Long-term Adverse Clinical Outcomes Research Articles

Incidence of Nonfatal Traumatic Brain Injury-Related Hospitalizations - United States, 2018.

Traumatic brain injury (TBI), which can disrupt normal brain function and result in short- and long-term adverse clinical outcomes, including disability and death, is preventable. To describe the 2018 incidence of nonfatal TBI-related hospitalizations in the United States by sociodemographic characteristics, injury intent, and mechanism of injury, CDC analyzed data from the Healthcare Cost and Utilization Project (HCUP) National (Nationwide) Inpatient Sample. During 2018, there were 223,050 nonfatal TBI-related hospitalizations; rates among persons aged ≥75 years were approximately three times higher than those among persons aged 65-74 years, and the age-adjusted rate among males was approximately double that among females. Unintentional falls were the most common mechanism of injury leading to nonfatal TBI-related hospitalization, followed by motor vehicle crashes. Proper and consistent use of recommended restraints (i.e., seatbelts, car seats, and booster seats) and, particularly for persons aged ≥75 years, learning about individual fall risk from health care providers are two steps the public can take to prevent the most common injuries leading to nonfatal TBIs. The findings in this report could be used by public health officials and clinicians to identify priority areas for prevention programs.

Abstract 12408: Fragmented QRS is Independently Predictive of Long-Term Adverse Clinical Outcomes in Asian Patients Hospitalized for Heart Failure: A Retrospective Cohort Study

Introduction: Fragmented QRS (fQRS) results from myocardial scarring and predicts cardiovascular mortality and ventricular arrhythmia (VA). We evaluated the prevalence and prognostic value of fQRS in Asian patients hospitalized for heart failure. Hypothesis: fQRS is predictive of adverse clinical outcomes. Methods: This was a retrospective cohort study of adult patients hospitalized for heart failure between 1st January 2000 and 31st December 2019 at a tertiary center in Hong Kong. The baseline ECG was analysed. QRS complexes (<120 ms) with fragmented morphology in ≥2 contiguous leads were defined as fQRS. The primary outcome was a composite of cardiovascular mortality, VA, and sudden cardiac death (SCD). The secondary outcomes were the components of the primary outcome, myocardial infarction, and new-onset atrial fibrillation. Results: In total, 2192 patients were included, of whom 179 (8.20%) exhibited fQRS. The follow-up duration was 5.63±4.09 years. fQRS in any leads was associated with a higher risk of the primary outcome (adjusted hazard ratio (HR) 1.541 [1.185, 2.004], p=0.001; Figure A), but not myocardial infarction or new-onset atrial fibrillation. fQRS in >2 contiguous leads was an independent predictor of the primary outcome (HR 1.841 [1.119, 3.029], p=0.016; Figure B), driven by a higher risk of SCD (adjusted HR 2.679 [1.252, 5.729], p=0.011). In patients without ischaemic heart disease (N=1396), fQRS in any leads remained predictive of VA and SCD (adjusted HR 3.336 [1.343, 8.282], p=0.009, and 1.928 [1.135, 3.278], p=0.015, respectively), but not cardiovascular mortality (adjusted HR 1.049 [0.662, 1.662], p=0.839). Conclusions: fQRS is an independent predictor of cardiovascular mortality, VA, and SCD. Higher fQRS burden increased SCD risk. The implications of fQRS in heart failure patients without ischaemic heart disease require further studies.

Fragmented QRS Is Independently Predictive of Long-Term Adverse Clinical Outcomes in Asian Patients Hospitalized for Heart Failure: A Retrospective Cohort Study.

