Index Event Research Articles

Triglyceride-glucose index improves risk prediction beyond traditional risk factors and hypertension mediated organ damage in healthy adults

Background and aimsTriglyceride-glucose (TyG) index, a surrogate measure of insulin resistance, is associated with hypertension mediated organ damage (HMOD) and cardiovascular disease. This study investigated the association between TyG index and major adverse cardiovascular events (MACE) and its interaction with traditional risk factors and HMOD. Methods and resultsHealthy subjects recruited from the general population were thoroughly examined and followed for MACE using nation-wide registries. Cox proportional hazard models were used to calculate the association between TyG index and MACE occurrence. Models were adjusted for Systematic Coronary Risk Evaluation (SCORE) risk factors, pulse wave velocity, left ventricular mass index, carotid atherosclerotic plaque status, and microalbuminuria. Continuous net reclassification and Harrell's Concordance index (C-index) were used to assess the added prognostic value of TyG index.During a follow-up period of mean 15.4 ± 4.7 years, MACE were observed in 332 (17%) of 1970 included participants. TyG index was associated with MACE; HR = 1.44 [95%CI:1.30–1.59] per standard deviation. After adjustment for traditional cardiovascular (CV) risk factors, HR was 1.16 [95%CI:1.03–1.31]. The association between TyG index and MACE remained significant after further adjustment for each HMOD component. However, this finding was evident only in subjects aged 41 or 51 years (HR = 1.39; 95%CI:1.15–1.69). Including TyG index in a risk model based on traditional CV risk factors improved C-index with 0.005 (P = 0.042). ConclusionIn this population-based study of healthy middle-aged subjects, TyG index was associated with MACE independently of traditional CV risk factors and HMOD. TyG index may have a potential role in future risk prediction systems.

Association between triglyceride glucose-body mass index and all-cause mortality in critically ill patients with acute myocardial infarction: retrospective analysis of the MIMIC-IV database.

Insulin resistance (IR) is closely related to the development of cardiovascular diseases. Triglyceride-glucose-body mass index (TyG-BMI) has been proven to be a reliable surrogate of IR, but the relationship between TyG-BMI and acute myocardial infarction (AMI) is unknown. The present study aims to determine the effects of TyG-BMI on the clinical prognosis of critically ill patients with AMI. The data of AMI patients were extracted from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. All patients were divided into four groups according to the TyG-BMI quartile. Outcomes were defined as 30-, 90-, 180-, and 365-day all-cause mortality. Kaplan-Meier (K-M) curve was used to compare survival rate between groups. Meanwhile, Cox regression analysis and restricted cubic splines (RCS) were used to explore the relationship between TyG-BMI index and outcome events. A total of 1,188 critically ill patients with AMI were included in this study. They were divided into four groups according to TyG-BMI quartiles, there were significant differences in 90-, 180-, and 365-day all-cause mortality while there was no difference in 30-day all-cause mortality. Interestingly, with the increase of TyG-BMI, the 90-, 180-, and 365-day survival rate increased first and then gradually decreased, but the survival rate after decreasing was still higher than that in the group with the lowest TyG-BMI. U-shaped relationships between TyG-BMI index and 90-, 180-, and 365-day all-cause mortality were identified using RCS curve and the inflection point was 311.1, 316.5, and 320.1, respectively, whereas the TyG-BMI index was not non-linearly associated with 30-day all-cause mortality. The results of Cox proportional hazard regression analysis are consistent with those of RCS analysis. U-shaped relationships are existed between the TyG-BMI index and 90-, 180-, and 365-day all-cause mortality in critically ill patients with AMI, but not 30-day all-cause mortality. The TyG-BMI index can be used as an effective index for early prevention of critically ill patients with AMI.

Recurrent stroke prediction by applying a stroke polygenic risk score in the Japanese population.

Recently, various polygenic risk score (PRS)-based methods were developed to improve stroke prediction. However, current PRSs (including cross-ancestry PRS) poorly predict recurrent stroke. Here, we aimed to determine whether the best PRS for Japanese individuals can also predict stroke recurrence in this population by extensively comparing the methods and maximizing the predictive performance for stroke onset. We used data from the BioBank Japan (BBJ) 1st cohort (n=179,938) to derive and optimize the PRSs using a 10-fold cross-validation. We integrated the optimized PRSs for multiple traits, such as vascular risk factors and stroke subtypes to generate a single PRS using the meta-scoring approach (metaGRS). We used an independent BBJ 2nd cohort (n=41,929) as a test sample to evaluate the association of the metaGRS with stroke and recurrent stroke. We analyzed recurrent stroke cases (n=174) and non-recurrent stroke controls (n=1,153) among subjects within the BBJ 2nd cohort. After adjusting for known risk factors, metaGRS was associated with stroke recurrence (adjusted OR per SD 1.18 [95% CI: 1.00-1.39, p=0.044]), although no significant correlation was observed with the published PRSs. We administered three distinct tests to consider the potential index event bias; however, the outcomes derived from these examinations did not provide any significant indication of the influence of index event bias. The high metaGRS group without a history of hypertension had a higher risk of stroke recurrence than that of the low metaGRS group (adjusted OR 2.24 [95% CI: 1.07-4.66, p=0.032]). However, this association was weak in the hypertension group (adjusted OR 1.21 [95% CI: 0.69-2.13, p=0.50]). The metaGRS developed in a Japanese cohort predicted stroke recurrence in an independent cohort of patients. In particular, it predicted an increased risk of recurrence among stroke patients without hypertension. These findings provide clues for additional genetic risk stratification and help in developing personalized strategies for stroke recurrence prevention.

