Occurrence Of Clinical Events Research Articles

Non-invasive imaging to guide percutaneous coronary revascularization in chronic total occlusion: a systematic review and meta-analysis

Abstract Background and aims Whether recanalization of coronary chronic total occlusions (CTO) leads to improved patient outcomes is uncertain. We set out to investigate the use of noninvasive imaging modalities to guide patient selection for percutaneous recanalization of coronary chronic total occlusions (CTO-PCI) and its association with outcomes. Methods Systematic review and meta-analysis of studies involving patients undergoing CTO-PCI to detail use of preprocedural non-invasive imaging, change in clinical endpoints and the occurrence of clinical events in these patient cohorts. PubMed and Embase, the Cochrane Database of Systematic Reviews, the PROSPERO database and the Clinical Trials Registry were searched for relevant randomized and observational studies up to May 2023. This study is registered with PROSPERO. The study primary endpoint was a composite of all-cause death and nonfatal myocardial infarction (MI), with a secondary composite endpoint of cardiovascular death, nonfatal MI and target vessel revascularization (TVR). Additional endpoints were individual components of the composite endpoints along with changes in angina burden, LV ejection fraction, ischemic burden, and infarct extent after PCI. Results Of 1264 publications retrieved, 31 studies (26 observational and 5 randomized) were finally included for a total of 7260 patients. Guidance to CTO-PCI varied greatly among included studies, with only a minority implementing routine preprocedural inducible ischemia and myocardial viability assessment. At a median of 3.1 years (range 1-5 years), the primary endpoint occurred at a rate of 3.1 events per 100 patient-years (95%CI: 2.4-3.7). When non-invasive imaging was used to guide CTO-PCI, patients with myocardial ischemia and/or viability, a reduced risk for the primary endpoint was observed (OR 0.3 95%CI 0.2-0.5) compared to CTO-PCI without evidence of myocardial ischemia and/or viability. CTO-PCI was associated with improvements in SAQ summary score, LVEF, reduction of ischemic burden, improvement in myocardial perfusion (all P-values < 0.01), with no change in the burden of myocardial scarring. At meta-regression analysis, a greater improvement in LVEF was observed in studies enrolling patients with lower average baseline LVEF (≤ 45%) (R2 = 63%, p < 0.0001). Conclusions CTO-PCI led to a significant improvement in symptom status (reduction of chest pain) and LV ejection fraction. CTO-PCI guided by the presence of ischemia and/or viability was associated with improved patient outcomes compared with CTO-PCI in the absence of ischemia and/viability, or in patients where non-invasive imaging testing was not performed. Future randomized clinical trials testing whether ischemia and viability-guided CTO-PCI improves clinical outcomes are lacking and warranted.PRISMA Flow diagramGraphical abstract

Radiologically isolated syndromes: to treat or not to treat?

The widespread use of magnetic resonance imaging (MRI) has led to increased detection of individuals exhibiting asymptomatic brain and spinal cord lesions suggestive of multiple sclerosis (MS), defined as "radiologically isolated syndrome" (RIS). Specific criteria have been proposed and updated over time to identify individuals with RIS. Moreover, a younger age, the presence of infratentorial, spinal cord or gadolinium-enhancing lesions, as well as of cerebrospinal fluid-specific oligoclonal bands have been recognized as relevant risk factors for the occurrence of a first clinical event. Recent randomized controlled trials conducted in individuals with RIS have shown that dimethyl fumarate and teriflunomide significantly reduce the occurrence of clinical events in this population. These findings support the notion that early treatment initiation may positively influence the prognosis of these patients. However, several aspects should be taken into account before treating individuals with RIS in the real-world clinical setting, including an accurate identification of individuals with RIS to avoid misdiagnosis, a precise stratification of their risk of experiencing a first clinical event and further data supporting favorable balance between benefits and risks, even in the long term. This commentary provides an overview of the latest updates in RIS diagnosis, prognosis, and emerging treatment evidence.

Left ventricular strain-volume loops in bicuspid aortic valve disease: new insights in cardiomechanics.

