Noncardiovascular Causes Research Articles

Comparison in Patients < 75 Years of Age - Versus – Those > 75 Years on One-year-Events With Atrial Fibrillation and Left Atrial Appendage Occluder (From the Prospective Multicenter German LAARGE Registry)

Left atrial appendage closure (LAAC) is an alternative to oral anticoagulation therapy in patients with non-valvular atrial fibrillation for the prevention of embolic stroke and systemic embolism. Although elderly patients (>75 years) have both higher ischemic and bleeding risk as compared with younger patients, they benefit from optimal anticoagulation. The subanalysis aimed to assess the indications, the safety, efficacy, and 1-year outcomes of interventional LAAC in elderly patients (≥ 75 years) compared with younger (< 75 years) patients in clinical practice. We analyzed data from the prospective Left-Atrium-Appendage Occluder Registry Germany. A total of 638 patients were included in the registry, 402 (63%) were aged ≥ 75 years. Compared with younger subjects, patients aged ≥75 were more likely to have higher CHA2DS2-VASC and HAS-BLED scores. Procedural success rate was high und similar in both groups (97.6%). Periprocedural adverse events were not statistically significant in groups (11.9% in <75 years vs 12.9% in ≥75 years; p = 0.80). At 1 year follow-up, all-cause mortality was higher in patients aged ≥75 compared withwith younger group (13.0% vs 7.8 %,p = 0.04), mainly due to non-cardiovascular causes (10.6% vs 6.0%). No significant differences in major bleeding, stroke, systemic embolism were observed. In conclusion, LAAC is feasible and safe in patients with AF at high stroke risk and with contraindications for OAC and should be considered as candidates for LAA closure. Elderly patients often present these characteristics and could benefit from this novel therapy.

Combining the Passeo-18 Lux Drug-Coated Balloon and the Pulsar-18 Bare Metal Stent: 12- and 24-Month Outcomes of the BIOLUX 4EVER Investigator-Initiated Trial

Purpose: To report the outcomes after treating stenotic or occluded femoropopliteal lesions with a drug-coated balloon (DCB) followed by the implantation of a thin-strut self-expanding bare metal stent in the BIOLUX 4EVER trial (ClinicalTrials.gov identifier NCT02211664). Materials and Methods: The prospective, multicenter, physician-initiated BIOLUX 4-EVER trial was conducted at 5 centers in Belgium and enrolled 120 patients (mean age 70.9±10.5 years; 79 men) with symptomatic stenotic or occluded de novo femoropopliteal lesions. A fifth of the patients had diabetes mellitus and nearly half had previous peripheral artery interventions. The lesions were a mean 83.3±49.5 mm long with a mean reference vessel diameter of 5.26±0.59 mm. Lesions were treated with a Passeo-18 Lux DCB followed by the implantation of a Pulsar-18 bare metal stent. Follow-up visits were conducted at 1, 6, 12, and 24 months postprocedure; the main outcome was primary patency at 12 months. Results: Technical success was obtained in all patients. Primary patency was observed in 89.9% of patients (95% CI 84.0% to 95.8%) at 12 months and in 83.5% at 24 months (95% CI 89.9% to 97.3%), and freedom from target lesion revascularization was 93.6% (95% CI 89.9% to 97.3%) and 86.1% (95% CI 79.9% to 92.3%), respectively. Ten patients died throughout the course of the trial (90.7% survival at 24 months), all of noncardiovascular causes. The ankle-brachial index improved from 0.68±0.09 at baseline to 0.93±0.11 and 0.93±0.12 at 12- and 24-month follow-up visits (p<0.001). An improvement of at least 1 Rutherford category was observed in 91 of 94 patients (96.8%) at 12 months and 78 of 83 patients (93.4%) at 24 months (p<0.001). Conclusion: The combination of a Passeo-18 Lux DCB followed by a Pulsar-18 stent implantation produced safe and effective outcomes in the treatment of femoropopliteal lesions at up to 24 months. Adding paclitaxel to the bare nitinol stent platform by predilating with a Passeo-18 Lux DCB seems to increase efficacy at 1 and 2 years compared with the use of bare metal stents only, which were investigated in the precursor 4-EVER study.