Background: Fragmented QRS (fQRS) results from myocardial scarring and predicts cardiovascular mortality and ventricular arrhythmia (VA). We evaluated the prevalence and prognostic value of fQRS in Asian patients hospitalized for heart failure.Methods and Results: This was a retrospective cohort study of adult patients hospitalized for heart failure between 1st January 2010 and 31st December 2016 at a tertiary center in Hong Kong. The baseline ECG was analyzed. QRS complexes (<120 ms) with fragmented morphology in ≥2 contiguous leads were defined as fQRS. The primary outcome was a composite of cardiovascular mortality, VA, and sudden cardiac death (SCD). The secondary outcomes were the components of the primary outcome, myocardial infarction, and new-onset atrial fibrillation. In total, 2,182 patients were included, of whom 179 (8.20%) had fQRS. The follow-up duration was 5.63 ± 4.09 years. fQRS in any leads was associated with a higher risk of the primary outcome (adjusted hazard ratio (HR) 1.428 [1.097, 1.859], p = 0.001), but not myocardial infarction or new-onset atrial fibrillation. fQRS in >2 contiguous leads was an independent predictor of SCD (HR 2.679 [1.252, 5.729], p = 0.011). In patients without ischaemic heart disease (N = 1,396), fQRS in any leads remained predictive of VA and SCD (adjusted HR 3.526 [1.399, 8.887], p = 0.008, and 1.873 [1.103, 3.181], p = 0.020, respectively), but not cardiovascular mortality (adjusted HR 1.064 [0.671, 1.686], p = 0.792).Conclusion: fQRS is an independent predictor of cardiovascular mortality, VA, and SCD. Higher fQRS burden increased SCD risk. The implications of fQRS in heart failure patients without ischaemic heart disease require further studies.

The association of myocardial injury during chronic total occlusion percutaneous coronary intervention with lesion complexity and treatment strategy

Abstract Background Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is associated with procedural myocardial injury (PMI), and adverse long-term clinical outcomes [1–4].CTO lesion complexity is quantified using established scores [5–8], with high complexity known to determine the need for dissection and re-entry techniques and the retrograde approach, which are then associated with a higher incidence of procedural complications [9,10]. If CTO recanalization is unsuccessful, a modification procedure can be performed, with the intention to improve subsequent procedural success [11–14]. There are limited data on the association between PMI, CTO complexity and treatment strategy. Purpose To report the incidence of myocardial injury following CTO PCI, and assess whether this is associated with lesion complexity, crossing strategy, or the use of a modification procedure. Methods This is a retrospective analysis of consecutive elective CTO PCI procedures performed at a single centre in Norway between January 2020 and March 2021. High-sensitivity troponin T (hsTnT) was measured pre and 12–18 hours post-procedure. Myocardial injury defined as a post-procedure elevation of hsTnT &amp;gt;5x 99th percentile URL with a normal baseline value or a rise &amp;gt;20% with elevated pre-procedure hsTnT. CTO complexity was described using the J-CTO, PROGRESS, RECHARGE and EuroCASTLE scores [5–8]. Procedures were classified as technical successful or unsuccessful according to CTO academic research consortium (CTO-ARC)criteria [15], and further categorised according to final crossing strategy [antegrade wiring (AW), antegrade dissection re-entry (ADR), retrograde wiring (RW) or retrograde dissection re-entry (RDR)]. If unsuccessful they were further categorised as “failure” or “unplanned modification procedure”. A “planned modification procedure” defined as intentional antegrade modification of the occlusive segment with no attempt to complete CTO crossing. Results We analysed 122 CTO PCI procedures. Mean J-CTO, PROGRESS, RECHARGE, EuroCASTLE scores were 2.7, 1.2, 3.0 and 3.1 respectively. Technical success during the index procedure was 75%. An unplanned or planned modification procedure was performed in 16% and 2% of cases, respectively. Technical failure occurred in 7% of cases. Myocardial injury occurred in 65% of all procedures (78% of failed procedures, 64% of successful procedures, 63% of unplanned and none of 3 planned CTO modification procedures). The mean hs-TnT according to treatment strategy and outcomes are reported in Table 1. The relationship between the CTO complexity scores and hs-TnT are illustrated in Figure 1. Conclusions Myocardial injury is common during CTO PCI, particularly with more complex anatomy, requiring the retrograde approach or an unplanned modification procedure. A prospective analysis of whether myocardial injury can be avoided using a planned investment procedure in high complexity cases is currently being conducted. Funding Acknowledgement Type of funding sources: None.

Neutrophil to lymphocyte ratio and adverse clinical outcomes in patients with ischemic stroke.