By combining temporal changes in left ventricular (LV) global longitudinal strain (GLS) with LV volume, LV strain-volume loops can assess cardiac function across the cardiac cycle. This study compared LV strain-volume loops between bicuspid aortic valve (BAV) patients and controls, and investigated the loop's prognostic value for clinical events. From a prospective cohort of congenital heart disease patients, BAV patients were selected and compared with healthy volunteers, who were matched for age and sex at group level. GLS analysis from apical views was used to construct strain-volume loops. Associations with clinical events, i.e. a composite of all-cause mortality, heart failure, arrhythmias, and aortic valve replacement, were assessed by Cox regression. A total of 113 BAV patients were included (median age 32 years, 40% female). BAV patients demonstrated lower Sslope (0.21%/mL, [Q1-Q3: 0.17-0.28] vs. 0.27%/mL [0.24-0.34], P < 0.001) and ESslope (0.19%/mL [0.12-0.25] vs. 0.29%/mL [0.21-0.43], P < 0.001) compared with controls, but also greater uncoupling during early (0.48 ± 1.29 vs. 0.05 ± 1.21, P = 0.04) and late diastole (0.66 ± 1.02 vs. -0.07 ± 1.07, P < 0.001). Median follow-up duration was 9.9 [9.3-10.4] years. Peak aortic jet velocity (HR 1.22, P = 0.03), enlarged left atrium (HR 3.16, P = 0.003), E/e' ratio (HR 1.17, P = 0.002), GLS (HR 1.16, P = 0.008), and ESslope (HR 0.66, P = 0.04) were associated with the occurrence of clinical events. Greater uncoupling and lower systolic and diastolic slopes were observed in BAV patients compared with healthy controls, suggesting presence of altered LV cardiomechanics. Moreover, lower ESslope was associated with clinical events, highlighting the strain-volume loop's potential as prognostic marker.

Targeting the ACOD1-itaconate axis stabilizes atherosclerotic plaques

Inflammatory macrophages are key drivers of atherosclerosis that can induce rupture-prone vulnerable plaques. Skewing the plaque macrophage population towards a more protective phenotype and reducing the occurrence of clinical events is thought to be a promising method of treating atherosclerotic patients. In the current study, we investigate the immunomodulatory properties of itaconate, an immunometabolite derived from the TCA cycle intermediate cis-aconitate and synthesised by the enzyme Aconitate Decarboxylase 1 (ACOD1, also known as IRG1), in the context of atherosclerosis. Ldlr−/− atherogenic mice transplanted with Acod1−/− bone marrow displayed a more stable plaque phenotype with smaller necrotic cores and showed increased recruitment of monocytes to the vessel intima. Macrophages from Acod1−/− mice contained more lipids whilst also displaying reduced induction of apoptosis. Using multi-omics approaches, we identify a metabolic shift towards purine metabolism, in addition to an altered glycolytic flux towards production of glycerol for triglyceride synthesis. Overall, our data highlight the potential of therapeutically blocking ACOD1 with the aim of stabilizing atherosclerotic plaques.

Near Infrared Light-Activatable Platelet-Mimicking NIR-II NO Nano-Prodrug for Precise Atherosclerosis Theranostics.

Atherosclerosis is a chronic inflammatory disease that affects arteries and is the main cause of cardiovascular disease. Atherosclerotic plaque formation is usually asymptomatic and does not manifest until the occurrence of clinical events. Therefore, early diagnosis and treatment of atherosclerotic plaques is particularly important. Here, a series of NIR-II fluorescent dyes (RBT-NH) are developed for three photoresponsive NO prodrugs (RBT-NO), which can be controllably triggered by 808nm laser to release NO and turn on the NIR-II emission in the clinical medicine "therapeutic window". Notably, RBT3-NO is selected for its exhibited high NO releasing efficiency and superior fluorescence signal enhancement. Subsequently, a platelet-mimicking nano-prodrug system (RBT3-NO-PEG@PM) is constructed by DSPE-mPEG5k and platelet membrane (PM) for effectively targeted diagnosis and therapy of atherosclerosis in mice. The results indicate that this platelet-mimicking NO nano-prodrug system can reduce the accumulation of lipids at the sites of atherosclerotic plaques, improve the inflammatory response at the lesion sites, and promote endothelial cell migration, thereby slowing the progression of plaques.

