regression and ROC curve analysis, diastolic blood pressure (DBP), serum sodium, serum creatinine, and pulmonary artery systolic pressure (PASP) were identified as independent predictors of all-cause death in male AHF patients, while systolic blood pressure (SBP), serum aspartate transaminase (AST), serum creatinine, and serum D-dimer as independent predictors in females. Kaplan-Meier analysis showed a higher probability of all-cause death over time in male AHF patients with DBP ≤ 77mmHg, serum sodium ≤ 138.5mM, serum creatinine ≥ 126.2μM, or PASP ≥ 52mmHg, and in female AHF patients with SBP ≤ 129mmHg, serum AST > 29.3U/L, serum creatinine ≥ 102.7μM, or serum D-dimer ≥ 1.76mg/L. In conclusion, these data provide novel insights into gender differences in prognostic markers of outcomes of AHF patients.

Prognostic implications of troponin I elevation in emergency department patients with tachyarrhythmia.

BackgroundTachyarrhythmias are very common in emergency medicine, and little is known about the long‐term prognostic implications of troponin I levels in these patients.HypothesisThis study aimed to investigate the correlation of cardiac troponin I (cTnI) levels and long‐term prognosis in patients admitted to the emergency department (ED) with a primary diagnosis of tachyarrhythmia.MethodsA retrospective cohort study was conducted between January 2012 and December 2013, enrolling patients admitted to the ED with a primary diagnosis of tachyarrhythmia and having documented cTnI measurements. Clinical characteristics and 5‐year all‐cause mortality were analyzed.ResultsOf a total of 222 subjects with a primary diagnosis of tachyarrhythmia, 73 patients had elevated levels of cTnI (32.9%). Patients with elevated cTnI levels were older and presented significantly more cardiovascular risk factors. At the 5‐year follow‐up, mortality was higher among patients with elevated cTnI levels (log‐rank test P < 0.001). In the multivariable Cox regression analysis, elevated cTnI was an independent predictor of all‐cause death (hazard ratio, 1.95, 95% confidence interval: 1.08‐3.50, P = 0.026), in addition to age and prior heart failure.ConclusionPatients admitted to the ED with a primary diagnosis of tachyarrhythmia and high cTnI levels have higher long‐term mortality rates than patients with low cTnI levels. cTnI is thus a biomarker with predictive capacity for mortality in late follow‐up, conferring utility in the risk stratification of this population.

Impact of the clinical frailty scale on mid-term mortality in patients with ST-elevated myocardial infarction

Background“Frailty” is associated with poor prognosis in ST-elevated myocardial infarction (STEMI). However, there is little data regarding the impact of the Canadian Study of Health and Aging Clinical Frailty Scale (CFS), a simple and semiquantitative tool for assessing frailty, on mid-term mortality in STEMI patients. MethodsA total of 354 consecutive STEMI patients (mean age 69.8 ± 12.4 years; male 76.6%) who underwent percutaneous intervention between July 2014 and March 2017 were retrospectively reviewed. The study endpoint was mid-term mortality according to the CFS classification. Furthermore, in order to clarify the impact of CFS upon admission on mid-term mortality, the independent predictors of all-cause death were evaluated. ResultsPatients were categorized into three groups (CFS 1–3, n = 281; CFS 4–5, n = 62; and CFS 6–7, n = 11). During the study period (median 474 days), all-cause death was observed in 39 patients. After multivariate Cox regression analysis, higher CFS (adjusted hazard ratio [HR] 2.34, 95% confidence interval [CI] 1.43–3.85, p < 0.001), higher Killip score (adjusted HR 2.46, 95%CI 1.30–5.78, p = 0.002), and lower serum albumin level (adjusted HR 4.29, 95%CI 2.16–8.51, p < 0.001) were significantly associated with an increased risk of all-cause death. ConclusionIn conclusion, severe frailty was associated with mid-term mortality in STEMI patients who underwent PCI.