Co-occurring psychiatric disorders in young people with eating disorders: An multi-state and real-time analysis of real-world administrative data

ObjectiveWe aimed to use real-world data to characterize the burden of psychiatric comorbidities in young people with eating disorders (EDs) relative to peers without EDs. MethodThis retrospective cohort study used a large federated multi-national network of real-time electronic health records. Our cohort consisted of 124,575 people (14,524 people receiving their index, first-ever, ED diagnosis, compared to 110,051 peers without EDs initiating antidepressants). After 1:1 propensity score matching of the two cohorts by pre-existing demographic and clinical characteristics, we used multivariable logistic regression to compute the adjusted odds ratio (aOR) of psychiatric diagnoses arising in the year following the index event (either first ED diagnosis or first antidepressant script). ResultsOver 50% of people with EDs had prior psychiatric diagnoses in the year preceding the index EDs diagnosis, with mood disorders, generalized anxiety disorder (GAD), post-traumatic stress disorder (PTSD), specific phobia (SP), attention-deficit hyperactivity disorder (ADHD), and autism spectrum disorder (ASD) being the most common. Adjusted analyses showed higher odds for mood disorders (aOR = 1.20 [95% CI = 1.14–1.26]), GAD (aOR = 1.28 [1.21–1.35]), PTSD (aOR = 1.29 [1.18–1.40]), and SP (aOR = 1.45 [1.31–1.60]) in the EDs cohort compared to antidepressant-initiating peers without EDs, although rates of ADHD and ASD were similar in both cohorts. ConclusionThis large-scale real-time analysis of administrative data illustrates a high burden of co-occurring psychiatric disorders in people with EDs.

The Evaluation of Lipid-Lowering Treatment in Patients with Acute Coronary Syndrome in a Hungarian Invasive Centre in 2015, 2017, and during the COVID-19 Pandemic-The Comparison of the Achieved LDL-Cholesterol Values Calculated with Friedewald and Martin-Hopkins Methods.

Background/Objectives: Patients with acute coronary syndrome (ACS) represent a vulnerable population. We aimed to investigate serum lipid levels of patients with ACS upon admission and during one year of the COVID-19 pandemic in a rural county hospital, and compared these findings with the data of patients with ACS in 2015 and 2017. The secondary aim of this paper was the comparison of the LDL-C values calculated with the Friedewald and Martin-Hopkins methods. Methods: A retrospective analysis of lipid-lowering data of patients treated with ACS in 2015, 2017 and in a COVID-19 year (1 April 2020-31 March 2021) was performed; the patient's numbers were 454, 513 and 531, respectively. Results: In the COVID-19 period one year after the index event, only 42% of the patients had lipid values available, while these ratios were 54% and 73% in 2017 and in 2015, respectively. Using the Friedewald formula, in the COVID-19 era the median of LDL cholesterol (LDL-F) was 1.64 (1.09-2.30) mmol/L at six months and 1.60 (1.19-2.27) mmol/L at one year, respectively. These values were 1.92 (1.33-2.27) mmol/L and 1.73 (1.36-2.43) mmol/L using the Martin-Hopkins method (LDL-MH). The LDL-F yielded significantly lower values (15% lower at six months, p = 0.044; and 8% lower at one year, p = 0.014). The LDL-F reached the previous target of 1.8 mmol/L during the COVID-19 pandemic 36% at one year vs. 48% in 2017, and 37% in 2015. The recent target LDL-C level of 1.4 mmol/L was achieved in 22% of cases in the COVID-19 pandemic, 16% in 2015 and 19% in 2017. Conclusions: A significantly lower proportion of patients with ACS had available lipid tests during the COVID-19 pandemic. Besides the lower number of available samples, the proportion of achieved 1.4 mmol/L LDL-C target lipids was stable. More rigorous outpatient care in the follow-up period may help to improve the quality of lipid lowering treatments and subsequent secondary cardiovascular prevention. If direct LDL-C determination is not available, we prefer the LDL calculation with the Martin-Hopkins method.

High ankle-brachial index participants experienced similar long-term mortality as peripheral artery disease in a national sample of community-dwelling adults

BackgroundOnly a few small studies have shown the association between high ankle-brachial pressure index (ABI >1.4) and adverse cardiovascular (CV) events and mortality. Although there is abundant literature depicting the association between ABI and overall systemic atherosclerosis, it typically focuses on low ABI. Furthermore, historically, many studies focusing on peripheral artery disease have excluded high ABI participants. We aimed to study the mortality outcomes of persons with high ABI in the National Health and Nutrition Examination Survey (NHANES). MethodsWe obtained ABI from participants aged ≥40 years for survey years 1999 to 2004. We defined low a ABI as ≤0.9, normal ABI as 0.9 to 1.4, and high ABI as >1.4 or if the ankle pressures were >245 mm Hg. Demographics, various comorbidities, and laboratory test results were obtained at the time of the survey interview. Multivariable adjusted hazard ratios (HRs) along with 95% confidence intervals (CIs) were calculated for CV and all-cause mortality via Cox proportional hazards regression. Mortality was linked to all NHANES participants for follow-up through December 31, 2019, by the Centers for Disease Control and Prevention. ResultsWe identified 7639 NHANES participants with available ABI. Of these, 6787 (89%) had a normal ABI, 646 (8%) had a low ABI, and 206 (3%) had elevated ABI. Of participants with high ABI, 50% were men, 15% were African Americans, 10% were current smokers, 56% had hypertension, 33% had diabetes, 15% had chronic kidney disease (CKD), and 18% had concomitant coronary artery disease (CAD). Diabetes (odds ratio [OR], 2.4; 95% CI, 1.7-3.2), CAD (OR, 1.6; 95% CI, 1.0-2.4), and CKD (OR, 1.5; 95% CI, 1.0-2.3) at baseline were associated with having a high ABI, respectively. A high ABI was associated independently with elevated CV (HR, 2.6; 95% CI, 2.1-3.1; P < .0001) and all-cause mortality (HR, 2.5; 95% CI, 2.2-2.8; P < .0001) after adjusting for covariates, including diabetes, CKD, CAD, current smoking, cancer, and hypertension. ConclusionsA high ABI is associated with an elevated CV and all-cause mortality, similar to patients with PAD. High ABI participants should receive the same attention and aggressive medical therapies as patients with PAD.

