Powerful Predictor Of Mortality Research Articles

Usefulness of Regional Distribution of Coronary Artery Calcium to Improve the Prediction of All-Cause Mortality

Although the traditional Agatston coronary artery calcium (CAC) score is a powerful predictor of mortality, it is unknown if the regional distribution of CAC further improves cardiovascular risk prediction. We retrospectively studied 23,058 patients referred for Agatston CAC scoring, of whom 61% had CAC (n=14,084). CAC distribution was defined as the number of vessels with CAC (0 to 4, including left main). For multivessel CAC, "diffuse" CAC was defined by decreasing percentage of CAC in the single most affected vessel and by ≤75% total Agatston CAC score in the most calcified vessel. All-cause mortality was ascertained through the social security death index. The mean age was 55±11 years, with 69% men. There were 584 deaths (2.5%) over 6.6±1.7 years. Considerable heterogeneity existed between the Agatston CAC score group and the number of vessels with CAC. In each CAC group, increasing number of vessels with CAC was associated with an increased mortality rate. After adjusting for age, gender, Agatston CAC score, and cardiovascular risk factors, increasing number of vessels with CAC was associated with higher mortality risk compared with single-vessel CAC (2-vessel: HR 1.61 [95% CI 1.14 to 2.25], 3-vessel: 1.99 [1.44 to 2.77], and 4-vessel: 2.22 [1.53 to 3.23]). "Diffuse" CAC was associated with a higher mortality rate in the CAC 101 to 400 and >400 groups. Left main CAC was associated with increased mortality risk. In conclusion, increasing number of vessels with CAC and left main CAC predict increased all-cause mortality and improve the prognostic power of the traditional Agatston CAC score.

The combined incremental prognostic value of left ventricular ejection fraction, late gadolinium enhancement and global circumferential strain assessed by cardiovascular magnetic resonance

Background Left ventricular ejection fraction (LVEF) is powerful predictor of mortality and is used to guide treatment decisions. It is however subject to limitations, particularly when measured using echocardiography, as is most commonly done. Additionally, many major cardiovascular events occur in patients typically adjudged to be at lower risk using echocardiography (LVEF >35%). Assessment of myocardial deformation (strain) using tagging has the potential to overcome some of the limitations of LVEF. The value of global circumferential strain (GCS) measured by CMR tagging in patients with suspected cardiac disease has not been fully explored despite it being considered as the non-invasive gold standard method of assessment of LV deformation. We aimed to assess the incremental prognostic value of GCS measured using tagging for the prediction of major adverse cardiovascular events in addition to baseline clinical characteristics, LVEF and late gadolinium enhancement (LGE) in an unselected cohort of patients.

Fitness versus Fatness: Which Influences Health and Mortality Risk the Most?

Cardiorespiratory fitness (CRF) is a more powerful predictor of mortality than body mass index or adiposity, and improving CRF is more important than losing body fat for reducing risk of cardiovascular disease and all-cause mortality. Data on reduced morbidity and mortality associated with increased CRF are strong and consistent. By contrast, data on intentional weight loss and mortality are uncertain, and weight loss-induced risk factor modification may be largely transient. Because weight loss maintenance is poor and considering the health risks associated with chronic weight instability ( "yo-yo" dieting), we propose an alternative paradigm that focuses on improving CRF rather than reducing body weight. We contend that this is a safer alternative for management of obesity and the associated comorbidities. Exercise adherence may improve if clinicians emphasized to their patients the importance of CRF compared with weight loss in improving health and reducing the risk of chronic diseases.

Frailty and cardiovascular disease: potential role of gait speed in surgical risk stratification in older adults.

Frailty is a state of late life decline and vulnerability, typified by physical weakness and decreased physiologic reserve. The epidemiology and pathophysiology of frailty share features with those of cardiovascular disease. Gait speed can be used as a measure of frailty and is a powerful predictor of mortality. Advancing age is a potent risk factor for cardiovascular disease and has been associated with an increased risk of adverse outcomes. Older adults comprise approximately half of cardiac surgery patients, and account for nearly 80% of the major complications and deaths following surgery. The ability of traditional risk models to predict mortality and major morbidity in older patients being considered for cardiac surgery may improve if frailty, as measured by gait speed, is included in their assessment. It is possible that in the future frailty assessment may assist in choosing among therapies (e.g., surgical vs. percutaneous aortic valve replacement for patients with aortic stenosis).