Predictors of outcome in patients with de novo diagnosis of heart failure with reduced ejection fraction: Role of combined myocardial and lung Iodine-123 Meta-Iodobenzylguanidine imaging

BackgroundThe predictors of outcome in patients with de novo diagnosis of heart failure (HF) with reduced ejection fraction (HFrEF) are poorly known. Methods and ResultsAll consecutive HFrEF patients admitted between October 2012 and November 2017 with their first episode of HF were scheduled for an outpatient follow-up. After 3 months, patients with confirmed HFrEF underwent Iodine-123 Meta-Iodobenzylguanidine imaging. We defined three study endpoints: HF rehospitalization, cardiac death and all-cause death. Eighty-four patients were enrolled. During follow-up (39.9 ± 18.6 months) HF rehospitalization occurred in 33 cases, cardiac death in 18 and all-cause death in 24. At multivariate analysis, systolic pulmonary arterial pressure (sPAP; HR: 1.047; p = .027) and Late lung to heart ratio (L/H; HR: 1.341; p < .001) independently predict HF rehospitalization; left ventricular end-systolic volume (LVESV; HR: 1.016; p = .017), sPAP (HR: 1.064; p = .034) and Late L/H (HR: 1.323; p = .009) were predictors of cardiac death; LVESV (HR: 1.013; p = .018) and Late L/H (HR: 1.245; p = .012) were independent predictors of all-cause death. Kaplan–Meier analysis of the individual predictors confirmed their prognostic ability during follow-up; of note, the Late L/H cut-off of 1.1 improved the risk stratification capability of echocardiographic parameters. ConclusionsLate L/H independently predicts HF rehospitalization, cardiac death and all-cause death in patients with de novo diagnosis of HFrEF and improves the prognostic stratification capability of conventional echocardiographic parameters.

Geriatric nutritional risk index predicts all-cause deaths in heart failure with preserved ejection fraction.

AimsThe objective of the study was to evaluate whether the geriatric nutritional risk index (GNRI) at discharge may be helpful in predicting the long‐term prognosis of patients hospitalized with heart failure (HF) with preserved ejection fraction (HFpEF, left ventricular ejection fraction ≥50%), a common HF phenotype in the elderly.Methods and resultsOverall, 110 elderly HFpEF patients (≥65 years) from the Ibaraki Cardiovascular Assessment Study‐HF (n = 838) were enrolled. The mean age was 78.5 ± 7.2 years, and male patients accounted for 53.6% (n = 59). All‐cause mortality was compared between the low GNRI (<92) with moderate or severe nutritional risk group and the high GNRI (≥92) with no or low nutritional risk group. Cox proportional hazard regression models were constructed to evaluate the influence of the GNRI on all‐cause death with the following covariates using forward stepwise selection: age, sex, nutritional status based on the GNRI as a categorical variable, history of HF hospitalization, haemoglobin level, estimated glomerular filtration rate, log brain natriuretic peptide levels (logBNP), history of hypertension, log C‐reactive protein levels, left ventricular ejection fraction, left ventricular mass index, and the New York Heart Association functional classification (I/II or III class). The prognostic value of the GNRI was compared with that of serum albumin using C‐statistics. The GNRI was added to the logBNP, serum albumin or the body mass index was added to the logBNP, and the C‐statistic was compared using DeLong's test. Cox regression analysis revealed that age and a low GNRI were independent predictors of all‐cause death (P < 0.05, n = 103; hazard ratio = 1.095, 95% confidence interval = 1.031–1.163, for age, and hazard ratio = 3.075, 95% confidence interval = 1.244–7.600, for the GNRI). DeLong's test for the two correlated receiver operating characteristic curves [area under the receiver operating characteristic curve (AUROC) of serum albumin, 0.71; AUROC of the GNRI, 0.75] demonstrated significant differences between the groups (P = 0.038). Adding the GNRI to the logBNP increased the AUROC for all‐cause death significantly (0.71 and 0.80, respectively; P = 0.040, n = 105). The addition of serum albumin or the body mass index to the logBNP did not significantly increase the AUROC for all‐cause death (P = 0.082 and P = 0.29, respectively).ConclusionsNutritional screening using the GNRI at discharge is helpful to predict the long‐term prognosis of elderly HFpEF patients.