Severe hypoglycaemia and absolute risk of cause-specific mortality in individuals with type 2 diabetes: a UK primary care observational study

Aims/hypothesisSeveral pathophysiological mechanisms would suggest a causal link between hypoglycaemia and cardiovascular death; conversely, current knowledge would not support a causal relationship with other causes of death. To clarify the nature and the magnitude of the association between hypoglycaemia and death, we investigated the 5 year mortality risks for cardiovascular disease, cancer and other causes in individuals with type 2 diabetes admitted to hospital for a severe hypoglycaemic episode.MethodsWe defined in the UK Clinical Practice Research Datalink database a prevalent cohort of adults with type 2 diabetes diagnosed between 1 January 1998 and 1 January 2011 (index date), with available linkage to the Office for National Statistics (ONS) and the Hospital Episode Statistics (HES). A hospital admission reporting hypoglycaemia as the underlying cause was identified before the index date in the HES; date and underlying cause of death were obtained from the ONS. We quantified the 5 year risk of cause-specific death in people with and without admission to hospital for severe hypoglycaemia, adjusting for potential confounders and accounting for competing risk.ResultsOf the 74,610 subjects included in the cohort, 388 (0.5%) were admitted at least once for a severe hypoglycaemic episode; subjects admitted were older, with higher HbA1c and a greater prevalence of multimorbidity. During a median follow-up of 7.1 years, 236 (60.8%) and 18,539 (25.0%) deaths occurred in subjects with and without a previous severe hypoglycaemia, respectively. Non-cardiovascular causes accounted for 71% of all deaths in both subjects with and without hypoglycaemia. In a 60-year-old person with severe hypoglycaemia, the 5 year absolute risk of death, adjusted for age, sex, ethnicity, systolic blood pressure, total cholesterol, HbA1c, BMI, eGFR, smoking status, alcohol consumption and deprivation (Townsend score), was 6.6%, 1.1% and 13.1% for cardiovascular, cancer and other causes, respectively, while the 5 year absolute risk difference compared with a subject without severe hypoglycaemia was 4.7% (95% CI 1.0, 8.3) for cardiovascular, −1.4% (−4.1, 1.4) for cancer and 11.1% (6.1, 16.1) for other causes of death. Results were consistent in models further adjusted for medications and comorbidities (myocardial infarction, stroke, peripheral artery disease, heart failure, atrial fibrillation, cancer), with sulfonylurea and insulin associated with increased mortality rates (from cause-specific hazard ratio of 1.06 [95% CI 0.99, 1.14] for cancer death with use of sulfonylurea to 1.42 [1.29, 1.56] for cardiovascular death with use of insulin). Results were robust to missing data.Conclusions/interpretationThe results of this study indicate severe hypoglycaemia as a marker of, rather than causally linked to, an increased risk of long-term mortality. Regardless of the nature of the association, a severe hypoglycaemic episode represents a strong negative prognostic factor in patients with type 2 diabetes.Graphical abstract

Non-adherence to established dietary guidelines associated with increased mortality: the Copenhagen General Population Study.

The relevance of adherence to established dietary guidelines is repeatedly challenged. We hypothesised that non-adherence to established dietary guidelines is associated with an excess risk of cardiovascular, non-cardiovascular and all-cause mortality. We studied 100,191 white adult Danes aged 20-100 years recruited in 2003-2015 and followed up until December 2018. During follow-up equalling 865,600 person-years, 9273 individuals died. Participants' diets were assessed at baseline by a food frequency questionnaire focusing on key foods defining a healthy diet according to Danish dietary guidelines. Individuals were divided into five categories ranging from very high to very low adherence to dietary guidelines and studied with Cox and Fine-Gray regression models. At study inclusion, we collected demographic and lifestyle characteristics by questionnaire, made a physical examination and took a blood sample. Cardiovascular, non-cardiovascular and all-cause mortality increased gradually with increasing non-adherence to dietary guidelines. Cardiovascular mortality was 30% higher (95% confidence interval 7-57%), non-cardiovascular mortality 54% higher (32-79%) and all-cause mortality 43% higher (29-59%) in individuals with very low adherence to dietary guidelines compared with those with very high adherence after adjustments for age, sex, education, income, smoking, leisure time physical activity and alcohol intake. Mortality risk estimates were similar in all strata of adjusted variables. Non-adherence to Danish food-based dietary guidelines is associated with up to 43% increased all-cause mortality in a dose-response manner. The mortality excess was seen for both cardiovascular and non-cardiovascular causes. The public has good reasons to have confidence in and to adhere to established dietary guidelines.

Association of nut intake with risk factors, cardiovascular disease, and mortality in 16 countries from 5 continents: analysis from the Prospective Urban and Rural Epidemiology (PURE) study