Visit-to-visit variability in systolic blood pressure is a risk factor for rapid loss of residual renal function in peritoneal dialysis patients.

Visit-to-visit systolic blood pressure variability (VTV-SBPV) is correlated with cardiovascular complications. However, it still remains unclear whether VTV-SBPV is related to cardiovascular outcomes in patients with peritoneal dialysis (PD), who often manifest hypertension. We, therefore, evaluated the association of VTV-SBPV with all-cause mortality, cardiovascular complications, or the loss of residual renal function (RRF) that is a powerful predictor of mortality and morbidity in PD patients. We retrospectively reviewed the medical records for patients undergoing maintenance PD for at least 12 months at Seoul National University Hospital. The patients were divided into quartiles of VTV-SBPV based on the standard deviation of systolic blood pressure (SBP). We checked the SBP of the patients for up to 2 years after the initiation of PD. Among 216 PD patients, 16 primary outcome events (cardiovascular complications and all-cause mortality) occurred. VTV-SBPV was not associated with primary outcomes. During the follow-up, RRF loss occurred in 46 patients. The hazard ratios (HRs) for the loss of RRF in the 4 quartiles of VTV-SBPV, based on the highest to the lowest variability, were as follows: 6.201 (95% CI: 1.982-19.401, p = 0.002), 2.542 (95% CI: 0.859-7.523, p = 0.092), and 2.133 (95% CI: 0.635-7.165, p = 0.246), respectively. The loss of RRF was more frequently detected in patients with higher VTV-SBPV. VTV-SBPV was indicated as an independent risk factor for the loss of RRF. Therefore, the degree of variations in SBP should be carefully monitored to preserve the RRF of these patients.

Prognostic significance of serum creatinine and its change patterns in patients with acute coronary syndromes

In acute coronary syndromes (ACS), serum creatinine (sCr) levels have short- and long-term prognostic value. However, it is possible that repeated evaluations of sCr during hospitalization, rather than measuring sCr value at admission only, might improve risk assessment. We investigated the relationship between sCr baseline value, its changes, and in-hospital mortality in patients hospitalized with ACS. In 2,756 ACS patients, sCr was measured at hospital admission and then daily, until discharge from coronary care unit. Patients were grouped according to the maximum sCr change observed: <0.3 mg/dL change from baseline (stable renal function [SRF] group), ≥0.3 mg/dL decrease (improved renal function [IRF] group), and ≥0.3 mg/dL increase (worsening renal function [WRF] group). Of the 2,756 patients, 2,163 (78%) had SRF, 292 (11%) had IRF, and 301 (11%) had WRF. In-hospital mortality in the 3 groups was 0.5%, 2%, and 14% (P < .001), respectively. Peak sCr value was a more powerful predictor of mortality (area under the curve 0.86, 95% CI 0.81-0.92) than the initial sCr value (area under the curve 0.69, 95% CI 0.63-0.77; P < .001). When sCr and its change patterns during coronary care unit stay were evaluated together, improved mortality risk stratification was found. In ACS patients, daily sCr value and its change pattern are stronger predictors of in-hospital mortality than the initial sCr value only; thus, their combined evaluation provides a more accurate and dynamic stratification of patients' risk. Finally, the intermediate mortality risk of IRF patients possibly reflects acute kidney injury started before hospitalization.

Blood pressure and lipid profile in young women: the role of anthropometric measurement

Body composition has fundamental importance in the quality of life and is a powerful predictor of mortality and morbidity in humans. The identification and monitoring of the amount of body fat have been receiving special attention in aspects related to health promotion, not just for its actions in the prevention and in the control of cardiovascular diseases but also for their induction and association with risk factors, especially in the plasmatic lipid levels and arterial pressure. It was investigated the relationship between body mass index (BMI) and body fat percentage (%BF) by bioelectrical impedance analysis (BIA) with the blood pressure levels (systolic and diastolic) and serum lipids (TC, HDL-c, LDL-c, VLDL-c, TG). In a group of fifty seven women (aged 18 to 26 years old ), obesity was detected in 5 and 19 women by BMI (≥ 30 kg/m2) and %BF (≥ 30%), respectively. BMI and % BF were positively correlated with blood pressure (systolic and diastolic), and highly significant in the obese group by %BF. Moreover, BMI and % BF were significantly correlated with all lipids and lipoprotein fractions VLDL-c and triglyceride, respectively. These results suggest that %BF is a good indicator of “occult obesity” in subjects with normal body mass index. The associated use of BMI and %BF to better evaluate obesity may improve the study of blood pressure levels and serum lipid changes that are commonly associated with obesity.