Prognostic significance of the wall to lumen ratio of retinal arterioles evaluated by adaptive optics

ObjectiveMicrovascular structural alterations may be considered an important form of hypertension-mediated organ damage. An increased media-to-lumen ratio of subcutaneous small arteries evaluated with locally invasive techniques (micromyography) predicts the development of cardiovascular (CV) events. However, it is not known whether retinal arteriole structural alterations evaluated with a noninvasive approach (Adaptive Optics) may have a prognostic significance. Design and methodsTwo-hundred and thirty-seven subjects (mean age 58.7 ± 16.1 years, age range 13–89 years; 116 males) were included in the study: 65 normotensive subjects (27.4 %) and 172 patients with essential hypertension or primary aldosteronism (72.6 %). All subjects underwent a non-invasive evaluation of retinal arteriolar wall-to-lumen ratio (WLR) by Adaptive Optics. Subjects were re-evaluated after an average follow-up time of 4.55 years in order to assess the occurrence of clinical events (non CV and/or CV death or events). ResultsFifty-four events occurred in the study population:26 were cardio-cerebrovascular events (ischemic or hemorragic stroke, atrial fibrillation, heart failure, coronary artery disease, peripheral artery disease, cardiac valvular disease) while the remaining were deaths for any cause, or neoplastic diseases. Subjects with events were older and had a WLR of retinal arterioles significantly greater than those without events. The event-free survival was significantly worse in those with a baseline WLR above the median value of the population (0.28) according to Kaplan-Mayer survival curves and multivariate analysis (Cox's proportional hazard model). The evidence was confirmed after restricting the analysis to CV events. ConclusionsStructural alterations of retinal arterioles evaluated by Adaptive Optics may predict total and CV events.

Prognosis of Older Adult Patients Suffering from Atrial Fibrillation and Hypokalemia.

To examine the effects of hypokalemia on the prognosis of older adult patients with atrial fibrillation (AF). We enrolled 794 older adult patients ≥ 75 years suffering from AF, and divided them into two groups according to the inclusion and exclusion criteria: Group 1, (hypokalemia group), 246 cases, serum K+<3.5 mmol/L; Group 2, (normal blood potassium group), 548 cases, 3.5mmol/L≤serum K+<5.5 mmol/L. The two groups of patients were followed for 70 months to observe the occurrence of clinical events. The primary endpoint was cardiovascular death and the secondary endpoint was all-cause death. The median follow-up time was 15.00 months. In terms of baseline profile characteristics, serum creatinine levels were significantly lower in Group 1 than in Group 2 patients (P=0.002). In terms of the relationship between hypokalemia and clinical outcomes, Kaplan-Meier survival analysis revealed that the incidence of clinical primary endpoint in Group 1 was significantly higher than that in Group 2 (P < 0.001), and the incidence of the secondary endpoint did not differ significantly between the two groups (P> 005). Based on multivariate Cox regression risk model analysis, coronary heart disease, hemoglobin content, serum uric acid and usage of anticoagulant drugs were the independent variables related to the primary endpoint of cardiovascular death (all P< 0.01). The incidence of hypokalemia in older adult patients with AF was 30.98%. Hypokalemia was closely related to the cardiovascular death, and coronary heart disease, hemoglobin content, serum uric acid level, and usage of anticoagulant drugs were the independent risk factors for the primary endpoint event.

The association of myocardial strain with cardiac magnetic resonance and clinical outcomes in patients with acute myocarditis.