The association of nuts with cardiovascular disease and deaths has been investigated mostly in Europe, the USA, and East Asia, with few data available from other regions of the world or from low- and middle-income countries. To assess the association of nuts with mortality and cardiovascular disease (CVD). The Prospective Urban Rural Epidemiology study is a large multinational prospective cohort study of adults aged 35-70 y from 16 low-, middle-, and high-income countries on 5 continents. Nut intake (tree nuts and ground nuts) was measured at the baseline visit, using country-specific validated FFQs. The primary outcome was a composite of mortality or major cardiovascular event [nonfatal myocardial infarction (MI), stroke, or heart failure]. We followed 124,329 participants (age=50.7 y, SD=10.2; 41.5% male) for a median of 9.5 y. We recorded 10,928 composite events [deaths (n=8,662) or major cardiovascular events (n=5,979)]. Higher nut intake (>120 g per wk compared with <30 g per mo) was associated with a lower risk of the primary composite outcome of mortality or major cardiovascular event [multivariate HR (mvHR): 0.88; 95% CI: 0.80, 0.96; P-trend=0.0048]. Significant reductions in total (mvHR: 0.77; 95% CI: 0.69, 0.87; P-trend<0.0001), cardiovascular (mvHR: 0.72; 95% CI: 0.56, 0.92; P-trend=0.048), and noncardiovascular mortality (mvHR: 0.82; 95% CI: 0.70, 0.96; P-trend=0.0046) with a trend to reduced cancer mortality (mvHR: 0.81; 95% CI: 0.65, 1.00; P-trend=0.081) were observed. No significant associations of nuts were seen with major CVD (mvHR: 0.91; 95% CI: 0.81, 1.02; P-trend=0.14), stroke (mvHR: 0.98; 95% CI: 0.84, 1.14; P-trend=0.76), or MI (mvHR: 0.86; 95% CI: 0.72, 1.04; P-trend=0.29). Higher nut intake was associated with lower mortality risk from both cardiovascular and noncardiovascular causes in low-, middle-, and high-income countries.

Abstract 108: Contemporary Timing and Etiology of Mortality in ST-Elevation Myocardial Infarction

Background: Acute treatment of ST-elevation myocardial infarction (STEMI) has focused on early reperfusion, prompt defibrillation, and appropriate mechanical support to mitigate short-term mortality. Long-term patterns of death in a contemporary population are not well described. Methods: We reviewed consecutive cases of STEMI treated with percutaneous coronary intervention (PCI) at our center between January 1, 2011, and December 31, 2016, and divided patients into two groups: uncomplicated STEMI (US) and complicated STEMI (CS). CS was defined by presence of cardiac arrest or cardiogenic shock, ascertained from first-medical-contact to device time for PCI. We assessed for differences in characteristics and short- and long-term mortality between the groups. Results: We identified 1,272 patients with STEMI; 214 of which were CS (16.8%). Those with CS were significantly more likely to have heart failure (22.9% vs 11.3%, p&lt;0.001), kidney disease (38.2% vs. 21.0%, p&lt;0.001), cerebrovascular disease (18.7% vs 11.0%, p=0.003), peripheral vascular disease (16.8% vs 7.9%, p&lt;0.001), and left main or left anterior descending culprit vessel (51.9% vs. 40.3%, p&lt;0.002). Total in-hospital mortality was 5.0% (63 patients), with 19.6% (42/214) and 2.0% (21/1058) of those with CS and US respectively (p&lt;0.001). Among 1209 of patients that survived to hospital discharge, total long-term mortality was 10% (121 patients) of which 18.0% (31/172) had CS and 8.7% (90/1037) had US (p=0.001) over mean follow-up of 3.1±1.9 years. Of those, 52% and 50%, respectively, were from non-cardiovascular etiologies (Figure) including malignancy (13% vs. 22%), infection (22% vs. 19%), or other causes (17% vs. 9.0%). Conclusion: Despite advances in the in-hospital care of patients with STEMI, there remains a significant risk of long-term mortality for both patients with uncomplicated and complicated STEMI. A substantial proportion of overall STEMI mortality now occurs after hospital discharge predominantly due to non-cardiovascular causes. Systems of care to mitigate this long-term risk are needed.

P109: Does an elevated troponin ultimately matter? An assessment of outcomes in patients presenting to the emergency department with non-cardiac complaints

Introduction: Acute myocardial infarction (MI) is one of the most time-sensitive diagnoses made in the emergency department (ED). Troponin (TNI) measurement is an invaluable tool; however, its utility depends on the clinical context and is highest where there is a strong pre-test probability. Studies show that most TNI elevations are due to non-cardiovascular causes; however, elevated TNI has been associated with increased morbidity and mortality, often prompting additional investigations. The aim of our study was to compare 1-year cardiac outcomes of patients who presented to the ED with non-cardiac complaints and elevated TNI who had further cardiac testing versus those who did not. Methods: We conducted a retrospective chart review of patients ≥18 seen in the ED for non-cardiac complaints with a high TNI from January-June 2016. Patients were stratified into two groups: 1) those who received diagnostic testing for ischemia and/or a cardiac consultation and 2) those without cardiac consultation or testing. Data was also collected on major adverse cardiac events within 1-year of ED presentation. Chi-squared analysis assessed the difference in proportions of outcomes between groups. We present our preliminary data. Results: In total, 1500 patients met inclusion criteria and 861 have been analyzed thus far. Of these 861, 209 went on to have either diagnostic testing for ischemia and/or a cardiology consult while 652 had no further investigations. There was no statistically significant difference in the proportion of patients who developed unstable angina (p = 0.9824), ST-elevation myocardial infarction (STEMI) (p = 0.9956), non-STEMI (p = 0.9008), stroke/TIA (p = 0.9657), revascularization (p = 0.8873), cardiac hospitalization (p = 0.9446) or died (p = 0.8972), within 1-year of their ED presentation. Conclusion: In patients with isolated elevated TNI and non-cardiac complaints, preliminary data showed no difference in mortality or cardiac event rates between those who had further testing/consultations and those who did not. TNI ordering could be cautiously limited to only presenting complaints/preliminary diagnoses likely to have cardiac etiology or sequelae or those in whom further testing would impact management/outcomes. Quality of care may be improved by reducing length of stay in the ED and potential risks of unnecessary tests. Future studies include determining cost implications and classifying what level of TNI elevation in non-ACS patients may predict a future cardiac outcome.