Abstract 11602: Impact of Pre-Operative Type-B Natriuretic Peptide Level on Survival After Aortic Valve Replacement for Aortic Stenosis

Introduction: Levels of type-B natriuretic peptide (BNP) adjusted for age and sex are a powerful predictor of mortality after the diagnosis of aortic stenosis (AS). Objective: To assess whether BNP activation (compared to normal values) affects mortality after aortic valve replacement (AVR). Methods: In 494 patients with AS, plasma level of BNP was measured pre-operatively at the time of Doppler-Echocardiography. BNP was normalized as BNPratio (BNP measured/BNP maximum normal value for age and sex) to evaluate the impact of BNP activation on post-operative outcomes. Results: Mean age was73±11 years and 300 (61%) patients were male. Mean aortic valve area was 0.82±0.20cm2, mean gradient 51±16mmHg, and mean Left Ventricular Ejection Fraction 59±15%. Incidence of hypertension was 65%, diabetes 27% and chronic kidney disease 22%. Median of BNP was 211 (interquartile: 87-508) and BNPratio 2.2 (1.0-5.2). After adjustment age, gender, body surface area, Charlson score index, presence of symptoms, creatinine, hemoglobin, systolic blood pressure, indexed aortic valve area and left ventricular ejection fraction, the BNPratio (log transformed) was a predictor of long-term mortality (p&lt;0.0001) with an hazard ratio 1.34 (1.14-1.60). Moreover, stratification by BNPratio showed increasing long-term post-operative mortality with BNPratios&gt;2 (Figure). Conclusions: BNP activation defined using BNPratios (normalized for age and sex) is a powerful independent predictor of long-term mortality after aortic valve replacement for AS. Furthermore, patients with a BNPratio&gt;2 before aortic valve replacement incur excess mortality during follow-up in relation to the increasing BNPratio. These data support the use of the BNPratio to guide the timing of AVR.

Impact of clinical and echocardiographic characteristics on occurrence of cardiac events in cardiac amyloidosis as proven by endomyocardial biopsy

BackgroundAlthough patients with immunoglobulin light chain (AL) cardiac amyloidosis exhibit worse outcomes than those with transthyretin (TTR) cardiac amyloidosis, few data exist regarding the occurrence of cardiac events and the echocardiographic indices in endomyocardial biopsy (EMBx) proven amyloidosis. MethodsFrom November 2007 to October 2012, we identified 33 patients with EMBx-proven amyloidosis. There were 12 patients (8 men; mean age: 66years) with AL and 21 patients (20 men; mean age: 78years) with TTR. We performed serial echocardiography and observed the patients during follow-up; defining all-cause mortality as the primary endpoint and hospitalization for heart failure as the secondary endpoint. ResultsThe survival rates at 12months were 20.8% and 85.7% in AL and TTR, respectively (p<0.001). The cumulative incidences of the composite of death or readmission for heart failure at 12months were 91.7% and 51.3% in AL and TTR, respectively (p<0.001). A multivariate analysis showed that the AL type amyloid was the powerful predictor of mortality (hazard ratio: 8.50, 95% confidence interval: 1.79 to 40.57, p<0.05). Under these conditions, the E/e′ in AL tended to increase from 23±13 to 28±11 (p=0.06) with marked increases in B-type natriuretic peptide (779±456pg/ml to 1576±895pg/ml, p<0.05), although these remained unchanged in TTR, which exhibited significantly increased left ventricular end-diastolic dimensions from 40±4mm to 42±4mm (p<0.05). ConclusionsThe survival rate was generally worse in AL cardiac amyloidosis, although the readmission for heart failure remains high in TTR cardiac amyloidosis with the occurrence of left ventricular dilatation.

The role of cardiac biomarkers in cardiovascular disease risk assessment.