BackgroundNeutrophils and lymphocytes mediate differential inflammatory responses after ischemic stroke and have different effects on patients’ clinical outcomes. Several studies have used the neutrophil to lymphocyte ratio (NLR) as a prognostic indicator for ischemic stroke; however, some limitations remain.MethodsWe derived data from the Third China National Stroke Registry. The NLR is defined as neutrophil count/lymphocyte count. Patients included in the study were classified into four groups by NLR quartiles. Odds ratios (ORs) of adverse clinical outcomes were calculated with the lowest quartile group as the reference category. We plotted receiver operating characteristic (ROC) curves of NLR for adverse clinical outcomes and calculated area under the curve (AUC) values and cutoff values. Under different TOAST classifications, medians of NLR and ORs of adverse clinical outcomes were also calculated. Furthermore, interaction tests between NLR and etiology were performed.ResultsA total of 13,018 patients were enrolled. At both 3- and 12-month follow-ups, higher quartile groups were associated with increased risks of death and poor functional outcomes, even after adjustments. For death, the cutoff values of NLR were 3.872 at 3-month follow-up and 3.180 at 12-month follow-up. For poor functional outcomes, the cutoff value of NLR was 2.846 at both 3- and 12-month follow-ups. The association between NLR and stroke recurrence was significant only at 3-month follow-up before adjustments. There was no correlation between NLR and hemorrhagic transformation during hospitalization. Under different TOAST classifications, the medians of NLR were different; conversely, the correlations of NLR with adverse clinical outcomes had no differences.ConclusionsHigh level of NLR within the first 24 h after admission was associated with increased risks of both short- and long-term adverse clinical outcomes in patients with ischemic stroke, regardless of etiology.

Clinical risk prediction models for the prognosis and management of acute coronary syndromes.

Patients with acute coronary syndromes (ACS), particularly non-ST-segment elevation ACS, represent a spectrum of patients at variable risk of short- and long-term adverse clinical outcomes. Accurate prognostic assessment in this population requires the simultaneous consideration of multiple clinical and laboratory variables which may be under-recognized by the treating physicians, leading to an observed risk-treatment paradox in the use of invasive and pharmacological therapies. The routine application of established clinical risk scores, such as the Global Registry of Acute Coronary Events risk score, is recommended by major international clinical practice guidelines for structured risk stratification at the time of presentation, but uptake remains inconsistent. This article discusses the methodology of designing, deriving, and validating clinical risk scores, reviews the major validated risk scores for assessing prognosis in ACS, and examines their role in guiding clinical decision-making in ACS management, especially the timing of invasive coronary angiography. We also discuss emerging data on the impact of the routine use of such risk scores on patient management and clinical outcomes, as well as future directions for investigation in this field.

The correlation between the increase rate of serum creatinine levels and long-term adverse clinical outcomes in patients with non st-segment elevation myocardial infarction

Aim: We purposed to evaluate the correlation between the rate of increase in SCrea levels and major adverse cardiac and cerebrovascular events(MACCE) in non ST-segment elevation myocardial infarction(NSTEMI) patients who was made coronary angiography(CAG) in this study. According to studies on especially stable coronary artery disease (SCAD); contrast-induced acute kidney injury CI-AKI) is described as an rising in serum creatinine (SCrea) levels more than 0.5 mg / dl or more than 25% within 48-72 hours after the contrast agent implementation. However, data on the increase rates of SCrea levels in patients with acute coronary syndrome (ACS) are insufficient..Materials and Methods: 884 NSTEMI patients were admitted to our study. We classified the patients into 3 groups according to the increase rates in SCrea values; first group(∆SCrea 10%), second group(10%≤ ∆SCrea 25%) and third group(∆SCrea ≥25%). Results: MACCE were defined as all-cause mortality, myocardial infarction (MI) and cerebrovascular accident (CVA) at one year follow-up. MACCE occurred in 123(13.9%) of the 884 patients. Patients in group three had a meaningfully higher rate of MACCE than in the other groups (P 0.001). This difference was primarily sourced from all-causes mortality; the all-causes mortality ratio was 3-4 times higher than the other groups. There was no meaningful difference in MACCE among first and second groups.Conclusion: Using an increase rate of ≥25% creatinine as the definition for CI-AKI is more reliable for primary end points in patients with NSTEMI than the increase rate of creatine in lower levels.

Guideline adherence and long-term clinical outcomes in patients with acute myocardial infarction: a Japanese Registry of Acute Myocardial Infarction Diagnosed by Universal Definition (J-MINUET) substudy.