Effect of early initiation of noninvasive ventilation in patients transported by emergency medical service for acute heart failure

Background While the indication for noninvasive ventilation (NIV) in severely hypoxemic patients with acute heart failure (AHF) is often indicated and may improve clinical course, the benefit of early initiation before patient arrival to the emergency department (ED) remains unknown. Objective This study aimed to assess the impact of early initiation of NIV during emergency medical service (EMS) transportation on outcomes in patients with AHF. Design A secondary retrospective analysis of the EAHFE (Epidemiology of AHF in EDs) registry. Setting Fifty-three Spanish EDs. Participants Patients with AHF transported by EMS physician-staffed ambulances who were treated with NIV at any time during of their emergency care were included and categorized into two groups based on the place of NIV initiation: prehospital (EMS group) or ED (ED group). Outcome measures Primary outcome was the composite of in-hospital mortality and 30-day postdischarge death, readmission to hospital or return visit to the ED due to AHF. Secondary outcomes included 30-day all-cause mortality after the index event (ED admission) and the different component of the composite primary endpoint considered individually. Multivariate logistic regressions were employed for analysis. Results Out of 2406 patients transported by EMS, 487 received NIV (EMS group: 31%; EMS group: 69%). Mean age was 79 years, 48% were women. The EMS group, characterized by younger age, more coronary artery disease, and less atrial fibrillation, received more prehospital treatments. The adjusted odds ratio (aOR) for composite endpoint was 0.66 (95% CI: 0.42–1.05). The aOR for secondary endpoints were 0.74 (95% CI: 0.38–1.45) for in-hospital mortality, 0.74 (95% CI: 0.40–1.37) for 30-day mortality, 0.70 (95% CI: 0.41–1.21) for 30-day postdischarge ED reconsultation, 0.80 (95% CI: 0.44–1.44) for 30-day postdischarge rehospitalization, and 0.72 (95% CI: 0.25–2.04) for 30-day postdischarge death. Conclusion In this ancillary analysis, prehospital initiation of NIV in patients with AHF was not associated with a significant reduction in short-term outcomes. The large confidence intervals, however, may preclude significant conclusion, and all point estimates consistently pointed toward a potential benefit from early NIV initiation.

Risk factors and major adverse cardiovascular events of isolated coronary artery ectasia: An observational study.

To evaluate the cardiac index and major adverse cardiovascular events (MACE) events between isolated coronary artery ectasia (CAE) and control groups over 1 year period from diagnosis. A total of 18 patients who were diagnosed with isolated CAE in the Second Hospital of Hebei Medical University from December 2020 to December 2021 were included in CAE group. About 36 patients with non-obstructive coronary artery lesions were included in the control group. All patients in 2 groups completed dobutamine stress echocardiography (DSE) during hospitalization. The chamber size, wall thickness, left ventricular ejection fraction, and left ventricular diastolic function indicators (including E/A ratio, e', and E/e' ratio) were measured. MACE and all-cause death were measured during follow-up after discharge. Interventricular septum thickness (IVSd), left ventricular posterior wall (LVPW) thickness in diastole and E/e' in CAE group were significantly higher than control group (P < .05). No significant differences were found in prognosis including angina, myocardial ischemia (MI), patient readmission and cardiovascular death (P > .05). In CAE group, coronary angiography showed dilation of left anterior descending (LAD) in 1 case, left circumflex (LCX) in 3 cases and right coronary artery (RCA) in 14 cases. Multivariate logistic regression analysis showed that BMI and IVSd were independent risk factors for CAE. IVSd, LVPW thickness in diastole and E/e' in CAE group were significantly higher than control group. BMI and IVSd were independent risk factors for isolated CAE, and had a good predictive value for isolated CAE.