A range of cardiovascular biomarkers have come into the routine clinical use for the diagnosis and assessment of patients with symptomatic coronary disease. The review will consider the current evidence base for the role of measurement of a number of these biomarkers in asymptomatic patients. Measurement of the cardiac troponins, cardiac troponin T and cardiac troponin I, using sensitive methods, defines a true reference population, and has demonstrated risk of cardiovascular events with small elevations above the reference interval and a gradient of risk across the reference range even in normal healthy individuals. Similar results can be seen for the measurement of the ventricular stress marker B-type natriuretic peptide. In an asymptomatic population, there is occult cardiovascular disease which can be detected by cardiovascular biomarker measurement. Novel markers of myocardial inflammation and fibrosis, such as growth differentiation factor 15, are also powerful predictors of mortality. Measurement of these cardiovascular biomarkers provides additional risk prediction when added to risk prediction models based on the conventional risk factors. The measurement of cardiovascular biomarkers has the potential to provide additional risk stratification beyond conventional risk factors. The challenge is to translate biomarker measurements to treatment strategies which will reduce long-term cardiovascular risk.

Is there a role for diastolic function assessment in era of delayed enhancement cardiac magnetic resonance imaging?: A multimodality imaging study in patients with advanced ischemic cardiomyopathy

Cardiac magnetic resonance (CMR) identifies important prognostic variables in ischemic cardiomyopathy (ICM) patients such as left ventricular (LV) volumes, LV ejection fraction (LVEF), peri-infarct zone, and myocardial scar burden (MSB). It is unknown whether Doppler-based diastolic dysfunction (DDF) retains its prognostic value in ICM patients, in the context of current imaging, medical, and device therapies. Diastolic function was evaluated in ICM patients (LVEF ≤ 40% and ≥ 70% stenosis in ≥ 1 coronary artery) who underwent transthoracic echocardiogram and delayed hyperenhancement CMR studies within 7 days. The association of DDF with the combined end point was assessed after risk-adjustment using Cox proportional hazards models. A total of 360 patients with severe LV dysfunction (LVEF = 24 ± 9%) and extensive MSB (31 ± 17%) were evaluated; DDF was present in all patients (stage 1%-44%, stage 2%-25%, stage 3%-31%). There were 130 events (124 deaths and 6 heart transplants) over a median follow-up of 5.8 years (IQR, 3.7-7.4 years). On multivariable analysis, DDF > stage 1 (HR, 1.37; P = .007) was associated with the combined end-point, independent of clinical risk score (HR, 2.40; P < .0001), implantable cardioverter defibrillator implantation (HR, 0.60; P = .009), incomplete revascularization (HR, 1.32; P = .003), mitral regurgitation (HR, 3.37; P = .01), peri-infarct zone area (HR, 1.04; P = 0.02), and MSB (HR, 1.02; P = .01). DDF had incremental prognostic value for the combined end-point (model χ(2) increased from 89 to 95, P = .02). DDF is a powerful predictor of mortality in ICM patients with significant LV dysfunction, independent of clinical and CMR data. DDF assessment provides incremental value, improving risk stratification.

0432: Impact of admission hyperglycemia on one-year mortality in non-diabetic patients admitted for rescue PCI: Data from the “Observatoire des infarctus de Côte d’Or”

Rescue percutaneous coronary intervention (PCI) is associated with improved clinical outcomes for ST-segment myocardial infarction (STEMI) patients after failed fibrinolysis therapy. Hyperglycemia on admission has been shown to be a powerful predictor of mortality after acute myocardial infarction, particularly in non-diabetic patients. The aim of our study was to assess the predictive value of admission glucose levels on long-term mortality in patients with rescue PCI. From the “Observatoire des infarctus de Côte d’Or” (RICO) survey, 510 consecutive non-diabetic STEMI patients admitted to the intensive care unit for rescue PCI after failed fibrinolysis therapy were included in the study. We analyzed one-year cardiovascular mortality in these patients. Rescue PCI was deemed necessary in patients with ST-segment resolution <50% 90 minutes after lysis, or a thrombolysis in myocardial infarction (TIMI) perfusion grade in the infarct-related artery <3 at the time of angiography in patients with persisting equivocal symptoms. Patients were classified according to admission glycemia: <11 mmol/L (group I, n=452) and =11 mmol/L (group II, n=58). One-year cardiovascular (CV) mortality was 6% in group I and 29% in group II (p<0.001). Patients with hyperglycemia on admission were more likely to develop cardiogenic shock (43% vs. 10%, p<0.001) and to have higher peak CPK (4052(2465-6283) vs. 2667 (1303-4865), p=0.007), reflecting a bigger infarct size than the others, although the revascularization results were similar. By multivariate analysis, glycemia on admission =11 mmol/L (odds ratio 6.380, 95% confidence interval 2.075 to 19.617, p=0.001) and GRACE risk score (OR: 1.027, 95% CI 1.012-1.042, p<0,001) were independently associated with 1-year CV mortality. In non-diabetic patients undergoing rescue PCI after failed fibrinolysis, glycemia on admission is a predictive factor for long-term CV survival. This study suggests that evaluating early glycemic control may be useful in the setting of rescue PCI.