The role of myocardial strain in risk prediction for acute myocarditis (AMC) patients, measured by cardiac magnetic resonance (CMR), deserves further investigation. Our objective was to evaluate the association between myocardial strain measured by CMR and clinical events in AMC patients. This was a prospective single-center study of patients with AMC. We included 100 patients with AMC with CMR confirmation. The primary outcome was the composite of all-cause mortality, heart failure and AMC recurrence in 24 months. A subgroup analysis was performed on a sample of 36 patients who underwent a second CMR between 6 and 18 months. The association between strain measures and clinical events or an increase in left ventricular ejection fraction (LVEF) was explored using Cox regression analysis. Global peak radial, circumferential and longitudinal strain in the left and right ventricles was assessed. ROC curve analysis was performed to identify cutoff points for clinical event prediction. The mean follow-up was 18.7 ± 2.3 months, and the composite primary outcome occurred in 26 patients. The median LVEF at CMR at baseline was 57.5% (14.6%). LV radial strain (HR = 0.918, 95% CI: 0.858-0.982, p = 0.012), LV circumferential strain (HR = 1.177, 95% CI: 1.046-1.325, p = 0.007) and LV longitudinal strain (HR = 1.173, 95% CI: 1.031-1.334, p = 0.015) were independently associated with clinical event occurrence. The areas under the ROC curve for clinical event prediction were 0.80, 0.79 and 0.80 for LV radial, circumferential, and longitudinal strain, respectively. LV longitudinal strain was independently correlated with prognosis (HR = 1.282, CI 95%: 1.022-1.524, p = 0.007), even when analyzed together with ejection fraction and delayed enhancement. LV and right ventricle (RV) strain were not associated with an increase in LVEF. Finally, when the initial CMR findings were compared with the follow-up CMR findings, improvements in the measures of LV and RV myocardial strain were observed. Measurement of myocardial strain by CMR can provide prognostic information on AMC patients. LV radial, circumferential and longitudinal strain were associated with long-term clinical events in these patients.

Correlation between step count and clinical outcomes for patients with cancer during treatment: A feasibility study.

e18804 Background: Step count, as measured by a wearable accelerometer, has been shown to have a relationship to premature death, cardiovascular events, functional decline, longer stay, and higher rehospitalization rates. However, few cancer studies or trials have incorporated accelerometers to measure response to active treatment. We developed the DigiBioMarC™ smartphone application for cancer patients to enable participation in decentralized clinical trials and remote cancer care by collecting informed consent, ePROs and accelerometer data using an Apple Watch. This analysis assessed whether daily step data were associated with participants clinical events. Methods: We tested the feasibility of the DigiBioMarC application along with the Apple Watch for approximately 4 weeks with 50 cancer patients undergoing IV chemotherapy or immunotherapy recruited in a fully decentralized study through Kaiser Permanente Northern California. Participants used the app for at least 28 days and were provided with an Apple Watch if they did not already have one. Data pre-processing was performed to identify periods of missing data and non-wear time. Step count was calculated for each calendar day and days that included at least ten hours of wear time while awake were considered sufficient and included in the analysis. Specific clinical events were collected from the patients’ electronic health records (EHR) up to six months following the study. Results: Thirteen participants experienced at least one clinical event, and there were 5 deaths. Using Cox regression, patients with more sufficient days were less likely to die during follow up (p = 0.122) than patients with fewer sufficient days. On sufficient days, median daily steps &lt; = 2,510 were associated with one or more adverse clinical events, while daily steps &gt; 2,510 were associated with no clinical events and had a longer time to adverse clinical event (p = 0.068) compared to those with less than or equal to 2,510 median daily steps on sufficient days. Daily median step count on sufficient days predicted clinical event occurrence with an accuracy of 0.833. Conclusions: Findings from this feasibility study support the hypothesis that daily stepping behavior is a valid real-world digital measure to predict clinical events in patients undergoing cancer treatment. Although the predictive models did not reach statistical significance (p &lt; 0.05), this is likely due to the low frequency of clinical events in the dataset. These findings indicate that future investigations with larger sample sizes are warranted as this may be a beneficial tool for decentralized trials or care when patients have longer periods of time between clinical visits. In patients undergoing cancer treatment, real-world based step data extracted from wearables can provide early indication of poor or declining health.