Troponin measurements, myocardial infarction diagnoses and outcomes. An analysis of linked data from New South Wales, Australia.

Cardiac troponin assays are very widely requested tests, particularly in emergency departments. Thus, many seriously ill patients who may not have heart disease as their primary discharge diagnosis have undergone troponin testing during hospitalisation. To determine associations between cardiac troponin levels and mortality, including from cardiovascular and non-cardiovascular causes, among patients hospitalised in New South Wales, Australia over a 2-year period. Over a 2-year period (2006-2008), 172 753 hospitalised patients had a quantitative or qualitative troponin assay performed in New South Wales (Australia). The associations were examined, using data linked to late outcomes, between elevations in levels of troponins T or I and 1-year mortality. Mortality was determined for International Statistical Classification of Diseases 10th Revision diagnostic groups. Of 172 753 patients undergoing troponin testing, 44 357 (25%) had a cardiovascular diagnosis of whom (7% had myocardial infarction) 47 827 (28%) had a probable ischaemic heart disease diagnosis if the 23 873 (14%) of patients coded with 'chest pain' were included. In patients with a cardiovascular diagnosis and elevated troponin 3060 (1.8%) died in 12 months in comparison to 6262 (3.6%) in those with a non-cardiovascular disease diagnoses and elevated troponin. The 1-year mortality hazard with respect to a troponin elevation was 2.5 (95% confidence interval 2.3-2.7) and 2.0 (95% confidence interval 1.99-2.01) for those with a cardiovascular and non-cardiovascular diagnosis respectively. In a very large state-wide hospitalised patient cohort, among patients with elevated troponin levels and non-cardiac diagnoses, mortality was higher than in those with cardiovascular diagnoses, including MI.

Abstract P350: The Link Between Cognitive Function and Cause-specific Mortality in US Adults

Introduction: Multiple studies demonstrated an independent and inverse association between cognitive function and mortality but little is known about the cause of death. Hypothesis: We hypothesized that lower cognitive function is related to higher mortality risk and this association is stronger for cardiovascular related deaths. Methods: We included 5569 persons (mean[SE] age 71[0.05], 52% women), from the Third National Health and Nutrition Examination Survey (NHANES III) with available cognitive function measurements and mortality follow-up. Cognitive domains include orientation, attention, immediate and delayed memory as well as global cognition. We used weighted Cox proportional regression models adjusted for age, sex, education, systolic and diastolic blood pressure, body mass index, smoking, history of diabetes and cardiovascular disorders. Results: During an average follow-up of 12 years, 1887 participants died from cardiovascular causes and 2675 died from non-cardiovascular causes. Each SD lower global cognitive performance (SD=6) was related to a 1.11 (95% CI: 1.05, 1.17) higher hazard of all-cause mortality. The associations were more prominent with cardiovascular mortality than with non- cardiovascular mortality (Table). Conclusion: Cognitive impairment in the absence of manifest dementia is an important independent predictor of mortality, in particular from cardiovascular causes.

Abstract P492: Circulating Sphingolipids and Risk of Mortality: The Cardiovascular Health Study