The association between guideline adherence and long-term outcomes in patients with acute myocardial infarction in real-world clinical practice remains unclear. We investigated 3283 consecutive patients with acute myocardial infarction who were selected from a prospective, nation-wide, multicentre registry (J-MINUET) database covering 28 institutions in Japan between July 2012 and March 2014. Among the 2757 eligible patients, we evaluated the use of seven guideline-recommended therapies, including urgent revascularisation, door-to-balloon time of 90 minutes or less, and five discharge medications (P2Y12 inhibitors on aspirin, beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, statins, lipid-lowering drugs). The primary endpoint was a composite of all-cause death, non-fatal myocardial infarction, non-fatal stroke, cardiac failure and urgent revascularisation for unstable angina up to 3 years. The overall median composite guideline adherence was 85.7%. Patients were divided into the following three groups: complete (100%) adherence group (n=862); moderate adherence (75% to <100%) group (n=911); and low adherence (0-75%) group (n=984). The rate of adverse cardiovascular events was significantly lower in the complete adherence group than in the low and moderate adherence groups (log rank P<0.0001). Multivariate Cox regression analysis showed complete guideline adherence was also significantly associated with lower adverse cardiovascular events compared with low guideline adherence (hazard ratio 0.66; 95% confidence interval 0.52-0.85; P=0.001). The use of guideline-based therapies for patients with acute myocardial infarction in contemporary clinical practice was associated with significant decreases in adverse long-term clinical outcomes. UMIN Unique trial Number: UMIN000010037.

The incidence and impact of cardiac conduction disturbances after transcatheter aortic valve replacement.

Transcatheter aortic valve replacement (TAVR) has developed into an established therapy for patients with severe aortic stenosis (AS) across the spectrum of surgical risk. Despite improvements in transcatheter heart valve (THV) technologies and procedural techniques, cardiac conduction disturbances, including high degree atrioventricular block (AVB) requiring permanent pacemaker (PPM) implantation and new-onset left bundle branch block (LBBB), remain frequent complications. TAVR-related conduction disturbances occur due to injury to the conduction system from interactions with interventional equipment and the transcatheter valve stent frame. Risk factors for post-TAVR conduction disturbances have been identified and include clinical characteristics, baseline electrocardiogram findings (right bundle branch block), anatomic factors, and potentially modifiable procedural factors (type of transcatheter valve, depth of implantation, over-sizing). New-onset LBBB and PPM implantation after TAVR have been shown to be associated with adverse long-term clinical outcomes, including mortality and heart failure hospitalization. These clinical consequences are likely to be of increasing importance as TAVR is utilized in younger and lower risk population. This review provides an updated overview of the literature regarding the incidence, predictors, and clinical outcomes of TAVR-related conduction disturbances, as well as proposed strategies for the management of this frequent clinical challenge.

Prevalence of Noncardiac Multimorbidity in Patients Admitted to Two Cardiac Intensive Care Units and Their Association with Mortality

BackgroundCurrent cardiac intensive care unit (CICU) practice has seen an increase in patient complexity, including an increase in noncardiac organ failure, critical care therapies, and comorbidities. We sought to describe the changing epidemiology of noncardiac multimorbidity in the CICU population. MethodsWe analyzed consecutive unique patient admissions to 2 geographically distant tertiary care CICUs (n = 16,390). We assessed for the prevalence of 0, 1, 2, and ≥3 noncardiac comorbidities (diabetes, chronic lung, liver, and kidney disease, cancer, and stroke/transient ischemic attack) and their associations with hospital and postdischarge 1-year mortality using multivariable logistic regression. ResultsThe prevalence of 0, 1, 2, and ≥3 noncardiac comorbidities was 37.7%, 31.4%, 19.9%, and 11.0%, respectively. Increasing noncardiac comorbidities were associated with a stepwise increase in mortality, length of stay, noncardiac indications for ICU admission, and increased utilization of critical care therapies. After multivariable adjustment, compared with those without noncardiac comorbidities, there was an increased hospital mortality for patients with 1 (odds ratio [OR] 1.30; 95% confidence interval [CI], 1.10-1.54, P = .002), 2 (OR 1.47; 95% CI, 1.22-1.77, P < .001), and ≥3 (OR 1.79; 95% CI, 1.44-2.22, P < .001) noncardiac comorbidities. Similar trends for each additional noncardiac comorbidity were seen for postdischarge 1-year mortality (P < .001, all). ConclusionsIn 2 large contemporary CICU populations, we found that noncardiac multimorbidity was highly prevalent and a strong predictor of short- and long-term adverse clinical outcomes. Further study is needed to define the best care pathways for CICU patients with acute cardiac illness complicated by noncardiac multimorbidity.