Evolución clínica de los pacientes con FA y diabetes mellitus en la pandemia de COVID-19. Registro REFADI

Introduction and objectivesTo analyze the evolution of patients with atrial fibrillation (AF) and diabetes in the mid-term follow-up during the COVID-19 pandemic and to describe its impact on this population. MethodsMulticenter and prospective registry that included patients with AF and diabetes attended in cardiology clinics. A multivariate analysis was performed to determine the variables associated with the occurrence of clinical events and mortality. Recruitment was performed in February-December 2019. ResultsThe evolution of 633 patients, 96,2% of those included in the REFADI registry with a median follow-up of 835 days was analyzed (mean age 73.8±8.5 years, 54.3% male, CHA2DS2-VASc 4,34±1,4, HAS-BLED 2,47±0,96) were analyzed. The proportion of anticoagulated patients remained constant (95.6% vs 94.5%; P=.24). There was a decrease in the prescription of vitamin K antagonists (from 31.4% to 19.7%; P <.01), and an increase in the use of direct anticoagulants (from 62.0% to 70.3%; P <.01). During the follow-up there was an increase in the prescription of SGLT2 inhibitors (from 20.0% to 25.5%; P <.01) and GLP1 agonists (from 4.2% to 9.1%; P <.01). During this period, 17.2% of patients died, the majority from cardiovascular causes, 6.4% from COVID-19, 2.8% from stroke, and 1.8% from hemorrhage. Older age, lower ejection fraction, lower hemoglobin levels, and especially lower direct anticoagulants prescription were associated with mortality. ConclusionsPatients with AF and diabetes have a high thromboembolic risk and a high risk of developing complications, especially of cardiovascular origin.

Multidimensional variability in ecological assessments predicts two clusters of suicidal patients

The variability of suicidal thoughts and other clinical factors during follow-up has emerged as a promising phenotype to identify vulnerable patients through Ecological Momentary Assessment (EMA). In this study, we aimed to (1) identify clusters of clinical variability, and (2) examine the features associated with high variability. We studied a set of 275 adult patients treated for a suicidal crisis in the outpatient and emergency psychiatric departments of five clinical centers across Spain and France. Data included a total of 48,489 answers to 32 EMA questions, as well as baseline and follow-up validated data from clinical assessments. A Gaussian Mixture Model (GMM) was used to cluster the patients according to EMA variability during follow-up along six clinical domains. We then used a random forest algorithm to identify the clinical features that can be used to predict the level of variability. The GMM confirmed that suicidal patients are best clustered in two groups with EMA data: low- and high-variability. The high-variability group showed more instability in all dimensions, particularly in social withdrawal, sleep measures, wish to live, and social support. Both clusters were separated by ten clinical features (AUC = 0.74), including depressive symptoms, cognitive instability, the intensity and frequency of passive suicidal ideation, and the occurrence of clinical events, such as suicide attempts or emergency visits during follow-up. Initiatives to follow up suicidal patients with ecological measures should take into account the existence of a high variability cluster, which could be identified before the follow-up begins.

Prognostic value of reactive hyperemia index using peripheral artery tonometry in patients with heart failure

Given the high prevalence and poor prognosis of heart failure (HF), finding prognostic factors for patients with HF is crucial. This study investigated the prognostic value of reactive hyperemia index (RHI), a measure of endothelial function, in HF. A total of 90 HF patients (mean age, 63.7 ± 13.2 years; female, 25.6%) with a history of hospitalization for HF treatment were prospectively enrolled. RHI was measured using digital arterial tonometry in a stable condition. Clinical events, including all-cause death and HF admission, were assessed. During the median follow-up of 3.66 years (interquartile range, 0.91–4.94 years), 26 clinical events (28.9%) occurred. Although there were no significant differences in risk factors and laboratory findings according to the occurrence of clinical events, the RHI value was significantly lower in patients with clinical events than in those without (1.21 ± 0.34 vs. 1.68 ± 0.48; P < 0.001). Kaplan–Meier survival analysis showed that a lower RHI value (< 1.48) was associated with a significantly higher incidence rate of clinical events (log-rank P < 0.001). In multivariable cox regression analysis, a low RHI value (< 1.48) was associated with an increased risk of clinical events (hazard ratio, 14.09; 95% confidence interval, 3.61–54.99; P < 0.001) even after controlling for potential confounders. Our study showed that reduced RHI was associated with an increased risk of adverse clinical outcomes in HF. This suggests that endothelial dysfunction may be an important prognostic marker in patients with HF.

Severe Impairment of Left Ventricular Regional Strain in STEMI Patients Is Associated with Post-Infarct Remodeling.