Risk of recurrent venous thromboembolism and major bleeding according to risk factor profiles in Asian patients: a subgroup analysis EINSTEIN-Extension and EINSTEIN-CHOICE

BackgroundRisks of recurrence and major bleeding with extended anticoagulation in Asian patients with venous thromboembolism (VTE) are similar to those in non-Asian patients but risks according to baseline risk factor profiles is not well documented.MethodsSubgroup analysis of two randomized trials, which compared once-daily rivaroxaban (20 mg or 10 mg) with placebo or aspirin (100 mg) for extended treatment in Asian patients with VTE who had completed 6–12 months of anticoagulation. Index events were classified as unprovoked, provoked by major persistent risk factors, minor persistent risk factors, minor transient risk factors, or major transient risk factors. One-year cumulative risks of recurrent VTE were calculated for these risk factor profiles.Results367 patients received rivaroxaban, 159 aspirin, and 48 placebo. For patients with unprovoked VTE, one-year cumulative incidences of recurrence in the 202 patients given rivaroxaban, the 89 given aspirin and the 28 given placebo were 1.6%, 5.8%, and 14.8%, respectively. For patients with VTE provoked by minor persistent risk factors, these incidences were 0% in the 74 patients given rivaroxaban, 9.3% in the 36 given aspirin, and 0% in the 12 given placebo. No recurrent VTE occurred in patients with VTE provoked by major persistent or transient risk factors or minor transient risk factors. Rivaroxaban was not associated with a significant increase in major bleeding.ConclusionsRivaroxaban seems to be an effective and safe option for extended treatment in Asian patients, especially those presenting with unprovoked VTE. Subgroups of patients with provoked risk factors were too small to draw meaningful conclusions.Trial registrationNCT00439725 and NCT02064439.

Medicare Fee-For-Service Spending for Fall Injury and Nonfall Events: The Health, Aging, and Body Composition Study.

Fall injuries are prevalent in older adults, yet whether higher spending occurs after nonfracture (NFFI) and fracture is unknown. We examined whether incident fall injuries, including NFFI and fractures, were associated with higher Medicare spending in 12 months after incident events in older adults. The Health, Aging, and Body Composition Study included 1595 community-dwelling adults (53% women, 37% Black; 76.7 ± 2.9 years) with linked Medicare Fee-For-Service (FFS) claims at 2000/01 exam. Incident outpatient and inpatient fall injuries (N = 448) from 2000/01 exam to December 31, 2008 were identified using the first claim with a nonfracture injury diagnosis code with a fall E-code, or a fracture diagnosis code with/without an E-code. Up to 3 participants without fall injuries (N = 1147) were matched on nonfall events to 448 participants in the fall injury month. We calculated the change in monthly FFS spending in 12 months before versus after index events in both groups. Generalized linear regression with centered outcomes and gamma distributions examined the association of prepost expenditure changes with fall injuries (including NFFI and fractures) adjusting for related covariates. Monthly spending increased after versus before fall injuries (USD$2261 vs $981), nonfracture (N = 105; USD$2083 vs $1277), and fracture (N = 343; USD$2315 vs $890) injuries (all p < .0001). However, after adjusting for covariates in final models, fall injuries were not significantly associated with larger increases in spending/month versus nonfall events (differential increase: USD$399.58 [95% CI: -USD$44.95 to $844.11]). Fracture prepost change in monthly spending was similar versus NFFI (differential increase: USD$471.93 [95% CI: -USD$21.17 to $965.02]). Although substantial increases occurred after injuries, with fracture and NFFI increasing similarly, changes in monthly spending after fall injury were not different compared to nonfall events. Our results contribute to the understanding of subsequent spending after fall injury that may inform further research on fall injury-related health care spending.

Celiac Disease and the Risk of Micronutrient Deficiencies in Ethnic Minority Populations: A Retrospective Cohort Study

Introduction: Celiac disease (CD) is a chronic immune-mediated disorder triggered by gluten ingestion in genetically predisposed individuals. Historically, CD was primarily recognized and described as a disease of the Caucasian population. Data from a national survey in 2015 revealed that 0.79% of the population was formally diagnosed with celiac disease, with the non-Hispanic white population having a prevalence of 4–8 times higher than other underrepresented races. Although there is evidence that CD affects minorities at higher than reported rates, there is little data on its effects on minority populations. Our study aimed to characterize celiac-related complications among underrepresented populations in a large health database. Methods: We performed a cohort study among patients aged ≥18, utilizing the TriNetX US Collaborative Network. Two cohorts of patients (minority and non-Hispanic white) with CD were identified between 2016 and 2021. Cohorts were propensity scores matched on demographics and baseline clinical characteristics. Outcomes were assessed up to 1 year after the index event (CD diagnosis), including vitamin/mineral deficiencies and hospital visits. Data were analyzed using the TriNetX Analytics function. Results: Each group was matched with 817 patients. Compared to the non-Hispanic white population, the minority group had a similar incidence of iron, vitamin B, and zinc deficiencies. The minority group had a higher risk of vitamin D deficiency, anemia secondary to iron deficiency, inpatient hospital stays, and emergency department visits. Conclusion: Our results indicate that minority patients with celiac disease have a higher incidence of vitamin D and iron deficiency.

Prediction of recurrent heart failure hospitalizations and mortality using the echocardiographic Killip score.