Introduction: Recent studies suggest that the type of saturated fatty acid bound to sphingolipids influences sphingolipid activity, and that associations of ceramides (Cer) and sphingomyelins (SM) with cardiovascular outcomes may differ by lipid species. The purpose of this study was to assess associations of Cer and SM species with mortality among 4,612 older adults from the Cardiovascular Health Study, a population-based prospective study of adults aged ≥65 y who were followed from 1992-2015. Hypothesis: Higher levels of circulating Cer and SM with palmitic acid (Cer-16) are associated with a higher risk of mortality (i.e., deaths from cardiovascular disease (CVD) and non-cardiovascular causes) while higher levels of Cer and SM with very-long chain saturated fatty acids arachidic acid (Cer-20 and SM-20), behenic acid (Cer-22 and SM-22), and lignoceric acid (Cer-24 and SM-24) are associated with a lower risk. Methods: The associations of each sphingolipid with mortality were assessed using Cox proportional hazards models. Models adjusted for age, sex, self-reported race, geographic area, education, smoking, alcohol use, BMI, activities of daily living, HDL and LDL cholesterol, triglycerides, systolic blood pressure, physical activity, use of hypertension or lipid-lowering drugs, self-reported health status, prevalent diabetes, CVD, heart failure (HF), and other sphingolipids species. Results: During a median follow-up of 10.2 years (range 0-23 years), 4,099 deaths occurred. At each time, higher levels of Cer-16 and SM-16 were associated with a higher risk of mortality, while higher levels of Cer-22, Cer-24, SM-20, SM-22, and SM-24 were associated with a lower risk of mortality (Figure). Models that did not adjust for diabetes, CVD, and HF produced similar results. Conclusions: These findings suggest that the associations of Cer and SM with the risk of death differ according to the length of their acylated saturated fatty acid, and support the need for future studies to explore mechanisms underlying these relations.

Pathogenic FBN1 Genetic Variation and Aortic Dissection in Patients With Marfan Syndrome

BackgroundAortic risk has not been evaluated in patients with Marfan syndrome and documented pathogenic variants in the FBN1 gene. ObjectivesThis study sought to describe aortic risk in a population with Marfan syndrome with pathogenic variants in the FBN1 gene as a function of aortic root diameter. MethodsPatients carrying an FBN1 pathogenic variant who visited our reference center at least twice were included, provided they had not undergone aortic surgery or had an aortic dissection before their first visit. Aortic events (aortic surgery or aortic dissection) and deaths were evaluated during the 2 years following each patient visit. The risk was calculated as the number of events divided by the number of years of follow-up. ResultsA total of 954 patients were included (54% women; mean age 23 years). During follow-up (9.1 years), 142 patients underwent prophylactic aortic root surgery, 5 experienced type A aortic dissection, and 12 died (noncardiovascular causes in 3, unknown etiology in 3, post-operative in 6). When aortic root diameter was <50 mm, risk for proven type A dissection (0.4 events/1,000 patient-years) and risk for possible aortic dissection (proven aortic dissection plus death of unknown cause, 0.7 events/1,000 patients-years) remained low in this population that was treated according to guidelines. Three type A aortic dissections occurred in this population during the 8,594 years of follow-up, including 1 in a patient with a tubular aortic diameter of 50 mm, but none in patients with a family history of aortic dissection. The risk for type B aortic dissection in the same population was 0.5 events/1,000 patient-years. ConclusionsIn patients with FBN1 pathogenic variants who receive beta-blocker therapy and who limit strenuous exercise, aortic risk remains low when maximal aortic diameter is <50 mm. The risk of type B aortic dissection is close to the remaining risk of type A aortic dissection in this population, which underlines the global aortic risk.

Risk of de-novo heart failure and competing risk in asymptomatic patients with structural heart diseases

AimsAsymptomatic patients with structural heart diseases are classified as a population at high risk for heart failure (HF) in Stage B. However, limited data are available regarding incidence and related factors of de-novo HF (DNHF) considering competing risk in this population. Methods and resultsIn 3362 Stage B patients (mean age 68 yrs, male 76%) from the CHART-2 Study (N = 10,219), we examined incidence of death and DNHF, defined as the first episode of either HF hospitalization or HF death, and factors related to DNHF. ResultsDuring the median 6.0-year follow-up, 627 deaths (31/1000 person-years) and 293 DNHF (15/1000 person-years) occurred. Among the 627 deaths, 212 (34%) and 325 (52%) were specified as cardiovascular and non-cardiovascular deaths, respectively. During the follow-up of 271 DNHF hospitalizations, we observed 124 deaths, including 65 (52%) cardiovascular and 47 (40%) non-cardiovascular deaths. The competing risk model showed that age, diabetes mellitus, stroke, atrial fibrillation, diastolic blood pressure, hemoglobin levels, estimated glomerular filtration ratio and left ventricular ejection fraction was significantly associated with DNHF. Bayesian structural equation modeling showed that many of these cardiac and non-cardiac variables contribute to DNHF by affecting each other, while diabetes mellitus was independently associated with DNHF. ConclusionsStage B patients had a high incidence of DNHF as well as that of death due to both cardiovascular and non-cardiovascular causes. Thus, management of Stage B patients should include multidisciplinary approaches considering both cardiac and non-cardiac factors, in order to prevent DNHF as well as non-HF death as a competing risk.Trial registration: clinicaltrials.gov identifier: NCT00418041.

Etiologies and predictors of readmission among obese and morbidly obese patients admitted with heart failure.