Circulating Osteocrin Levels Do Not Track with Myocardial Function in Chronic Systolic Heart Failure

Background Osteocrin was originally classified as a muscular and bone secretory protein with the ability to modulate bone growth through osteoblast activity, yet it shares a similar sequence to the family of natriuretic peptides (NPs). Despite their sequence homology, it is yet unknown whether osteocrin exhibits similar properties to NPs. However, recent work has shown that osteocrin can limit C-type NPs and more definitively, that a transgenic osteocrin mouse strain exhibited improved outcomes and alleviated echocardiographic parameters, after myocardial infarction (MI). Hypothesis With previous evidence showing improved prognosis and cardiac function in osteocrin-overexpressing mice post-MI, we hypothesize that circulating osteocrin levels in chronic heart failure patients could track with echocardiographic indices and other heart failure (HF) biomarkers of interest. Method Eighty-seven symptomatic chronic HF subjects with LVEF ≤35% underwent detailed echocardiographic evaluation and measurements of plasma NPs and osteocrin by ELISA assay, with long-term follow-up for all-cause mortality, transplantation, or mechanical circulatory support. Results In our study cohort (mean age 57 years, 72% male, 44% ischemic), median plasma osteocrin level was 198.3 (IQR 131.5, 386.3) ng/L. Plasma osteocrin levels did not track with demographics, comorbidities, medications, or laboratory values including ANP and BNP. Furthermore, osteocrin did not correlate to major echocardiographic indices (Table) or long-term adverse clinical outcomes. Conclusions Although osteocrin shows similarity to NPs and has been shown to exert cardioprotective effects in mice after cardiac insult, we did not observe any relationship between circulating osteocrin levels and clinical or echocardiographic parameters in chronic HFrEF patients.

Mitral Regurgitation Severity After Continuous-Flow LVAD Implantation as ot Associated with Adverse Long-Term Clinical Outcomes

Introduction Mitral regurgitation (MR) resulting from a markedly dilated left ventricle (LV) is common in advanced heart failure patients undergoing LV assist device (LVAD) implant. Significant MR post-LVAD therapy can contribute to worsening pulmonary venous hypertension, right ventricular (RV) failure, morbidity and mortality. Our aim was to examine the impact of MR severity on survival outcomes in patients on LVAD support. Methods A single-center retrospective chart review was conducted for any patient with LVAD implant for demographic, clinical, and echocardiographic variables. Post-LVAD MR severity was used to categorize patients into minimal or significant MR groups. Significant (severe) MR was defined by the presence of EROA ≥0.4cm2, regurgitant volume ≥60ml, regurgitant fraction ≥50%, jet >40% of LA, or grade ≥2+. Results 270 patients (mean age 57 ± 12 years) were analyzed. The majority were male (84%), and had non-ischemic cardiomyopathy (60%), bridge-to-transplant LVAD therapy (52%), significant pre-implant MR (75%), and minimal post-LVAD MR (87%). Median survival time after LVAD implant was 5.96 vs 4.74 years among patients with minimal vs significant MR, respectively (p=0.50). No significant difference was seen between groups even after adjusting for age, gender and device indication (hazard ratio 1.49 [95% CI 0.91, 2.24], p=0.119). Median survival time post-LVAD was 4.90 vs 5.41 years among patients with vs without grade ≥1 MR improvement post-LVAD, respectively (p=0.30). Overall, 28 patients (45%) and 75 patients (36%) died in the respective significant and minimal MR cohorts post-LVAD. Conclusions In our cohort, a minority of patients had persistence of significant MR on LVAD support. Survival outcomes on LVAD support or as bridge to heart transplant did not differ based on MR severity post-LVAD implant. Future studies are warranted on the implications of post-LVAD MR severity on hospital readmission burden.

Prognostic Impact of B-Type Natriuretic Peptide on Long-Term Clinical Outcomes in Patients with Non-ST-Segment Elevation Acute Myocardial Infarction Without Creatine Kinase Elevation.