Systolic blood pressure influences the interpretation of cardiopulmonary exercise tests and helps identify a very high-risk cohort of heart failure patients

Ventilatory inefficiency (high volume of expired air/volume of carbon dioxide eliminated [Ve/Vco2] slope), and impaired exercise tolerance (low peak volume of oxygen consumption) obtained from cardiopulmonary exercise testing (CPX) strongly predict mortality in heart failure (HF) patients; however, other CPX variables may also contain prognostic information. Therefore, the purpose of this study was to determine the prognostic power of the aggregate of CPX data. The study prospectively monitored 390 patients referred for cardiac transplantation evaluation for 10 years for events (death, urgent transplant, left ventricular assist devices). Cox regression was used to analyze 18 CPX variables to identify the best survival model. Ve/Vco2 slope was the most powerful mortality predictor, and only resting systolic blood pressure (SBP) added additional independent prognostic power when expressed at its threshold effect value as SBP ≤ 100 mm Hg. Patients with low SBP had a greater risk than those who were within the next higher quartile of Ve/Vco2 slope with SBP > 100 mm Hg. A very high-risk cohort included 9% of the population that had a Ve/Vco2 slope > 41 and SBP ≤ 100 mm Hg and an associated 2-year event rate of 67%; conversely, a low-risk cohort had a Ve/Vco2 slope ≤ 30 and SBP >100 mm Hg and associated 2-, 5-, and 10-year event rates of 5%, 12%, and 30%, respectively. Ve/Vco2 slope was the best individual predictive CPX variable and its interpretation was significantly altered by the presence of hypotension. An algorithm combining these CPX variables identifies a HF population at very high risk of early death and warranting advanced therapies.

Assessment of Cardiac Autonomic Function by Using Heart Rate Turbulence in Behcet’s Disease

Behcet’s disease (BD) is a chronic inflammatory disorder that can affect many systems in the body. Cardiac involvement increases the risk of cardiovascular mortality and occurs in 1%-5% of patients with BD. Ventricular arrythmias are believed to be the cause of this increased risk of cardiovascular mortality and it is also thought to be related with cardiac autonomic dysfunction. Heart rate turbulence (HRT) is a new predictor of cardiac autonomic activity. HRT is an independent and powerful predictor of mortality. In this study, we investigated the cardiac autonomic activity which can be determined by HRT in patients with BD. Forty patients with BD (20 men, mean age: 40 ± 9 years, range: 27-55 years) were diagnosed according to the International Study Group Criteria (ISGC) and gender and age matched healthy volunteers (20 men, mean age: 39 ± 8 years, range: 26-56 years) were included in this study. All of the participants (patients and controls) underwent 24 hours Holter electrocardiogram. HRT parameters, turbulence onset (TO) and turbulence slope (TS) were calculated with HRT (View Version 0.60-0.1 of Software Program). There were no significant differences in TO and TS values between patients with BD and control subject (TO-BD: 0.014 ± 0.03, TO-Control: 0.011 ± 0.04; TS-BD: 7.88 ± 4.9, TS-Control: 9.42 ± 6.7 respectively). Although increased cardiovascular mortality rates in BD have been shown in many studies, HRT values—detecting the risk of sudden death—do not seem to be altered in this disease.

Clinical course, prognosis, and cause of death in primary Sjögren's syndrome.

