Perform Risk Stratification Research Articles

QTc variability. Is a single measurement of QT/QTc interval enough to perform risk stratification and therapeutic decisions in a patient with long QT syndrome?

We described a case of 30 year-old woman with episodes of syncope primarily diagnosed as epilepsy, and finally recognised as long QT syndrome. Based on QTc prolongation > 600 ms in series of electrocardiograms and Holter monitoring the patient was implanted with cardioverter-defibrillator (ICD). During follow-up many appropriate ICD shocks due to ventricular fibrillation occurred.

Prediction of outcome in patients with urothelial carcinoma of the bladder following radical cystectomy using artificial neural networks

AimThe outcome of patients with urothelial carcinoma of the bladder (UCB) after radical cystectomy (RC) shows remarkable variability. We evaluated the ability of artificial neural networks (ANN) to perform risk stratification in UCB patients based on common parameters available at the time of RC. MethodsData from 2111 UCB patients that underwent RC in eight centers were analysed; the median follow-up was 30 months (IQR: 12–60). Age, gender, tumour stage and grade (TURB/RC), carcinoma in situ (TURB/RC), lymph node status, and lymphovascular invasion were used as input data for the ANN. Endpoints were tumour recurrence, cancer-specific mortality (CSM) and all-cause death (ACD). Additionally, the predictive accuracies (PA) of the ANNs were compared with the PA of Cox proportional hazards regression models. ResultsThe recurrence-, CSM-, and ACD- rates after 5 years were 36%, 33%, and 46%, respectively. The best ANN had 74%, 76% and 69% accuracy for tumour recurrence, CSM and ACD, respectively. Lymph node status was one of the most important factors for the network's decision. The PA of the ANNs for recurrence, CSM and ACD were improved by 1.6% (p = 0.247), 4.7% (p < 0.001) and 3.5% (p = 0.007), respectively, in comparison to the Cox models. ConclusionsANN predicted tumour recurrence, CSM, and ACD in UCB patients after RC with reasonable accuracy. In this study, ANN significantly outperformed the Cox models regarding prediction of CSM and ACD using the same patients and variables. ANNs are a promising approach for individual risk stratification and may optimize individual treatment planning.

Short‐term mortality among older persons hospitalized for pneumonia: Influence of baseline patient characteristics beyond severity of illness

Although severity of illness indices such as pneumonia severity index (PSI) are good predictors of short-term mortality for community-acquired pneumonia (CAP) and healthcare-associated pneumonia (HCAP), other patient factors may have added prognostic value. To identify patient factors beyond the PSI which explain 30-day mortality among older persons hospitalized with CAP and HCAP. Retrospective cohort study. Three acute care hospitals in Singapore in 2007. Hospitalized adults aged 65 years or older who have primary International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) codes 480 to 486 with clinical and radiological features of pneumonia. None. Thirty-day mortality, PSI class, demographic and clinical features, comorbid conditions, functional status, selected laboratory tests, and chest radiographic findings. Among 1607 patients included, 890 (55.4%) had CAP and 717 (44.6%) had HCAP. After adjustment for PSI class in logistic regression analyses, pre-morbid ambulation impairment (odds ratio [OR] 2.61, 95% confidence interval [CI] 1.98 to 3.45), hospitalization in the prior 30 days (OR 1.93, 95% CI 1.38 to 2.71), and absence of cough and purulent sputum (OR 1.47, 95% CI 1.14 to 1.90) were all significantly associated with 30-day mortality. These associations remained constant when CAP and HCAP were analyzed separately. Recent hospitalization, pre-morbid ambulation impairment, and atypical presentation were independently associated with higher 30-day mortality among older persons hospitalized for pneumonia, after adjusting for severity of illness. These factors could be considered in addition to PSI when performing risk stratification and adjustment in this setting.

Prognostic significance of adipocytokines and extracellular matrix activity in heart failure patients with high B-type natriuretic peptide

Objectives To perform risk stratification by serum adipocytokines and serum markers of extracellular matrix in heart failure patients with high b-type natriuretic peptide (BNP). Methods Patients with heart failure were enrolled in this study. Serum adipocytokines and serum markers of extracellular matrix were analyzed. Results In total, 131 patients were enrolled and followed-up for 240 ± 174 days. Mortality was significantly associated with adiponectin, resistin, type III amioterminal propeptide of procollagen (PIIINP), matrix metalloproteinase-2 (MMP-2), tissue inhibitor of metalloproteinase 1 (TIMP-1), and serum creatinine. Heart failure-related admission was significantly associated with apelin, and PIIINP. Cox regression analysis identified that mortality and heart failure-related admissions were significantly associated with MMP-2 ( P = 0.008) and PIIINP ( P = 0.011), respectively. Conclusions Serum markers of extracellular matrix rather than adipocytokines may warrant further risk stratification for impacting the prognosis of patients with heart failure with high BNP.