The relationship between severity of obesity and outcomes in heart failure (HF) has long been under debate. We studied index HF admissions from the 2013-14 National Readmission Database. Admissions were separated into three weight-based categories: non-obese (Non-Ob), obese (Ob), and morbidly obese (Morbid-Ob) to analyze hospital mortality and readmission at 30days and 6months. We investigated etiologies and predictors of 30-day readmission among these weight categories. We studied a total of 578,213 patients of whom 3.0% died during index hospitalization (Non-Ob 3.3% vs. Ob 1.9% vs. Morbid-Ob 1.9%; p< 0.01). Non-Ob comprised 79.5%, Ob 9.9%, and Morbid-Ob 10.6% of patients. Morbid-Ob patients were the youngest among age categories and more likely to be female. In-hospital mortality during readmission at 30days and 6months was significantly lower among Morbid-Ob and Ob compared with Non-Ob patients (all p< 0.01). Thirty-day readmission among Morbid-Ob was lower than Non-Ob and higher than Ob patients (19.6% vs. 20.5% vs. 18.6%, respectively; p< 0.01). Morbid-Ob patients were less likely to be readmitted for cardiovascular etiologies compared with both Ob and Non-Ob (45.0% vs. 50.3% vs. 50.6%; p< 0.01). Multivariable regression analysis revealed that Ob (adjusted odds ratio 0.84, 95% confidence intervals 0.82-0.86) and Morbid-Ob (aOR 0.83, 95% CI 0.81-0.85) were independently associated with lower 30-day readmission. Readmission at 6months was highest among Morbid-Ob followed by Non-Ob and Ob (51.1% vs. 50.2% vs. 49.1%, p< 0.01). Morbid-Ob and Ob patients experience lower in-hospital mortality during index HF admission and during readmission with 30days or 6months compared with Non-Ob. Morbid-Ob patients experience greater readmission at 6months despite the lower rate at 30days post discharge. Morbid-Ob patients are most likely to be readmitted for non-cardiovascular causes.

Type 2 myocardial infarction: is it a geriatric syndrome?

Type 2 myocardial infarctions (T2-MI) is a type of necrosis that results from reduced oxygen supply and/or increased demand secondary to other causes unrelated to acute coronary atherothrombosis. The development and implementation of sensitive and high-sensitivity cardiac necrosis marker and the age-related increase of comorbidity lead to a boost of the frequency of T2-MI. T2-MI is often a complication of a high degree of clinical frailty in older adults, emerging as a "geriatric syndrome". Age-related non-cardiovascular causes may be the triggering factors and are strongly associated with the diagnosis, treatment, and prognosis of T2-MI. To date, there are no guidelines on management of this pathology in advancing age. Patient-centered approach and comprehensive geriatric assessment play a key role in the diagnosis, therapy and prognosis of geriatric patients with T2-MI.

Long-term mortality and factors of poor outcomes in patients undergoing percutanenous coronary intervention

Data concerning long-term mortality after percutaneous coronary intervention (PCI) and factors of poor outcomes are scarce. To describe short-term, intermediate-term, and long-term mortality and their correlates after PCI. In this prospective cohort study, we included and followed-up consecutive patients admitted for PCI from 2008 to 2011. Independent adjudicators reviewed the ischemic outcomes and causes of death until January 2019. A survival analysis was performed to compare the occurrence of cardiovascular and non-cardiovascular death at 30 days, one year and up to 8 years. Of the 3524, patients treated with PCI from 2008 to 2011, 2720 (77.2%) were men and 804 (22.8%) were women with a mean age of 65.8 years old. The median follow-up was 7.0 years (IQ1: 5.4; IQ3: 7.2) and complete for 97.6% of the patients. One third of the patients died (30.3%; n = 1070) in a median time of 2.5 years after PCI, with a rate of 5.3 deaths per 100 patient-years. Overall, mortality was mostly related to cardiovascular causes than non-cardiovascular causes (17.7% versus 12.6%, log-rank < 0.001) ( Fig. 1 ). Cardiovascular death was more frequent within 30 days (4.7% vs. 0.3%, P < 0.0001) and the first year after PCI (3.1% vs. 2.2 P = 0.01), but then become similar to non-cardiovascular death one year (9.9% vs. 10.2%, P = 0.67). Cancer was the major cause of non-cardiovascular death (5.6%; 1 per 100 patient-years). Diabetes (adjHR = 1.48 95% [1.29–1.71], p < 0.001), active smoking (adjHR = 1.37, 95% [1.16–1.62]) and chronic kidney disease (adjHR = 1.97, 95% [2.55–3.45], P < 0.001) were the strongest risk factors for all-cause death. Cardiovascular death was more frequent than non-cardiovascular death in patients treated with PCI in the short and intermediate-term but not beyond one year. Cancer accounted for one fifth of the overall mortality.