Examine the performance of a simple echocardiographic "Killip score" (eKillip) in predicting heart failure (HF) hospitalizations and mortality after index event of decompensated HF hospitalization. HF patients hospitalized at our facility between 03/2019-03/2021 who underwent an echocardiography during their index admission were included in this retrospective analysis. The cohort was divided into 4 classes of eKillip according to: stroke volume index (SVI) < 35ml/m2 > and E/E' ratio < 15 > . An eKillip Class I was defined as SVI ≥ 35ml/m2 and E/E' ≤ 15 and was used as reference. Included 751 patients, median age 78.1 (IQR 69.3-86) years, 59% men, left ventricular ejection fraction 45 (IQR 30-60)%, brain natriuretic peptide levels 634 (IQR 331-1222)pg/ml. Compared with eKillip Class I, a graded increase in the combined endpoint of 30-day mortality and rehospitalizations rates was noted: (Class II: HR 1.77, CI 0.95-3.33, p = 0.07; Class III: HR 1.94, CI 1.05-3.6, p = 0.034; Class IV: HR 2.9, CI 1.64-5.13, p < 0.001 respectively), which overall persisted after correction for clinical (Class II: HR 1.682, CI 0.9-3.15, p = 0.105; Class III: HR 2.104, CI 1.13-3.9, p = 0.019; Class IV: HR 2.74, CI 1.54-4.85, p = 0.001 respectively) or echocardiographic parameters (Class II: HR 1.92, CI 1.02-3.63, p = 0.045; Class III: HR 1.54, CI 0.81-2.95, p = 0.189; Class IV: HR 2.04, CI 1.1-3.76, p = 0.023 respectively). Specifically, the eKillip Class IV group comprised one-third of the patient population and persistently showed increased risk of 30-day HF hospitalizations or mortality following multivariate analysis. A simple echocardiographic score can assist identifying high-risk decompensated HF patients for recurrent hospitalizations and mortality.

Ventricular arrhythmias associated with electrical cardioversion for atrial fibrillation, a multicenter study

Abstract Background Cases of ventricular arrhythmias (VAs) associated with QT prolongation after electrical cardioversion (ECV) for atrial fibrillation have been reported. Purpose To assess the incidence, timing and clinical characteristics of patients with VAs post-ECV for AF. Methods This is a multicenter international study. Seventy-seven centers were approached. Data was received from 13 worldwide centers. VAs included were torsades de pointes (TdP), NSPVT&amp;gt;3 beats or SCD within 7 days of ECV. The total number of ECVs performed at each center during the time period for which data was sent was provided. Results VAs occurred after ECV at an estimated incidence of 0.16%, range 0- 1.3% at different centers. Twenty-three patients with VAs were identified from 8 European centers, from 2008-2023, of whom 18 (78%) were from 2019-2023. There were 13 (56.5%) females, aged 71+11 years, mean LVEF=45+9%. AF duration prior to ECV was 72+65 days. Antiarrhythmic drugs (AADs) used prior to ECV were amiodarone in 9 (39%), sotalol in 4 (17%), class Ic in 3 (13%), beta blockers in 19 (83%), CCB in 1(4%) and digoxin in 4 (17%) patients. Five (22%) patients received QT prolonging drugs other then AADs. Baseline hypokalemia &amp;lt;3.5mmol/L was seen in 3(13%) patients (range 2.9-3.4mmol/L). ECV was elective, urgent and emergent in 10 (43%), 12 (52%) and 1(4%) patient, respectively. The arrhythmias documented were TdP in 17(74%), NSPVT &amp;gt;3 beats in 5(22%) and 1(4%) SCD. Arrhythmia documentation was available in 19 (83%) patients. Baseline mean HR pre-ECV was 115+30bpm and QT 388+61ms, both significantly differed from post-ECV mean HR which was 58+11bpm and QT 469+63ms, P&amp;lt;0.0001. Arrhythmia occurred 45+54 hours post-ECV, median 28.5 hours, range 5 minutes- 10 days. Figure 1 demonstrates an example of serial ECG changes from baseline to TdP occurrence. An arrhythmic storm occurred in 11 (48%) patients. Arrhythmia reoccurred in 9 (39%) patients, mean 13.25 + 15 (range 0.5-48) hours after the index event. The arrhythmias which reoccurred were TdP in 5 (22%), VF in 2 (9%), NSPVT in 1 (4%) and monomorphic VT in 1 (4%) patient. Acute therapy with DCCV was needed in 10 (43%) patients. AADs were discontinued in 16 patients. IV electrolytes were helpful in arrhythmia control in 16 (89%) of 18 patients, IV isoproterenol was helpful in 1 (25%) of 4 patients, temporary pacing with arrhythmia control in 2(40%) of 5 patients in whom it was used. ICD was implanted in 7 patients and a pacemaker in 4 others. Two (8.7%) patients expired, 1 died suddenly at home 12 hours after ECV and 1 suffered from acute heart failure and fatal TdP 72 hours after ECV while hospitalized. Conclusion VAs associated with QT prolongation after ECV for AF occur mainly 24-48 hours after ECV and may reoccur. Prolonged monitoring prior to discharge should be considered for prevention of fatal outcomes in patients with any evidence of QT prolongation following ECV.Figure 1

Using cardiac magnetic resonance feature tracking to discover novel abnormalities in patients with idiopathic ventricular fibrillation

Abstract Background Despite an extensive diagnostic work-up, the underlying diagnosis leading to ventricular fibrillation (VF) remains elusive in patients with idiopathic VF. Emerging diagnostic techniques can be used to discover previously unidentified abnormalities in these patients. Purpose The purpose of this study was to investigate the potential of cardiac magnetic resonance feature tracking (CMR-FT) to discover structural abnormalities in idiopathic VF patients. Methods Cine CMR images of idiopathic VF patients and age and sex matched controls were analyzed. Left ventricle global circumferential strain (GCS), global longitudinal strain (GLS) and global radial strain (GRS) were determined using Circle Cardiovascular Imaging. Student’s t-test was used to compare means. Results In total, 26 idiopathic VF patients (mean age 37 (±13) years, 62% male) and 26 controls (mean age 38 (±13) years) were included. CMR was performed in idiopathic VF patients at a median of 9 [IQR 3 – 15] days after the index event. Left ventricle ejection fraction was 55 ± 6% for idiopathic VF patients, 59 ± 6% for controls, p = 0.04. GCS and GRS were comparable for idiopathic VF patients and controls (-17.36 ± 1.78% vs. -18.04 ± 1.83%, p = 0.182 and 28.28 ± 4.63 vs. 29.29 ± 5.09, p = 0.438, respectively). GLS was lower for idiopathic VF patients compared with controls (-14.85 ± 3.21% vs. -18.44 ± 2.11%, p &amp;lt; 0.001). Conclusion CMR-FT GLS distinguished idiopathic VF patients from controls and could imply subclinical abnormalities in idiopathic VF patients. Future studies with a larger cohort should reveal if this finding can be correlated with an arrhythmic substrate.