HLA Class I Antibodies in Patients Awaiting Kidney Transplantation and the Association With Renal Graft Survival

The presence of alloantibodies against human leukocyte antigens (HLA) in the circulation of a transplant recipient shows a significant negative impact on the outcome of solid-organ transplantations. The aim of this study was to examine the impact on renal graft survival of various patterns of alloantibodies detected among patients awaiting kidney transplantation. Among more than 2000 patients awaiting kidney transplantations between July 1992 and March 2006, were 683 patients who displayed anti-HLA alloantibodies, 318 of whom were enrolled in this study. Each patient was followed for at least 9 months; the presence of HLA alloantibodies was checked every 3 months by an enzyme-linked immunosorbent assay. Among these 318 patients, 55 patients underwent kidney transplantations. Their median follow-up time was 69 (range, 9–129) months, including 267 (84%) who displayed persistent class I HLA alloantibodies. The intermittent presence of class I HLA alloantibodies was seen in 20 (6.3%) patients. Serum class I HLA antibodies which was positive at first then became undetectable in 4 (1.3%) patients. Three (0.9%) patients were unsensitized at first and then developed class I HLA alloantibodies later; & 24 (7.5%) patients had class I HLA alloantibodies only once during the follow-up period. Among these patients, 55 patients received renal transplantations. The median survival time was shortest in the patients with persistent class I HLA alloantibodies (59.9 months) and longest among patients who were positive at first and then became negative thereafter or in whom class I HLA alloantibodies was detected only once (132 months). There was a significant difference in graft survival times between patients who had persistent HLA alloantibodies and those in whom to have class I HLA alloantibodies were detected only once ( P < .05). In this study, the persistent presence of class I HLA alloantibodies among pretransplantation patients was associated with poorer renal graft outcomes. Surveys of various patterns of sensitization to class I HLA antigen may help us to perform risk stratification. High-risk patients may need more aggressive approaches to deplete antibody or complement levels.

Coping with new challenges in acute coronary syndromes

The acute coronary syndromes have become well-established clinical entities and are used as working diagnoses tied in with elaborate investigation and treatment practice guidelines. However, these syndromes remain challenging because their prevalence, morbidity and mortality remain high. Furthermore, these syndromes are demanding on the health care system because an early invasive management strategy is recommended for most patients with these conditions. Coping with these challenges requires the following initiatives: stepping beyond current diagnostic and management algorithms to a better performing risk stratification scheme that considers specific patient risk factors in addition to the disease risk, and a reintegration of acute coronary syndromes into the more global perspective of coronary artery disease; more effective antithrombotic therapy that does not further compromise bleeding risk, or drugs that control thrombogenic stimuli; and medical and revascularization therapies targeted to more specific individual pathophysiologies identified by novel blood markers and imaging techniques.

Risk stratification of patients with advanced squamous cell carcinoma of cervix treated by radiotherapy alone

To identify prognostic factors for local and distant relapse and perform risk stratification for patients with advanced cervical cancer treated with radiotherapy (RT) alone. A total of 1031 patients with Stage IB-IVA squamous cell carcinoma of the cervix treated with full-course RT but without any chemotherapy were included for analysis. Of these, 311 patients with nonbulky Stage IB-IIA disease were designated the reference group and the other 720 patients were the study group. The associations of stage, squamous cell carcinoma antigen (SCC-ag) level, hemoglobin level, age, cell differentiation, and pelvic lymph node status with treatment failure were evaluated. The independent prognostic factors were identified by multivariate analysis. The study group was further stratified into subgroups using combinations of these risk factors. In the study group, independent risk factors for local relapse were advanced stage and age <45 years. The 5-year local relapse-free survival rate was 86% for patients > or =45 years with bulky Stage IB-IIA or IIB disease, and was even greater, up to 90% if the SCC-ag level was <2. In contrast, it was 65% for patients with Stage IIIB who were <45 years old. The independent risk factors for distant failure were advanced stage, SCC-ag level >2, and positive pelvic lymph nodes. The 5-year distant relapse-free survival rate was 83% for patients with bulky Stage IB-IIA and IIB disease, SCC-ag level <2, and negative lymph nodes and 43% for patients with Stage III, SCC-ag level >2, and positive lymph nodes. The risk of treatment failure in advanced-stage cervical cancer patients treated by RT alone can be more precisely predicted by risk stratification. A certain subgroup of patients had better control than the others. The benefit of treating these relatively low-risk patients with additional treatment such as concurrent chemotherapy should be further evaluated in prospective studies or meta-analyses.