The aim of this retrospective, single-centre study was to investigate the clinical and laboratory features and disease outcomes of 547 patients diagnosed with primary Sjögren's syndrome (pSS) between 1975 and 2010. The patients were followed up for 11.4 ± 6.2 years. We evaluated the clinical and laboratory features, and assessed their influence on the time of diagnosis, survival, and mortality ratios, and compared them within subgroups defined by gender, glandular and extraglandular manifestations (EGMs), associated diseases, and immunoserological abnormalities. The most frequent EGMs were polyarthritis, Raynaud's phenomenon, and vasculitis among our patients; the most common associated disease was thyroiditis. During the follow-up period, 51 patients died; the median survival time was 33.71 years. Our results revealed a negative effect of cryoglobulinemia on survival ratios; additionally, the presence of vasculitis and lymphoproliferative diseases at the time of diagnosis increased the risk of mortality. The development of vasculitis was the most powerful predictor of mortality. Mortality in the group of patients with extraglandular symptoms was two- to threefold higher than in the glandular group. Attention is drawn to the importance of close monitoring and targeted diagnostic approaches in those pSS subgroups with obviously increased mortality risk.

A look at the upper heart chamber: the left atrium in chronic kidney disease

Altered left ventricular (LV) mass and function are classical hallmarks of cardiomyopathy in chronic kidney disease (CKD). The left atrium (LA), a heart chamber exquisitely sensitive to volume overload and diastolic function, is an independent predictor of death and adverse cardiovascular (CV) events in high-risk patients such as those with hypertension and/or with heart failure. In this review we focus on the relationship of LA size with LV diastolic function, and the association between LA enlargement and CV and renal outcomes in patients with CKD, including patients with end-stage renal disease. Increased LA size emerges as a powerful predictor of mortality and major adverse CV events in both end-stage and early CKD, and some studies also show a close association between enlarged LA and renal disease progression. Secondary analyses of clinical trials suggest that the LA has the potential to be elected as a surrogate end point in CKD patients but the issue remains to be tested in specifically designed clinical studies.

Paravalvular aortic regurgitation as the reason for second CoreValve bioprosthesis implantation in a patient with native bicuspid valve

We present the case of a 70-year-old male patient who was admitted to our centre with severe symptomatic aortic stenosis. His medical history included: hypertension, stroke (1998 and 2013) with subsequent left-sided paraparesis and status after traumatic upper right limb amputation in his youth. Patient’s logistic EuroSCORE was 18.1%, EuroSCORE II 5.7% and the Society of Thoracic Surgeons Score 2.7%. Transthoracic echocardiography showed impaired left ventricular ejection fraction of 27%, mean aortic pressure gradient of 70.5 mm Hg, aortic valve area of 0.6 cm2, and peak velocity of 6.3 m/s. For precise aortic annulus measurement, transoesophageal echocardiography (TEE) and a computed tomography scan were performed and revealed a heavily calcified bicuspid valve with mean annulus diameter of 24 mm. Angiography demonstrated a significant lesion in the 3rd segment of right coronary artery (RCA). Due to the high operative risk, the patient was referred by the Heart Team for percutaneous coronary intervention of RCA and transcatheter aortic valve implantation (TAVI) via the femoral route (considering the absence of atherosclerotic lesions in ilio-femoral arteries). Native valve was predilated with a 22 mm Numed balloon catheteter (Fig. 1A). On the basis of pre-procedural imaging, a 29 mm Medtronic CoreValveTM bioprosthesis was implanted at the annulus level. However, control angio and TEE showed low implantation accompanied by significant paravalvular aortic regurgitation (Fig. 1B). Haemodynamic measurement also confirmed a suboptimal effect with low diastolic aortic pressure (DAP) and high left-ventricular end-diastolic pressure (LVEDP) (Fig. 2A). Therefore, the decision was made to implant a second bioprosthesis — another 29 mm CoreValve was placed and deployed 8–10 mm higher than the first one (Fig. 1C). Implantation of the second valve significantly decreased the magnitude of regurgitation from severe to no or mild, both in angiography and pressure recordings (Figs. 1D and 2A, respectively). It has been shown in several observational and randomised trials that even mild paravalvular regurgitation after TAVI is an independent predictor of long-term mortality. It is therefore of crucial importance to diagnose early and minimise the grade of regurgitation by post-dilatation or second valve deployment. This case demonstrates that apart from imaging modalities, direct pressure measurement is an easy, reliable and reproducible method of paravalvular leak detection. Recently, it has been shown in a non-selected population of TAVI procedures that pressure gradient DDAP-LVEDP is a powerful predictor of mortality.