The efficacy and safety of apatinib combined with S-1 for advanced gastric cancer: A systematic review and meta-analysis.

Advanced gastric cancer (AGC) that does not respond to first-line therapy poses a challenge to clinical management. The objective of this study was to compare the efficacy and safety of apatinib combined with S-1 in second-line and above treatment of AGC. Cochrane Library, Science Direct, EMBASE, PubMed, and CNKI were searched for randomized controlled trial until August 2023. Only patients who met "Standardized Diagnosis and Treatment Guide for Gastric Cancer" were included in the study. The accurate data and distinguishing between follow-up time and drug dose were extracted to reduce heterogeneity and the risk of bias of the included trials was evaluated according to the Cochrane Handbook. Finally, the survival benefit of the treatment was evaluated based on clinical response rate, survival period, biochemical index, and adverse event occurrence in the trial. The meta-analysis included 29 randomized controlled trials involving 2149 participants. Statistically significant increases in clinical effective rate (odds ratios = 2.61, 95% confidence interval [2.13-3.20], P < .00001) and disease control rate (odds ratios = 3.16, 95% confidence interval [2.54-3.94], P < .00001) were found when apatinib combined with S-1, and also had obvious advantages in reducing tumor markers and regulating immune factors. In addition, apatinib combined with S-1 significantly increased the risk of hypertension but reduced damage to liver function, while the improvement of other adverse events was not pronounced. Apatinib combined with S-1 is more effective and safe for second-line and above treatment of AGC. This study minimized the conclusion bias caused by the basic data sources, but more high-quality studies are still needed to validate these conclusions.

Impact of Sulfonamide Allergy Label on Clinical Outcomes in Patients with Pneumocystis jirovecii Pneumonia.

The presence of antibiotic allergy labels can have harmful impacts on clinical outcomes, particularly among immunosuppressed patients, in whom there have been associations with increased complications, readmission rates, and mortality. We explore the effects of a sulfonamide allergy label (SAL) on clinical outcomes in adult patients with Pneumocystis jirovecii pneumonia (PJP). In this retrospective matched cohort study, we utilized TriNetX, a multicenter national database, to match 535 adult patients with PJP and SAL to an equal number of controls. We identified cases indexed between 01/01/2010 and 01/01/2023 utilizing ICD-10 codes for PJP and allergy status to sulfonamides and through detection of P. jirovecii antigen with immunofluorescence or PCR. Propensity score matching was performed in a 1:1 fashion for demographics and comorbidities, and our analysis included clinical outcomes that occurred within 30days after the occurrence of the index event. While hospitalization risk tended to be lower among patients with SAL as compared to controls (RR: 0.90; 95% CI 0.81-1.01), there were no major differences in the risk of respiratory failure (RR: 0.94; 95% CI 0.84-1.05), prednisone use (RR: 1; 95% CI 0.91-1.10), intensive level of care requirement (RR: 0.85; 95% CI 0.69-1.06), intubation (RR: 0.85; 95% CI 0.61-1.19), or mortality (RR: 0.98; 95% CI 0.68-1.42). The presence of SAL did however impact antibiotic prescription patterns, with an underutilization of trimethoprim (RR: 0.50; 95% CI 0.43-0.59) and sulfamethoxazole (RR, 0.47; 95% CI 0.40-0.56) and overuse of alternative agents by patients with SAL as compared to controls. Yet, there was no difference in the occurrence of adverse outcomes such as hepatotoxicity (RR: 1.09; 95% CI 0.49-2.45) or acute kidney injury (RR: 0.94; 95% CI 0.78-1.14) between patients with SAL and controls. The presence of SAL alters antibiotic prescription patterns among adults with Pneumocystis infection but has no clinically significant impact on outcomes.

Risk factors for asymptomatic bacterial colonization of cardiac implantable electronic devices