Although B-type natriuretic peptide (BNP) has gradually gained recognition as an indicator in risk stratification for patients with acute myocardial infarction (AMI), the prognostic impact on long-term clinical outcomes in patients with non-ST-segment elevation acute myocardial infarction (NSTEMI) without creatine kinase (CK) elevation remains unclear.This prospective multicenter study assessed 3,283 consecutive patients with AMI admitted to 28 institutions in Japan between 2012 and 2014. We analyzed 218 patients with NSTEMI without CK elevation (NSTEMI-CK) for whom BNP was available. In the NSTEMI-CK group, patients were assigned to high- and low-BNP groups according to BNP values (cut-off BNP, 100 pg/mL). The primary endpoint was defined as a composite of all-cause death, non-fatal myocardial infarction, non-fatal stroke, cardiac failure, and urgent revascularization for unstable angina up to 3 years. Primary endpoints were observed in 60 (33.3%) events among patients with NSTEMI-CK. Kaplan-Meier analysis revealed a significantly higher event rate for primary endpoints among patients with high BNP (log-rank P < 0.001). After adjusting for covariates, a higher BNP level was significantly associated with long-term clinical outcomes in NSTEMI-CK (adjusted hazard ratio, 4.86; 95% confidence interval, 2.18-12.44; P < 0.001).The BNP concentration is associated with adverse long-term clinical outcomes among patients with NSTEMI-CK who are considered low risk. Careful clinical management may be warranted for secondary prevention in patients with NSTEMI-CK with high BNP levels.

Independent and cumulative association of clinical and morphological heart failure with long-term outcome after percutaneous coronary intervention

BackgroundHeart failure (HF) is a risk factor for adverse post-procedural outcome after revascularization; however, it is unclear how left ventricular systolic dysfunction (LVSD) and clinical HF symptoms affect percutaneous coronary intervention (PCI) outcomes. We investigated the characteristics and long-term outcomes of patients with clinical HF or LVSD after PCI. MethodsThis was a Japanese multicenter registry study of adult patients receiving PCI. Among 4689 consecutive patients who underwent PCI at 15 hospitals from January 2009 to December 2012, we analyzed 2634 (56.2%) with documented left ventricular ejection fraction (LVEF). They were divided into four groups based on clinical HF (symptoms or HF hospitalization) and LVEF [≥35% and <35% (HF due to LVSD)]. The primary outcome was major adverse cardiovascular events (MACE), comprising all-cause death, acute coronary syndrome, HF hospitalization, performance of coronary artery bypass grafting, and stroke within 2 years after the initial PCI. ResultsOur findings revealed 354 patients (13.4%) with HF (clinical HF, n = 173, 48.9%; LVSD, n = 132, 37.3%; both, n = 49; 13.8%). The incidence of MACE was higher in patients with clinical HF or LVSD, and was largely due to higher non-cardiac death and HF hospitalization. After adjustment, clinical HF (hazard ratio 2.16, 95% confidence interval; 1.49−3.14) and lower LVEF (per 10%, hazard ratio 0.89, 95% confidence interval; 0.81−0.99) were independently associated with higher MACE risk. ConclusionsClinical HF and LVSD were independently associated with adverse long-term clinical outcomes, particularly with non-cardiac death and HF readmission, in patients treated with PCI.

Clinical Characteristics and Adverse Clinical Outcomes of Invasive Haemophilus influenzae Serotype a Cases-United States, 2011-2015.

Incidence of invasive disease due to Haemophilus influenzae serotype a (Hia) increased an average of 13% annually from 2002 through 2015. We describe clinical characteristics and adverse clinical outcomes of US invasive Hia cases detected through multistate surveillance during 2011-2015. Medical record data were abstracted for cases reported in 8 jurisdictions conducting active population- and laboratory-based surveillance for invasive Hia disease across the United States. Isolates from sterile sites were serotyped using real-time polymerase chain reaction. Adverse clinical outcomes were defined as any possible complication of meningitis, bacteremic pneumonia, or bacteremia (including hearing loss and developmental delay, but excluding death) and were assessed at hospital discharge and one-year post-disease onset. During 2011-2015, 190 Hia cases were reported to the 8 participating sites; 169 (88.9%) had data abstracted. Many patients were aged <5 years (42.6%). Meningitis was the most common clinical presentation among those aged <1 year (71.4%); bacteremic pneumonia was the most common presentation among persons aged ≥50 years (78.7%). Overall, 95.9% of patients were hospitalized. Among those hospitalized, 47.5% were admitted to an intensive care unit and 6.2% died during hospitalization. At hospital discharge and one-year post-disease onset, adverse outcomes were identified in 17.7% and 17.8% of patients overall and in 43.9% and 48.5% of patients with meningitis (primarily children). Hia infection can cause severe disease that requires hospitalization and may also cause short- and long-term adverse clinical outcomes, especially among children. Novel vaccines could prevent morbidity and mortality.