Background: Measures of global left ventricular (LV) systolic function have limitations for the prediction of post-infarct LV remodeling (LVR). Therefore, we tested the association between a new measure of regional LV systolic function—the percentage of severely altered strain (%SAS)- and LVR after acute ST-elevation myocardial infarction (STEMI). As a secondary objective, we also evaluated the association between %SAS and clinical events during follow-up. Methods: Of 177 patients undergoing echocardiography within 24 h from primary percutaneous coronary angioplasty, 172 were studied for 3 months, 167 for 12 months, and 10 died. The %SAS was calculated by dividing the number of LV myocardial segments with ≥−5% peak systolic longitudinal strain by the total number of segments. LVR was defined as the increase in end-diastolic volume >20% at its first occurrence compared to baseline. Results: LVR percentage was 10.2% and 15.8% at 3 and 12 months, respectively. Based on univariable analysis, a number of clinical, laboratory, electrocardiographic and echocardiographic variables were associated with LVR. Based on multivariable analysis, %SAS and TnI peak remained associated with LVR (for %SAS 5% increase, OR 1.226, 95% CI 1.098–1.369, p < 0.0005; for TnI peak, OR 1.025, 95% CI 1.004–1.047, p = 0.022). %SAS and LVR were also associated with occurrence of clinical events at a median follow-up of 43 months (HR 1.02, 95% CI 1.0–1.04, p = 0.0165). Conclusions: In patients treated for acute STEMI, acute %SAS is associated with post-infarct LVR. Therefore, we suggest performing such evaluations on a routine basis to identify, as early as possible, STEMI patients at higher risk.

Remote monitoring of implantable devices – a draft version of the directive by The Health Minister of Poland

Remote monitoring of patients treated with cardiac implantable electronic devices is a medical service known for more than two decades. Its efficacy has been proven in numerous clinical trials and the benefits of remote monitoring could not be overestimated during the COVID-19 pandemic. The telemonitoring of implanted devices, in addition to receiving and analyzing acquired data, should also provide effective action to protect patients from the occurrence of clinical events caused by a potential risk of heart failure deterioration or a system malfunction. The article discusses the main rules of the remote monitoring implementation contained in the Ministry of Health draft regulation.

P233 ASSOCIATIONS BETWEEN LEFT AND RIGHT ATRIAL BIDIMENSIONAL STRAIN AND HEART FAILURE PROGRESSION

Abstract Background Two dimensional speckle tracking is an innovative echocardiographic method which analyses myocardial deformation thus allowing the evaluation of both atrial and ventricular function. Recently, new software are available to measure it by semiautomatic analyses. Aim of the Study To evaluate the association between left and right atrial Strain and the occurrence of clinical events related to the heart failure (HF) progression. Method. We enrolled 165 outpatients with chronic HF (76% males, NYHA 2.2 ± 0.69, ejection fraction 39±11%). All underwent a clinical and echocardiographic evaluation. An innovative software (TomTec, Philips) was used to analyse the images in order to semi–automatically calculate of atrial Strain. For each patient all the measures relative to the different phases of atrial deformation were considered both for the left atrium (LA) and the right one (RA), i.e. reservoir (r), conduit (cd) and contraction (ct). During the follow–up, we defined the HF progression as hospitalization due to HF worsening and/or heart transplantation and/or cardiovascular death. Results During a median follow–up of 5 months, at least one event related to HF progression occurred in 22 patients: all underwent at least one hospitalization, 7 patients died because of cardiovascular reasons and 2 underwent heart transplantation. At Cox univariate analysis, LASr (HR: 0,93; 95%CI: 0,88–0,97, p: 0.004; C–index 0,7), LAScd (HR: 1,09; 95%CI: 1,01–1,19; p: 0,023; C–index: 0,64), RASr (HR: 0,95; 95%CI: 0,90–0,99; p: 0,031; C–index: 0,68), RAScd (HR: 1,08; 95%CI: 1,01–1,15; p: 0,021; C–index: 0,67), but not LASct (HR: 1,04; 95%CI: 0,99–1,09; p 0,094; C–index 0,62) and RASct (HR: 1,02; 95%CI: 0,96–1,09; p: 0,61; C–index: 0,55), were significantly associated to HF progression. LASr and RASr showed the higher accuracy in predicting the events by the estimation of C index. At ROC curve analysis, for LASr the best cut–off was 16.1% (Sensitivity 83%, Specificity 56%) and for RASr 17.3% (Sensitivity 79%, Specificity 60%). Figure shows Kaplan–Meier curves for the considered end–point according with these cut–offs. Conclusions The preliminary results of this study have showed the association between LA and RA Strain variables and the HF progression. The prosecution of this study will be finalised to demonstrate the prognostic independent and incremental significance.