Abstract Introduction With broadening indications and a progressively ageing demographic, incidence of cardiac electronic implantable device (CIED) implantation increased. Despite device infection being rare, it persists as a serious complication concomitant with a high mortality rate. While extensive research on cardiac device infection (CDI) has been conducted, the incidence and clinical significance of asymptomatic bacterial CIED colonisation has not been investigated so far. Purpose Our study aims to elucidate potential risk factors for and investigate the clinical significance of asymptomatic bacterial CIED colonisation. Methods and Results In this prospective single centre study, 345 patients with no clinical signs of CIED infection underwent a generator exchange. In total, 78 pacemakers (PM), 97 implantable cardiac defibrillators (ICD), 67 cardiac resynchronisation therapy devices (CRT), 1 baroreceptor stimulator, as well as 102 implantable loop recorders were sonicated to determine the presence of adherent microorganisms (biofilms). Intraoperative swabs were collected in 329 patients. For statistical analysis, detection of ≥1 colony forming units (CFU) during sonication was considered a significant level of bacterial colonisation. The ≥50 CFU threshold was established in order to examine risk factors relevant for higher levels of bacterial colonization. 88 CIED (25.5%) showed bacterial colonisation ≥1 CFU while 44 CIED (12.8%) were colonised with ≥50 CFU. Multivariate analysis revealed male gender as independent risk factor for both ≥1 CFU (p&amp;lt;0.001; OR 7.73, CI 2.84-21.04) and ≥50 CFU (p&amp;lt;0.001; OR 12.14, CI 2.79-52.78). and immunosuppressive medication (p=0.018; OR 3.31; CI 1.23-8.92) as independent risk factor identified for ≥50 CFU colonisation. For both cutoffs, Cutibacterium acnes emerged as the most frequently detected bacterium during sonication, followed by coagulase negative Staphylococci (CoNS) with Staphylococcus epidermidis being the most common within this CoNS group. During the follow-up (384.5 +/- 480.6 days), 287 patients showed absence of CDI (53 patients lost to follow-up). Of the five patients with CDI, one exhibited concordant results between sonication, swab, and blood culture for Cutibacterium acnes, one presented with partially concordant results, whereas the other three showed varying degrees of disconcordance between index event microbiological results and subsequent CDI pathogens. Conclusion Remarkably, 27.2% of CIEDs with leads (PM, ICD, CRT) exhibited bacterial colonisation. Out of the 5 CDIs identified, 4 were associated with positive sonication results. In addition, our study identifies male gender and immunosuppressive medication as significant risk factors for asymptomatic bacterial CIED colonisation. Thus, in patients with these given risk factors, CIED sonication should be considered for risk stratification with regard to a subsequent CIED infection and possible targeted antimicrobial therapy.Flow Chart

#1218 Investigating the association of chronic obstructive pulmonary disease with outcomes in patients with non-dialysis dependent chronic kidney disease

Abstract Background and Aims Kidneys and lungs have a strong pathophysiological link. However, studies on the association between chronic conditions involving these two organs, chronic kidney disease (CKD) and chronic obstructive pulmonary disease (COPD), are limited. Nephrologists better understand the pathophysiology and management of acute manifestations of these two organs' dysfunction, i.e., pulmonary-renal syndrome accompanying vasculitis, compared to their chronic alterations. Our study aims to investigate the prevalence and association of COPD with adverse outcomes in patients with CKD (stages 3-5). Method This retrospective observational cohort study was conducted on CKD patients (stages 3-5) enrolled in the Global Collaborative Network (GCN) of the TriNetX research platform between the years 2003 and 2023. TriNetX provides access to anonymized electronic medical records across large healthcare organizations (HCOs). This report includes patients from 112 HCOs with different demographic backgrounds. The study compared outcomes of patients aged 18-80, with and without COPD, in a propensity score matched (PSM) cohort of CKD patients. The characteristics included in the PSM were age, sex, ethnicity, comorbidities (neurological, hematological, cardiovascular, gastroenterological, and endocrine conditions) and baseline serum creatinine. The proportional hazard assumption was tested using the generalized Schoenfeld approach built in the TriNetX platform. A 95% confidence interval (95% CI) was considered evidence of statistical significance throughout the analyses. The Kaplan- Meier (KM) method was used for the survival probability. Statistical significance was defined as p-value &amp;lt; 0.05. Outcome events were included 180 days after the index event (COPD diagnosis) and ended 3650 days after. Results Of the total of 1 045 536 CKD patients, 181 207 had a co-existent diagnosis of COPD (prevalence rate—17.3%). A PSM generated a matched cohort of 174 308 patients each. The mean age of the cohort was 66.7 ± 7.9 years, with a predominance of white ethnicity (65.8%) and an equal male-to-female ratio. 73.1%, 51.5%, 69.6%, 54.1%, and 37.2% had a history of cardiovascular, nervous system, endocrine, gastroenterological, and hematological disease, respectively. The mean serum creatine at baseline was 1.3 ± 1.2 mg/dL. The comparison of differences in the outcomes on follow-up between the matched cohorts is illustrated in Table 1. CKD patients with concomitant COPD had a higher all-cause mortality (17.3% vs 8.7%, p &amp;lt; 0.0001), higher all-cause hospitalizations (14.7% vs 12.7%, p &amp;lt; 0.0001), and higher cardiovascular events. Proportional hazard models showed that COPD is a strong risk factor associated with all-cause mortality (HR: 2.189; 95% CI (2.13-2.22, p &amp;lt; 0.0001)), hospitalizations (HR:1.39; 95% CI (1.36–1.44); p &amp;lt; 0.0001), and other cardiovascular and mental health illness (Table 1). KM chart illustrates the differences in survival probability between the two groups (Log-Rank p &amp;lt; 0.001) (Fig. 1). Conclusion Our ‘real-world data’ findings emphasize that patients with CKD and COPD are a cluster that requires special attention due to poorer outcomes. Given the high frequency of these associations between these two chronic conditions, an improved awareness is warranted among the nephrological community.