P179 Forced vital capacity, systemic inflammation and cardiometabolic markers in adulthood: a cross-sectional analysis

IntroductionForced vital capacity (FVC) is a powerful predictor of mortality, more than airflow obstruction (Burney et al. Thorax 2011;66:49–54). FVC is associated with systemic inflammation as well as with cardiovascular...

Acute kidney injury is surprisingly common and a powerful predictor of mortality in surgical sepsis

Acute kidney injury (AKI) is a common and often catastrophic complication in hospitalized patients; however, the impact of AKI in surgical sepsis remains unknown. We used Risk, Injury, Failure, Loss, End stage (RIFLE) consensus criteria to define the incidence of AKI in surgical sepsis and characterize the impact of AKI on patient morbidity and mortality. Our prospective, institutional review board-approved sepsis research database was retrospectively queried for the incidence of AKI by RIFLE criteria, excluding those with chronic kidney disease. Patients were grouped into sepsis, severe sepsis, and septic shock by refined consensus criteria. Data including demographics, baseline biomarkers of organ dysfunction, and outcomes were compared by Student's t test and χ test. Multivariable regression analysis was performed for the effect of AKI on mortality adjusting for age, sex, African-American race, elective surgery, Acute Physiology and Chronic Health Evaluation II score, septic shock versus severe sepsis, and sepsis source. During the 36-month study period ending on December 2010, 246 patients treated for surgical sepsis were evaluated. AKI occurred in 67% of all patients, and 59%, 60%, and 88% of patients had sepsis, surgical sepsis, and septic shock, respectively. AKI was associated with Hispanic ethnicity, several baseline biomarkers of organ dysfunction, and a greater severity of illness. Patients with AKI had fewer ventilator-free and intensive care unit-free days and a decreased likelihood of discharge to home. Morbidity and mortality increased with severity of AKI, and AKI of any severity was found to be a strong predictor of hospital mortality (odds ratio, 10.59; 95% confidence interval, 1.28-87.35; p = 0.03) in surgical sepsis. AKI frequently complicates surgical sepsis, and serves as a powerful predictor of hospital mortality in severe sepsis and septic shock. Prognostic and epidemiologic study, level III.

The Incidence, Pattern, and Prognostic Value of Left Ventricular Myocardial Scar by Late Gadolinium Enhancement in Patients With Atrial Fibrillation

This study sought to identify the frequency, pattern, and prognostic significance of left ventricular (LV) late gadolinium enhancement (LGE) in patients with atrial fibrillation (AF). There are limited data on the presence, pattern, and prognostic significance of LV myocardial fibrosis in patients with AF. LGE during cardiac magnetic resonance imaging is a marker for myocardial fibrosis. A group of 664 consecutive patients without known prior myocardial infarction who were referred for radiofrequency ablation of AF were studied. Cardiac magnetic resonance imaging was requested to assess pulmonary venous anatomy. Overall, 73% were men, with a mean age of 56 years and a mean LV ejection fraction of 56 ± 10%. LV LGE was found in 88 patients (13%). The endpoint was all-cause mortality, and in this cohort, 68 deaths were observed over a median follow-up period of 42 months. On univariate analysis, age (hazard ratio [HR]: 1.05; 95% confidence interval [CI]: 1.03 to 1.08; chi-square likelihood ratio [LRχ(2)]: 15.2; p = 0.0001), diabetes (HR: 2.39; 95% CI: 1.41 to 4.09; LRχ(2): 10.3; p = 0.001), a history of heart failure (HR: 1.78; 95% CI: 1.09 to 2.91; LRχ(2): 5.37; p = 0.02), left atrial dimension (HR: 1.04; 95% CI: 1.01 to 1.08; LRχ(2): 6.47; p = 0.01), presence of LGE (HR: 5.08; 95% CI: 3.08 to 8.36; LRχ(2): 28.8; p < 0.0001), and LGE extent (HR: 1.15; 95% CI: 1.10 to 1.21; LRχ(2): 35.6; p < 0.0001) provided the strongest associations with mortality. The mortality rate was 8.1% per patient-year in patients with LGE compared with 2.3% patients without LGE. In the best overall multivariate model for mortality, age and the extent of LGE were independent predictors of mortality. Indeed, each 1% increase in the extent of LGE was associated with a 15% increased risk for death. In patients with AF, LV LGE is a frequent finding and is a powerful predictor of mortality.