Integrated approach of brachial-ankle pulse wave velocity and cardiovascular risk scores for predicting the risk of cardiovascular events.

The 2013 American College of Cardiology (ACC)/American Heart Association (AHA) atherosclerotic cardiovascular disease (ASCVD) risk score may be insufficient for accurate prediction of major adverse cardiac events (MACE) in Asians. This study was performed to investigate whether brachial-ankle pulse wave velocity (baPWV) has additional prognostic value to the risk score estimated by the ACC/AHA pooled cohort equations (PCEs). A total of 6,359 patients (3,534 men and 2,825 women) aged 40-79 years without documented cardiovascular disease who underwent baPWV measurement were retrospectively analyzed. Cardiovascular risk scores were calculated using the 2013 ACC/AHA PCEs. Cardiovascular events, including cardiac death, non-fatal myocardial infarction, coronary revascularization and ischemic stroke, were assessed. During a median follow-up period of 4.0 years (interquartile range 1.7-6.1 years), cardiovascular events occurred in 129 patients (2.0%). The receiver operating characteristic curve analysis showed that baPWV was stronger in the detection of cardiovascular events than the 2013 ACC/AHA risk score (area under the curve: 0.70 versus 0.62, p<0.001). In the multivariable Cox regression analysis, both baPWV and 2013 ACC/AHA risk score were independently associated with the occurrence of clinical events (p <0.001 for each). The baPWV had incremental prognostic value to the 2013 ACC/AHA risk score in predicting clinical events (global chi-square from 21.23 to 49.51, p<0.001). The baPWV appears to be a strong predictor of the risk of cardiovascular events in Koreans. Measuring baPWV in addition to the 2013 ACC/AHA risk score helps identify individuals at risk for MACE aged 40-79 years without previous cardiovascular diseases.

Effects of medical insurance system on the hospitalization cost of acute myocardial infarction patients

BackgroundAcute myocardial infarction is still a burden on Chinese patients. Whether different medical insurance system have any influence on the hospitalization cost and therapeutic effect of acute myocardial infarction patient needs further investigation.MethodIn this study, 600 patients were stratified by health insurance status to investigate the cost effectiveness.ResultCompared with free medical care, patients with other health insurance status have a significantly lower age (P ˂ 0.05–0.001), the youngest of which is new rural cooperative medical system. The hospital expense, nursing fee, length of stay, daily hospitalization cost, daily drug cost, daily nursing cost and percent of nursing cost of different health insurance status were statistically significant. ANCOVA analyses controlling for age showed that the differences of hospital expenses, nursing fee, length of stay and daily hospitalization cost were still statistically significant. Further studies found that health insurance status was the leading factors influencing length of stay (β = − 0.305, P = 0.0000001), nursing costs (β = − 0.319, P = 0.004), daily hospitalization costs (β = 0.296, P = 0.0001) and occurrence of clinical events (β = − 0.186, OR = 0.830, 95% CI 0.694–0.993, P = 0.041).ConclusionsThe hospitalization cost, length of stay, nursing work and therapeutic effect of acute myocardial infarction patients are affected by different health insurance status and age.