#1490 Long-term health outcomes in non-dialysis dependent chronic kidney disease patients with cognitive impairment or dementia

Abstract Background and Aims A decline in cognitive function, with a spectrum ranging from mild cognitive impairment to dementia (CI-D), is common in patients with chronic kidney diseases (CKD), rendering them frailer. Whether the coexistence of CKD and CI-D increases the health risk profile remains unclear. Our work aims to clarify how this association increases adverse outcomes for CKD patients (stages 3-5). Method This retrospective observational cohort study was conducted on CKD patients (stages 3-5) from the Global Collaborative Network (GCN) of the TriNetX research platform between 2004 and 2024. TriNetX provides access to anonymized electronic medical records from over half a million CKD patients in large healthcare organizations (HCOs) across the world. Our report includes patients from 110 HCOs with different demographic backgrounds. The study compared outcomes of patients with CKD stages 3-5, aged 18-70 years, with and without pre-existent CI-D (diagnosed within 5 years). The two cohorts were propensity score-matched (PSM) for age, sex, ethnicity, comorbidities (neurological, haematological, musculoskeletal, respiratory including smoking history, oncological, cardiovascular, gastroenterological and endocrine conditions) and CKD stage. The proportional hazard assumption was tested using the generalized Schoenfeld approach built in the TriNetX platform. A 95% confidence interval (95% CI) was considered evidence of statistical significance throughout the analyses. Kaplan- Meier (KM) was used for survival probability. Statistical significance was defined as p-value &amp;lt; 0.05. Outcome events were included from 1 day after the index event (CKD diagnosis) until 3650 days after. Results Of the total of 503,298 CKD patients, 7,891 had a co-existent diagnosis of CI-D made within 5 years (prevalence rate 1.56%). A PSM generated a matched cohort of 7,890 patients each. The mean age of the cohort was 60.7 ± 7.0 years, with a predominance of white ethnicity (53.7%) and an equal male-to-female ratio. Standardized difference (Std diff) was used to evaluate the balance of baseline characteristics in the PSM populations. Generally, Std diff &amp;lt; 0.1 is considered a small difference and all comorbidities fell below this threshold after PSM (Table 1). The comparison of the outcomes at follow-up between the matched cohorts is illustrated in Table 2. CKD patients with concomitant CI-D had higher all-cause mortality (18.4% vs 12.1%, p &amp;lt; 0.0001), a higher risk of cerebrovascular disease (10.8% vs 7.8%), malnutrition (6.7% vs 4.3%), mood disorders (13.7% vs 8.9%), anxiety (13.2% vs 10.9%), encephalopathy (9.6% vs 4.5%), epilepsy (4.3% vs 1.3%). All findings were statistically significant with a p &amp;lt; 0.0001. Proportional hazard models showed that CI-D was a strong risk factor associated with all-cause mortality (HR: 1.761; 95% CI (1.621-1.913, p &amp;lt; 0.0001)) and other cerebrovascular and mental health illnesses. Conclusion Our “real-world data” demonstrate that a concomitant CI-D diagnosis is a strong risk factor for negative health outcomes and mortality in patients with CKD stages 3-5. These results highlight the need for routine cognitive assessments in patients with advanced CKD to deliver personalised care.

Prognostic Impact of Iron Metabolism Changes in Patients with Acute Coronary Syndrome and its Correlation with TIMI Risk Score and 6-month Left Ventricular Performance

Objectives: Iron is vital for human metabolism and function. One major cause of anemia is a shortage of iron. On the other hand, a low blood iron level does not always indica te an abnormal hemoglobin concentration. Left ventricular function, ferritin, and blood iron levels were investigated 6 months following the acute coronary syndrome (ACS) index event. In addition, we searched for correlations between thrombolysis in myocardial infarction (TIMI) risk score, cytokines such as C-reactive protein (CRP), and serum iron content. Materials and Methods: From August 2021 to July 2022, 100 consecutive patients with ACS who were requesting admission to the critical care unit of the Cardiology Department at SCB Medical College in Cuttack, Odisha, were the subject of this study. Participants in our research with ST-elevation or non-ST-elevation myocardial infarction (ST elevation myocardial infarction [STEMI] or Non ST elevation myocardial infarction [NSTEMI]) ranged in age from 18 to 70 years. We measured CRP, transferrin saturation, total iron binding capacity, ferritin, and blood iron at baseline. The left ventricular ejection fraction (LVEF %) difference was assessed 6 months after baseline echocardiography and follow-up. Various factors were considered while calculating the short- and long-term prognoses, including the patient’s heart failure at admission and any deaths that took place in hospitals within 6 months after the index event. Results: There was no improvement in LVEF for 56.25% of patients (36 out of 66) 6 months after the index event; however, for 43.75% (28 patients) of the 66 STEMI patients, LVEF improved. Out of 34 NSTEMI patients, 14 (42.42%) improved their LVEF 6 months after ACS, whereas 19 (57.58%) did not. Serum iron levels and LVEF at 6 months were shown to be significantly correlated in all patients (overall P &lt; 0.001, STEMI P &lt; 0.001, and NSTEMI P = 0.001). Serum iron levels are positively correlated with improvements in LVEF after 6 months in both patients with STEMI; P &lt; 0.001, and NSTEMI P = 0.006. Serum iron levels and hospitalized STEMI patients’ TIMI risk scores showed a significant connection (P &lt; 0.001). Conclusion: Regardless of hemoglobin content, patients with &lt;10% improvement in LVEF from baseline had considerably lower blood iron levels. Six months after their initial ACS incident, patients with ACS who had lower blood iron concentrations at baseline recovered less well in terms of left ventricular systolic function. In our study, 48% of men and 68% of women were found to be iron deficient. In addition to being an indicator of inflammation, hypoferremia may be the target of a novel biomarker with potential applications in medicine in the near future. It could be useful in predicting left ventricular function following ACS.