Adenosine stress myocardial perfusion imaging in octogenarians: Safety, tolerability, and long-term prognostic implications of hemodynamic response and SPECT-related variables

BackgroundEvaluation of tolerability, safety, and prognostic implications of adenosine stress myocardial perfusion imaging (MPI) in octogenarians. Methods370 octogenarians (49% known coronary artery disease) were studied. Hemodynamic response, MPI-related data, and rest-left ventricular ejection fraction (LVEF) based on echocardiography were registered per patient, and prospective follow-up was performed to document all-cause death (ACD), cardiac death (CD), myocardial infarction (MI), and late revascularization. ResultsNo deaths or MIs were observed during adenosine infusion or the short-term post-infusion period. 86% of patients were able to tolerate a 6-minute infusion. All side effects terminated spontaneously after infusion cessation, except for one case of pulmonary oedema. After 9.3 years, there were 124 ACDs, 62 CDs, 16 MIs, and 35 revascularizations. Differences between survival curves of summed stress score (SSS)-based risk groups were significant for all end points (P < .001). SSS and LVEF were independent predictors of all end points (P ≤ .01) and lung uptake of cardiac end points. ΔHR <10 bpm (OR = 1.78, P = .004) and inability to increase HR by >10 bpm and decrease systolic blood pressure by >10 mmHg (OR = 2, P = .02) during adenosine infusion were independent predictors of ACD and CD, respectively. Hemodynamic response variables, SSS, and lung uptake provided incremental prognostic value over pre-test data for ACD and CD. ConclusionsIn octogenarians, adenosine stress MPI is well tolerated and provides effective long-term risk stratification.

Prognostic Value of Vascular Calcifications and Regional Fat Depots Derived From Conventional Chest Computed Tomography.

The prognostic value of vascular calcifications as well as of regional fat depots has been reported separately, in population-based studies, and using gated-computed tomography (CT) examinations. We, therefore, explored the interplay and prognostic value of vascular calcifications and adipose tissue depots assessed during conventional nongated chest CT. We enrolled a consecutive series of 1250 patients aged between 35 and 74 years who underwent clinically indicated chest CT scans. We measured the extent of coronary artery calcification (CAC) using the segment-involvement score (CACSIS), and aortic and valve calcification. Pericardial fat volume (PFV), hepatic fat, and abdominal subcutaneous adipose tissue were also calculated. Patients were followed-up for all-cause mortality. A total of 577 (46%) patients had presence of CAC in the coronary tree. Over a mean follow-up of 3.7 years, 51 (4%) deaths occurred, 23 (4.1%) in male patients and 28 (4.1%) in female patients. Patients with higher PFV were older (P<0.0001), more frequently male (P<0.0001), had higher abdominal subcutaneous adipose tissue (P<0.0001), hepatic fat (P<0.0001), as well as a larger extent of CAC (P<0.0001), aortic calcium (P<0.0001), and valve calcium (P<0.0001). From a multivariable Cox regression model, age (hazard ratio [HR], 1.07; 95% confidence interval [CI], 1.03-1.11), P=0.001, PFV upper tertile (HR, 4.07; 95% CI, 2.09-7.92), P<0.0001, and CACSIS>5 (HR, 2.19; 95% CI, 1.14-4.23; P<0.0001) were independent predictors of all-cause death. In this relatively large patient cohort undergoing clinically indicated conventional chest CT scans, PFV and coronary calcification were high-risk markers associated with worsening survival.

RF56 OPERATIVE AND SHORT-TERM RESULTS OF THE BENTALL OPERATION: RISK FACTORS ANALYSIS AND CLINICAL CONSIDERATIONS

Background and Aim: To analyse short-term results after the Bentall operation and get clinical considerations. Methods: One hundred and twenty-two patients (mean age 60.4 ± 15.8 years, 99 males,23 females) underwent Bentall operation from January 2015 to December 2017 for treatment of ascending aorta expansive aneurysm (i.e. degenerative aneurysm with tricuspid aortic valve, n = 69; bicuspid valve, n = 37; Marfan syndrome and other genetical disorders, n = 13; redo procedures n = 3). Associate procedures (i.e. coronary artery bypass grafting, mitral valve replacement, other) were performed in 26 patients (21.3%). Euroscore II was 4.7% ± 3.9%. Mean follow-up (99.2% complete) was 20 ± 10 months. Results: In-hospital mortality was 1.6% (1% for isolated Bentall). Three-year survival, freedom from cardiac death, from endocarditis, frome reoperation were 97 ± 1.2%, 99 ± 1.3%, 93 ± 5.1%, 98 ± 1.8%, respectively. No thromboembolism and major bleeding complications were observed. Independent predictors of all-cause death were preoperative higher left ventricular (LV) end-diastolic diameter (71.6 ± 12 vs 53.6 ± 8.6 mm; P = 0.009), LV end-systolic diameter (47.7 ± 9.2 vs 36.8 ± 7.9 mm; P = 0.02), lower LV ejection fraction (43.3 ± 15 vs 56.2 ± 8.7%; P = 0.015). Survival was 98.4 ± 1.6% after isolated Bentall, and 92 ± 5.4% after associated procdures (P = 0.04). As compared to preoperative values, clnical and echocardiography follow-up showed improvement of LV function and NYHA class. Conclusions: Excellent results can be expected after Bentall operation. Low rate of operative mortality and late complications, and significant improvement of clinical status make this operation the gold standard and the reference surgery therapy for the treatment of ascending aorta aneurysms. In presence of dilatation and dysfunction of the left ventricle, adequate medical treatment is necessary to improve survival.