Genome-wide methylation patterns in Marfan syndrome

BackgroundMarfan syndrome (MFS) is a connective tissue disorder caused by mutations in the Fibrillin-1 gene (FBN1). Here, we undertook the first epigenome-wide association study (EWAS) in patients with MFS aiming at identifying DNA methylation loci associated with MFS phenotypes that may shed light on the disease process.MethodsThe Illumina 450 k DNA-methylation array was used on stored peripheral whole-blood samples of 190 patients with MFS originally included in the COMPARE trial. An unbiased genome-wide approach was used, and methylation of CpG-sites across the entire genome was evaluated. Additionally, we investigated CpG-sites across the FBN1-locus (15q21.1) more closely, since this is the gene defective in MFS. Differentially Methylated Positions (DMPs) and Differentially Methylated Regions (DMRs) were identified through regression analysis. Associations between methylation levels and aortic diameters and presence or absence of 21 clinical features of MFS at baseline were analyzed. Moreover, associations between aortic diameter change, and the occurrence of clinical events (death any cause, type-A or -B dissection/rupture, or aortic surgery) and methylation levels were analyzed.ResultsWe identified 28 DMPs that are significantly associated with aortic diameters in patients with MFS. Seven of these DMPs (25%) could be allocated to a gene that was previously associated with cardiovascular diseases (HDAC4, IGF2BP3, CASZ1, SDK1, PCDHGA1, DIO3, PTPRN2). Moreover, we identified seven DMPs that were significantly associated with aortic diameter change and five DMP’s that associated with clinical events. No significant associations at p < 10–8 or p < 10–6 were found with any of the non-cardiovascular phenotypic MFS features. Investigating DMRs, clusters were seen mostly on X- and Y, and chromosome 18–22. The remaining DMRs indicated involvement of a large family of protocadherins on chromosome 5, which were not reported in MFS before.ConclusionThis EWAS in patients with MFS has identified a number of methylation loci significantly associated with aortic diameters, aortic dilatation rate and aortic events. Our findings add to the slowly growing literature on the regulation of gene expression in MFS patients.

Magnetic Resonance Elastography for Assessing Fibrosis in Patients with Crohn's Disease: A Pilot Study.

Patients with Crohn's disease can develop intestinal strictures, containing various degrees of inflammation and fibrosis. Differentiation of the main component of a stricturing lesion is the key for defining the therapeutic management. We assessed for the first time the accuracy of magnetic resonance elastography in detecting intestinal fibrosis and predicting clinical course in patients with Crohn's disease. This was a prospective study of adult patients with Crohn's disease and magnetic resonance imaging examination, including magnetic resonance elastography, between April 2019 and February 2020. The association between the bowel stiffness value and the degree of fibrosis was evaluated. The relationship between the stiffness value and the occurrence of clinical events was also investigated. A total of 69 patients were included. The stiffness value measured by magnetic resonance elastography was correlated with the degree of fibrosis (p < 0.001). A bowel stiffness ≥ 3.57kPa predicted the occurrence of clinical events with an area under the curve of 0.82 (95% CI 0.71-0.93). Bowel stiffness ≥ 3.57kPa was associated with an increased risk of clinical events (p < 0.0001). In Crohn's disease, magnetic resonance elastography is a reliable tool for detecting intestinal fibrosis and predicting a worse disease outcome.

Seasonal changes in blood pressure and related factors among older patients receiving home medical care

We investigated seasonal variations in blood pressure (BP) and factors related to these variations among older patients receiving home medical care. A total 57 patients ≥ 65 years old receiving home medical care who participated in the Osaka Home Care REgistry study (OHCARE), a prospective cohort study, were included. We investigated the seasonal patient characteristics and variations in the BP. In addition, to determine the influence of seasonal variations in the systolic blood pressure (SBP) on the occurrence of clinical events (hospitalization, falls and death), we classified patients into larger- and smaller- change groups based on the median seasonal variations in SBP. About 60% of subjects were very frail or bedridden. The mean BP was higher in winter than in summer (124.7±11/69.5±7 vs.120.5±12/66.9±8 mmHg) (P< 0.01). On comparing the characteristics of the two groups with larger and smaller changes in the SBP, the group with large BP changes had a significantly lower BP in summer than the group with small BP changes. In addition, the incidence of "hospitalization" was significantly higher in the group with large BP changes than in the group with small BP changes (P = 0.03). The present study revealed that there were seasonal changes in the BP in older patients receiving home medical care. It was also suggested that seasonal changes in the BP might be associated with the risk of hospitalization events. Given these BP variations, doctors and visiting nurses should be alert for systemic abnormalities, especially in frail patients receinving home medical care.