Outcomes of patients with active cancer undergoing transcatheter aortic-valve replacement

Cardiovascular diseases and cancer are the two leading causes of mortality in the world and their association is a therapeutic challenge. Current data showed that patients with active cancer and severe aortic stenosis have better survival after aortic-valve replacement in comparison with those have medical treatment. Presence of active cancer is frequently a reason to decline surgery due to the fear of periprocedural complications in this frail population and transcatheter aortic-valve replacement (TAVR) appears like the treatment of choice in this situation. However, data concerning outcomes in this case are limited and contradictory. This study aims to constitute the first French cohort of patients with active cancer undergoing TAVR in order to determine their prevalence, characteristics, perioperative outcomes and mortality. We prospectively included all consecutive patients who underwent TAVR in our institution (Nouvel Hôpital Civil, Strasbourg, France). Active cancer status at the time of the procedure was determined by a specialist physician with an anatomopathological diagnosis in all cases where it was possible. Primary endpoint was all-cause mortality during follow-up. Among 585 patients who underwent TAVR, 62 had an active cancer. All-cause mortality was significantly higher in patients with active cancer in comparison with those without cancer (38.7% vs. 20.1% respectively; P = 0.001). This excess of mortality is mainly driven by non-cardiovascular causes of death. Other periprocedural complications (major adverse cardiovascular events, bleeding, rehospitalization for heart failure, acute kidney injury) did not differ between the two groups ( Fig. 1 ). In patients who underwent TAVR, active cancer is a non-negligible comorbidity. All-cause mortality is higher in this population, mainly driven by non-cardiovascular mortality. However, periprocedural complications are not increased in this specific population.

Minimally Invasive Aortic Valve Replacement with Sutureless Valves: Results From an International Prospective Registry

To report the early and mid-term results of patients who underwent minimally invasive aortic valve replacement (MI-AVR) with a sutureless prosthesis from an international prospective registry. Between March 2011 and September 2018, among 957 patients included in the prospective observational SURE-AVR (Sorin Universal REgistry on Aortic Valve Replacement) registry, 480 patients underwent MI-AVR with self-expandable Perceval aortic bioprosthesis (LivaNova PLC, London, UK) in 29 international institutions through either minithoracotomy (n = 266) or ministernotomy (n = 214). Postoperative, follow-up, and echocardiographic outcomes were analyzed for all patients. Patient age was 76.1 ± 7.1 years; 64.4% were female. Median EuroSCORE I was 7.9% (interquartile range [IQR], 4.8 to 10.9). Median cardiopulmonary bypass and cross-clamp times were 81 minutes (IQR 64 to 100) and 51 minutes (IQR 40 to 63). First successful implantation was achieved in 97.9% of cases. Two in-hospital deaths occurred, 1 for noncardiovascular causes and 1 following a disabling stroke. In the early (≤30 days) period, stroke rate was 1.4%. Three early explants were reported: 2 due to nonstructural valve dysfunction (NSVD) and 1 for malpositioning. One mild and 1 moderate paravalvular leak were reported. In 16 patients (3.3%) pacemaker implantation was needed. Mean follow-up was 2.4 years (maximum = 7 years). During follow-up 5 explants were reported, 3 due to endocarditis and 2 due to NSVD. Follow-up stroke rate was 2.5%. Three structural valve deteriorations not requiring reintervention were reported. Five-year survival was 91.45%. In this large prospective international registry, MI-AVR with Perceval valve confirmed to be safe, reproducible, and effective in an intermediate-risk population, providing excellent clinical recovery both in early and mid-term follow-up.

Body mass index and all-cause readmissions following acute heart failure hospitalization.

Obesity is associated with a lower mortality risk among patients with heart failure (HF). Whether this obesity paradox applies to all-cause hospitalizations is unknown. We aimed to investigate the association between body mass index (BMI) and 30-day all-cause readmissions following HF hospitalization. We retrospectively evaluated 2252 HF hospital admissions of Centers of Medicare Services beneficiaries from an academic medical center. We classified obesity using established BMI categories. All 30-day postdischarge readmission to all hospitals and mortality events were documented. We evaluated 30-day postdischarge unplanned, all-cause readmission and death in the total cohort, propensity-matched cohort, and by ejection fraction (EF). An Overweight-Obese BMI (BMI ≥ 25 kg/m2) was paradoxically associated with a lower mortality rate than a Normal BMI (18.5-24.9 kg/m2) (5.0% vs 8.5%, p = 0.0018). In contrast, an Overweight-Obese BMI was associated with a 29% (95% CI: 1.03-1.63) increased relative risk of all-cause readmission compared with a Normal BMI (23.2% vs 18.9%, p = 0.0288), which was consistent across obesity severity subgroups. Among 966 matched admissions, an Overweight-Obese BMI retained higher readmission risk compared with a Normal BMI (25.1% vs 17.2%, p = 0.003). After matching, readmissions remained higher for Overweight-Obese vs Normal BMI in admissions with reduced EF (25.7% vs 17.8%, p = 0.032) and preserved EF (23.0% vs 15.0%, p = 0.048). No difference in the percentage of readmissions for HF (40%) or noncardiovascular causes (45%) existed between Overweight-Obese and Normal BMI groups. Despite a lower mortality risk, increased BMI is associated with increased all-cause hospital readmission rates in an elderly HF population which persists after propensity matching.