Neutrophil to Lymphocyte Ratio and Long-Term Cardiovascular Outcomes in Coronary Artery Disease Patients with Low High-Sensitivity C-Reactive Protein Level.

Although an elevated neutrophil to lymphocyte ratio (NLR) has been associated with the adverse outcomes of coronary artery disease (CAD), less is known about its prognostic value among patients with low high-sensitivity C-reactive protein (hs-CRP) levels. We enrolled 2,591 consecutive patients with stable CAD who underwent elective percutaneous coronary intervention (PCI) and had available data on preprocedural hs-CRP and NLR between 2000 and 2016. Of these patients, 1,951 with low-grade hs-CRP levels (< 2.0 mg/L) were divided into quartiles based on the NLR values. The primary endpoint was a composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke after the index PCI. Clinical follow-up data were obtained up to 5 years. The median NLR was 1.9 (interquartile range: 1.5-2.5). During the follow-up, 102 events occurred (5.2%), with a cumulative incidence that was significantly higher in the highest NLR group than in the other groups (log-rank, P = 0.02). After adjusting for the other cardiovascular risk factors, the risk for the primary endpoint was significantly higher for the highest than in the lowest NLR group (HR 1.97, 95% CI 1.09-3.54, P = 0.02). Increasing NLR as a continuous variable was associated with the incidence of adverse cardiovascular events (HR 1.85 per log 1 NLR increase, 95% CI 1.19-2.88, P = 0.007). In conclusion, the adverse long-term clinical outcomes of CAD patients with low-grade hs-CRP levels has been independently predicted by increased NLR level. NLR could be useful for risk stratification of CAD patients with increased inflammatory marker levels.

Under‐detection of acute kidney injury in hospitalised patients: a retrospective, multi‐site, longitudinal study

Acute kidney injury (AKI) is a rapid deterioration of renal function, often caused by a variety of co-existing morbidities complicating its recognition and treatment, leading to short- and long-term adverse clinical outcomes. There are limited data on the incidence of AKI in Australia using the Kidney Disease Improving Global Outcomes creatinine-based consensus definition. To determine the incidence and estimate the extent of under-reporting of AKI in four hospitals in the South-Eastern Sydney/Illawarra regions of New South Wales, Australia. A laboratory algorithm based on the Kidney Disease Improving Global Outcomes creatinine-based definition for AKI was applied retrospectively to laboratory data for adult patients admitted to the study hospitals between 2009 and 2013 to identify those with AKI. The results were compared with the incidence of AKI based on diagnostic codes for AKI reported for the same period. AKI was detected in 12.4% of all hospitalisations (46 101/370 969) and 16.4% of patients (31 448/192 133) across the 5-year study period using the laboratory algorithm. Of these, 72.1% were AKI Stage 1 (33 246/46101). AKI was coded in only 15.9% of hospitalisations with AKI Stage 1 (5294/33 246), 38.5% of hospitalisations with Stage 2 (2381/6185), and 46.8% with Stage 3 (3120/6670). Yearly incidence of laboratory-identified AKI trended downward between 2009 and 2013, while annual incidence determined by coding trended upward. Although coding trends suggested a continuous increase in clinician awareness of AKI across the study period, AKI in hospitalised patients remained significantly under-reported.

784 Adverse Long-Term Clinical Outcomes Among Patients With Pre-procedural Atrial Fibrillation Undergoing Percutaneous Coronary Intervention