Midterm Clinical Outcomes of the St Jude Medical Epic Porcine Bioprosthesis in the Mitral Position

The aim of this single-center study was to report the midterm clinical outcomes and hemodynamic performance of the St Jude Medical Epic porcine bioprosthesis, a tricomposite glutaraldehyde-preserved porcine bioprosthesis, in mitral position. Methods and Results: Between January 2011 and March 2017, 117 patients (62 men, 55 women; mean age, 66.7±12.8 years) who underwent mitral valve replacement (MVR) with the Epic valve were retrospectively analyzed for early and mid-term morbidity and mortality. The mean follow-up period was 2.6±1.7 years. Three operative deaths occurred, and the operative mortality rate was 2.6%. Sixteen patients died during the follow-up period. On Kaplan-Meier analysis, freedom from all-cause death and major adverse cardiovascular and cerebrovascular events at 5-year follow-up were 80.9% and 54.8%, respectively. There were 6 reoperations: 2 for structural valve deterioration (SVD), 2 for prosthetic valve endocarditis, and 2 for thrombosis. Freedom from valve-related reoperation and SVD at 5 years were 89.0% and 93.1%, respectively. On multivariate analysis, age ≥71 years (HR, 6.78; 95% CI: 2.12-25.2, P<0.01), and NYHA functional class ≥III (HR, 3.20; 95% CI: 1.03-10.4, P=0.04) were independent predictors for all-cause death. Mean mitral pressure gradient at 1 year and 2 years were 5.1±1.9 mmHg and 4.5±1.4 mmHg, respectively. Mid-term clinical results and durability of the Epic valve in the mitral position are satisfactory.

Doses of renin-angiotensin system inhibitors but not beta-blockers predict outcome after ST-elevation myocardial infarction

ABSTRACTObjectives: In patients with ST-elevation myocardial infarction (STEMI), it is not clear whether low-dose renin-angiotensin system inhibitors and beta-blockers can result in the same benefits achievable with higher target doses. This observational study aims to investigate whether higher doses of angiotensin converting enzyme inhibitors (ACEI)/angiotensin II receptor blockers (ARB) and beta-blockers can improve outcomes in patients with STEMI.Methods: We recorded daily doses of ACEI, ARB, and beta-blockers in 331 patients with STEMI. Echocardiographic studies were performed at baseline and were repeated 6 months later. Clinical events, including all-cause death and heart failure, were followed for 2 years.Results: Patients receiving high-dose ACEI/ARB had less increase in left ventricular end-diastolic volume index (LVEDVI) at 6 months. In multivariable linear regression model, ACEI/ARB dose or beta-blocker dose was not an independent predictor of increase in LVEDVI at 6 months. Kaplan-Meier survival curves showed that doses of ACEI/ARB (p = 0.003) and beta-blockers (p = 0.027) were significant predictors of death and heart failure. In multivariable Cox regression analysis, independent predictors of all-cause death and heart failure were diabetes mellitus (p = 0.001), left ventricular ejection fraction (p = 0.026), and ACEI/ARB dose (p = 0.025). Beta-blockers dose was not a predictor of clinical events in multivariable analysis (p = 0.413).Conclusion: High-dose ACEI/ARB, but not beta-blocker, was associated with lower rate of all-cause death and heart failure in patients with STEMI.