Association of Lymphopenia With Risk of Mortality Among Adults in the US General Population

Immune dysregulation can increase the risk of infection, malignant neoplasms, and cardiovascular disease, but improved methods are needed to identify and quantify immunologic hazard in the general population. To determine whether lymphopenia is associated with reduced survival in outpatients. This retrospective cohort study of the National Health and Nutrition Examination Survey (NHANES) included participants enrolled from January 1, 1999, to December 31, 2010, a large outpatient sample representative of the US adult population. Associations were evaluated between lymphopenia and other immunohematologic (IH) markers, clinical features, and survival during 12 years of follow-up, completed on December 31, 2011. Spearman correlations, Cox proportional hazards regression models, and Kaplan-Meier curves were used in univariable and multivariable models, allowing for nonlinear associations with bivariate cubic polynomials. Data were analyzed from September 1, 2018, through July 24, 2019. Absolute lymphocyte counts (ALC), red blood cell distribution width (RDW), and C-reactive protein (CRP) level. All-cause survival. Among the 31 178 participants, the median (interquartile range) age at baseline was 45 (30-63) years, 16 093 (51.6%) were women, 16 260 (52.2%) were nonwhite, and overall 12-year rate of survival was 82.8%. Relative lymphopenia (≤1500/μL) and severe lymphopenia (≤1000/μL) were observed in 20.1% and 3.0%, respectively, of this general population and were associated with increased risk of mortality (age- and sex-adjusted hazard ratios [HRs], 1.3 [95% CI, 1.2-1.4] and 1.8 [95% CI, 1.6-2.1], respectively) due to cardiovascular and noncardiovascular causes. Lymphopenia was also associated with worse survival in multivariable models, including traditional clinical risk factors, and this risk intensified when accompanied by bone marrow dysregulation (elevated RDW) and/or inflammation (elevated CRP level). Ten-year mortality ranged from 3.8% to 62.1% based on lymphopenia status, tertile of CRP level, and tertile of RDW. A high-risk IH profile was nearly twice as common as type 2 diabetes (19.3% and 10.0% of participants, respectively) and associated with a 3-fold risk of mortality (HR, 3.2; 95% CI, 2.6-4.0). Individuals aged 70 to 79 years with low IH risk had a better 10-year survival (74.1%) than those who were a decade younger with a high-risk IH profile (68.9%). These findings suggest that lymphopenia is associated with reduced survival independently of and additive to traditional risk factors, especially when accompanied by altered erythropoiesis and/or heightened inflammation. Immune risk may be analyzed as a multidimensional entity derived from routine tests, facilitating precision medicine and population health interventions.

Cierre percutáneo del foramen oval permeable en pacientes mayores de 60 años con ictus criptogénico

Introduction and objectivesRandomized trials have shown the efficacy of transcatheter closure of patent foramen ovale (PFO) in patients aged ≤ 60 years with cryptogenic embolism. We aimed to assess the long-term safety and efficacy of PFO closure in patients aged> 60 years. MethodsOf 475 consecutive patients with cryptogenic embolism who underwent PFO closure, 90 older patients aged> 60 years (mean, 66±5 years) were compared with 385 younger patients aged ≤ 60 years (mean, 44±10 years). ResultsOlder patients had a higher prevalence of cardiovascular risk factors (CVRF) (hypertension, dyslipidemia, diabetes; P <.01 for all vs younger patients). There were no differences in periprocedural complications between the 2 groups. During a median follow-up of 8 (4-12) years, there were a total of 17 deaths, all from noncardiovascular causes (7.8% and 2.6% in the older and younger patient groups, respectively; HR, 4.12; 95%CI, 1.56-10.89). Four patients had a recurrent stroke (2.2% and 0.5% in the older and younger patient groups, respectively; HR, 5.08; 95%CI, 0.71-36.2), and 12 patients had a transient ischemic attack (TIA) (3.3% and 2.3% in the older and younger patient groups, respectively; HR, 1.71; 95%CI, 0.46-6.39). There was a trend toward a higher rate of the composite of stroke/TIA in older patients (5.5% vs 2.6%; HR, 2.62; 95%CI, 0.89-7.75; P=.081), which did not persist after adjustment for CVRF (HR, 1.97; 95%CI, 0.59-6.56; P=.269). ConclusionsIn older patients with cryptogenic embolism, PFO closure was safe and associated with a low rate of ischemic events at long-term. However, older patients exhibited a tendency toward a higher incidence of recurrent stroke/TIA compared with younger patients, likely related to a higher burden of CVRF.