Approximately 5-10% of patients presenting for percutaneous coronary intervention (PCI) have concurrent atrial fibrillation (AF). To what extent AF portends adverse long-term outcomes in these patients remains to be defined. We analysed data from the multicentre Melbourne Interventional Group Registry from 2008-2018. Patients were identified as being in AF or sinus rhythm (SR) at the commencement of PCI. The primary endpoint was long-term mortality, obtained via linkage with the National Death Index. Multivariate logistic regression was used to compare predictors of long-term mortality. 26,208 procedures were included, with 1,485 (5.7%) patients in AF and 24723 (94.3%) in SR. Compared to SR, patients with AF were older (73.3±10.4 vs 64.0±12.0, p<0.001), more likely to be female (26.8% vs 23%, p=0.001), have diabetes (31.3% vs 25.0%, p<0.001), and left ventricular systolic dysfunction (38.5% vs 21.3%, p<0.001). AF was associated with an increased risk of in-hospital mortality (9.8% vs 2.1%, p<0.001) and MACE (composite of all-cause mortality, myocardial infarction or target vessel revascularisation) (10.7% vs 3.8%, p<0.001). In-hospital major bleeding was more common in the AF group (3.3% vs 1.0%, p<0.001). AF was an independent predictor of long-term mortality (adjusted HR 1.59, 95% CI 1.42–1.78, p<0.001) and was a stronger correlate than age (HR 1.07, 95% CI 1.06–1.07, p<0.001) and cerebrovascular disease (1.27, 95% CI 1.33–1.43, p<0.001). Patients with preprocedural AF represent a high-risk group of patients. When adjusted for other adverse predictors, preprocedural AF was associated with a 1.6 fold increase risk in long-term mortality.

Clinical significance of Pseudomonas aeruginosa 2-alkyl-4-quinolone quorum-sensing signal molecules for long-term outcomes in adults with cystic fibrosis.

Introduction. Pseudomonas aeruginosa is an important respiratory pathogen in cystic fibrosis (CF), which is associated with an accelerated decline in lung function, frequent pulmonary exacerbations and increased mortality. P. aeruginosa produces intercellular signalling molecules including 2-alkyl-4-quinolones (AQs), which regulate virulence-factor production and biofilm formation in the CF airways. Studies have shown that AQs are detectable in the sputum and plasma of adults with CF and chronic pulmonary P. aeruginosa.Aim. We tested the hypothesis that the presence of six AQs in plasma or sputum obtained from adults with CF was associated with long-term adverse clinical outcomes.Methodology. We analysed clinical data over an 8 year follow period for 90 people with CF who had previously provided samples for AQ analysis at clinical stability. The primary outcome was all cause mortality or lung transplantation. Secondary outcomes were the rate of lung-function decline and the number of intravenous (IV) antibiotic days for pulmonary exacerbations.Results. There was no statistical association between the presence of any of the six measured AQs and the primary outcomes or the secondary outcome of decline in lung function. One of the six AQs was associated with IV antibiotic usage. The presence of 2-nonyl-3-hydroxy-4(1 h)-quinolone (C9-PQS) in sputum was associated with an increase in the number of IV antibiotic days in the follow-up period (Mann-Whitney; P=0.011).Conclusion. Further investigation to confirm the hypothesis that C9-PQS may be associated with increased antibiotic usage for pulmonary exacerbations is warranted as AQ-dependent signalling is a potential future target for anti-virulence therapies.

Implications of renin-angiotensin-system blocker discontinuation in acute decompensated heart failure with systolic dysfunction.

BackgroundRenin‐angiotensin‐system blockers (RASB) improve clinical outcomes in patients with chronic heart failure with reduced fraction; however, there remains ambiguity whether RASB therapy should be continued during the treatment of acute decompensated heart failure (ADHF).HypothesisIn comparison to patients with RASB use, RASB discontinuation in ADHF will be associated with worsening renal function, hypotension, and adverse long‐term clinical outcomes.MethodsPatients in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization (ESCAPE) trial were separated into four groups based on RASB use at baseline and discharge: continuation (n = 316), discontinuation (n = 21), initiation (n = 42), and nonuse (n = 23). Post‐discharge outcomes were validated in an independent ADHF cohort admitted to the Cleveland Clinic (n = 253).ResultsRASB discontinuation and nonuse were associated with higher serial creatinine and blood urea nitrogen levels than RASB continuation or initiation (P < .001 for both), but not with serial potassium and systolic blood pressure measurements. No other clinical parameter changes were significant. In comparison to RASB continuation, RASB discontinuation and nonuse was associated with ~75% increased risk of a 180‐day composite of death, transplant, or rehospitalization (HR 1.87, 95% CI 1.09‐3.20, P = 0.02 and HR 1.72, CI 1.04‐2.82, P = .03, respectively). Post‐discharge outcomes were similar in the validation cohort.ConclusionCompared to RASB continuation, RASB discontinuation and nonuse were associated with higher baseline and serial creatinine levels during treatment for ADHF, but not with changes in SBP and potassium levels. Furthermore, RASB discontinuation and nonuse in ADHF were associated with an increased risk of adverse clinical outcomes.