Disposition of patients with established heart failure: A closer look at telemetry

Study objectives: Approximately 80% to 90% of patients presenting to the emergency department (ED) with decompensated heart failure are admitted. This is a review of previously validated high-risk criteria for inpatient complications associated with heart failure in defining a low-risk population that can be safely dispositioned from the ED to an unmonitored unit. This study was a retrospective medical record review of 179 patients admitted from the ED for inpatient management of heart failure from August 1999 to April 2001. Methods: High-risk criteria for predicting inpatient complications were retrospectively reviewed from the emergency setting: history of acute myocardial infarction, hypotension, hypoxia, moderate signs of heart failure (on physical examination or chest radiograph), arrhythmia in the ED, chest pain, and evidence of cardiac ischemia. Cardiac complications reviewed included new-onset atrial fibrillation, atrial fibrillation with rapid ventricular rate, symptomatic bradycardia, ventricular tachycardia, ventricular fibrillation, acute myocardial infarction, cardiac ischemia, and cardiac arrest. Other complications reviewed included need for mechanical ventilation, dialysis, acute cardiac intervention (balloon pump, pacemaker, and cardiac catheterization), transfer to a higher level of care, and death. Results: Of the 179 patients reviewed, there were 126 patients with established heart failure (defined as previous admission for heart failure or an ECG-proven heart failure). There was an overall inpatient complication rate of 13% (16/126). Arrhythmias accounted for 9% (11) of complications, followed by acute-onset renal failure in 3% (4) of patients. Cardiac ischemia and death occurred in 2% (2) of patients. Atrial dysrhythmias were the most common cardiac complication. Although this analysis was not statistically significant, the data suggest that patients identified as low risk (by absence of any high-risk criteria) could be more likely to have a noncomplicated hospital course (9.5% versus 25%, odds ratio 1.46, 95% confidence interval 0.307 to 6.968, P =.63). Conclusion: Performing risk stratification in the ED for the high-risk and low-risk patient with decompensated heart failure using valid predictors for inpatient complications to avoid routine use of cardiac monitoring for all heart failure admissions is a possible cost-effective intervention. A larger patient population or multicenter study is needed to test this defined low-risk patient population for safe admission to an unmonitored unit.

Radionuclide monitoring of left ventricular function

Several devices have been evaluated and validated for continuous monitoring of LV function. The diagnostic and prognostic roles of these techniques appear to be predominant in patients with CAD. Silent myocardial ischemia may be widely evaluated by these systems, which allow the clinician to predict ischemic cardiac events, perform risk stratification, and guide treatment in patients with CAD more accurately than can be done with exercise test results. In fact, it has been demonstrated that adverse cardiac events are more commonly observed during routine daily activities. The continuous improvement in miniaturizing these devices and the capability of online processing of data could make this technique useful and widely acceptable, facilitating simultaneous assessment of hemodynamic and metabolic changes in silent LV dysfunction and continuing to play an important role in noninvasive evaluation of ventricular performance.

Assessment of coronary plaque with optical coherence tomography and high-frequency ultrasound

This study compares the ability of intravascular optical coherence tomography (OCT) and high-frequency intravascular ultrasound (IVUS) to image highly stenotic human coronary arteries in vitro. Current imaging modalities have insufficient resolution to perform risk stratification based on coronary plaque morphology. OCT is a new technology capable of imaging at a resolution of 5 to 20 μm, which has demonstrated the potential for coronary arterial imaging in prior experiments. Human postmortem coronary arteries with severely stenotic segments were imaged with catheter-based OCT and IVUS. The OCT system had an axial resolution of 20 μm and a transverse resolution of 30 μm. OCT was able to penetrate and image near-occlusive coronary plaques. Compared with IVUS, these OCT images demonstrated superior delineation of vessel layers and lack of ring-down artifact, leading to clearer visualization of the vessel plaque and intima. Histology confirmed the accuracy and high contrast of vessel layer boundaries seen on OCT images. Thus, catheter-based OCT systems are able to image near-occlusive coronary plaques with higher resolution than that of IVUS.

Risk Stratification after Acute Myocardial Infarction by Means of Echocardiographic Wall Motion Scoring and Killip Classification

In order to perform risk stratification, 195 consecutive, unselected patients with acute myocardial infarction (AMI) underwent independent echocardiographic and clinical evaluation of their left ventricular function by means of the wall motion index (WMI) and Killip classification 5 days after AMI. The patients were prospectively allocated to a low, medium or high risk class depending on WMI alone, and the 1-year mortality in these classes was 2, 34 and 37%, respectively (p < 0.0001). The 1-year mortality of the patients in Killip class I, II, or III and IV was 6, 26 and 48%, respectively (p < 0.00001). The number of patients allocated to the low risk group by means of WMI was 87, and the number of patients in Killip class I was 86. Since these groups were not identical, a total of 103 patients, i.e. 53% of the study population, could be identified as low risk patients regarding 1-year mortality 5 days after AMI, when WMI and Killip classification were used in combination. We conclude that the combination of echocardiographic and clinical evaluation of left ventricular function after AMI provides a strong and yet very simple procedure to identify low risk patients, which could be easily implemented in the routine work of coronary care units.