Predictors Of 30-day All-cause Mortality Research Articles

Discordant High Activated Partial Thromboplastin Time Relative to Anti-Xa Values in Hospitalized Patients is an Independent Risk Factor for Increased 30-day Mortality.

The activated partial thromboplastin time (aPTT) and anti-factor-Xa levels (anti-Xa) are both used to monitor patients on unfractionated heparin. Our previous study demonstrated that patients with discordant high aPTT relative to anti-Xa had higher rates of mortality and bleeding events. To determine if underlying patient characteristics drive both discordance and adverse outcomes or if discordance is an independent risk factor to adverse outcomes. We analyzed all patients hospitalized at the Stanford Hospital between January 2011 and December 2019 who had simultaneous aPTT and anti-Xa levels performed. From the electronic medical record, we extracted and analyzed 51 patient features including baseline coagulation laboratory results, demographics, values of other common laboratories (basic metabolic panel, complete blood count, etc.), diagnostic procedures, medications, and death. A total of 17,728 patients had 78,701 paired aPTT and anti-Xa levels. Patients with discordant aPTT and anti-Xa where aPTT (seconds) was elevated beyond the expected therapeutic range had a higher 30-day mortality (odds ratio [OR]: 2.16, 95% confidence interval [CI]: 1.78-2.63, p < 0.001). Sectioning the patients based on the degree of discordance and whether aPTT or anti-Xa were signaling excess anticoagulation, we found those with an elevated aPTT discordant to their anti-Xa level had the highest odds of death (OR: 2.46, 95% CI: 1.99-3.10) compared with the concordant group. This finding was still present after controlling for patient comorbidity and other laboratory results at hospital admission. After controlling for patient features strongly associated with increased mortality in heparinized patients, we identified that the discordant pattern of high aPTT to anti-Xa served as an independent predictor of 30-day all-cause mortality, with a higher degree of discordance associated with increased odds of 30-day mortality.

Predictors of short-term mortality in cardiogenic shock: insights from an Egyptian multicenter registry

BackgroundCardiogenic shock (CS) remains a major cause of morbidity and mortality, particularly in developing countries where there are limited resources and a lack of data on CS outcomes. This study aimed to investigate 30-day all-cause mortality in Egyptian patients with CS at tertiary referral centers.ResultsThis prospective, observational multicenter registry analyzed 16,681 patients from six cardiac centers, to evaluate the incidence, causes and predictors of CS-related mortality. Among the 529 diagnosed CS patients, 68.2% had an ischemic etiology. No discernable variations were observed in clinical or laboratory features, as well as mortality rates, between ischemic and non-ischemic CS patients. Within 30 days, 210 deaths (39.7%) occurred. Non-survivors with ischemic CS had a higher prevalence of diabetes, worsening renal function, and were more likely to receive multiple inotropes. Mortality did not significantly differ between acute coronary syndrome patients with ST elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) (42.7% vs. 43.7%, p < 0.887). However, anterior STEMI patients had significantly higher mortality than those with inferior STEMI (49.5% vs. 21.6%, p < 0.003). Multivariate regression analysis identified predictors of mortality in CS, including the median hospital stay duration, leucocyte count, alanine transaminase levels, highest creatinine levels, resuscitated cardiac arrest, and use of norepinephrine, epinephrine, and dopamine.ConclusionIn an Egyptian cohort, CS incidence was 3.17%, with no mortality difference based on the underlying etiology. Independent predictors of 30-day all-cause mortality included worsening renal function, leucocyte count, resuscitated cardiac arrest, and use of multiple inotropes/vasopressors.Graphical abstract

Contrast Volume-to-Estimated Glomerular Filtration Rate Ratio as a Predictor of Short-Term Outcomes Following Transcatheter Aortic Valve Implantation.

Background/Objectives: Contrast-induced acute kidney injury (AKI) is associated with early mortality and adverse events. However, in the setting of transcatheter aortic valve implantation (TAVI), previous literature has failed to establish a correlation between the absolute volume of contrast media administered and mortality. We aimed to investigate the impact of contrast volume administered normalised to estimated glomerular filtration rate (CV/eGFR) on the development of AKI and on 30-day all-cause mortality in TAVI patients. Methods: We retrospectively analysed a cohort of 1150 patients who underwent TAVI at our unit between 2015 and 2018. Results: Follow-up was complete for 1064 patients. There were 23 deaths within the follow-up period and 76 cases of AKI, 9 of which required new renal replacement therapy (RRT). Receiver-operating characteristic (ROC) curve analysis showed fair discrimination for 30-day all-cause mortality at a CV/eGFR ratio of 3.6 (area under the ROC curve (AUC) 0.671). Of patients in whom CV data were available, 86.0% (n = 757) had a CV/eGFR < 3.6 and 14.0% (n = 123) had a CV/eGFR ≥ 3.6. In multivariate logistic regression analysis, CV/eGFR ≥ 3.6 was the strongest predictor of 30-day all-cause mortality (odds ratio 5.06, 95% confidence interval [1.61-15.7], p = 0.004). Other independent predictors were procedural urgency (3.28 [1.04-10.3], p = 0.038) and being under general anaesthesia (4.81 [1.10-17.3], p = 0.023). CV/eGFR ≥ 3.6 was also independently associated with significantly increased odds of AKI (2.28 [1.20-4.17], p = 0.009) alongside significant non-left main stem coronary artery disease (2.56 [1.45-4.66], p = 0.001), and diabetes (1.82 [1.03-3.19], p = 0.037). In supplementary ROC curve analysis, a similar CV/eGFR cut point of 3.6 was found to be an excellent predictor for new RRT (AUC 0.833). Conclusions: In conclusion, a CV/eGFR ≥ 3.6 post-TAVI was found to be a strong predictor of 30-day mortality and AKI. The maximum contrast volume that can be safely administered in each patient without significantly increasing the risk of mortality and AKI can be calculated using this ratio.

Intra-Aortic Balloon Pump Support in Patients with Acute Myocardial Infarction with Ventricular Septal Rupture

Background: An intra-aortic balloon pump (IABP) is the device most frequently used as a bridge to surgical repair in cases of myocardial infarction. However, robust evidence of IABP support for patients with postinfarction ventricular septal rupture (VSR) remains lacking. This study was aimed at assessing the effect of IABP support on 30-day prognosis in patients with acute myocardial infarction (AMI) complicated by VSR. Methods: Retrospective data for patients with VSR after AMI at Fuwai Hospital between April 2002 and August 2020 were analyzed. Patients were initially stratified into two groups according to IABP implantation. The Kaplan-Meier method was used to determine the cumulative incidence of 30-day all-cause mortality. Multivariate logistic regression was used to evaluate the independent risk factors for 30-day mortality. Results: A total of 92 patients (mean age of 67.8 ± 8.3 years; 46.7% male) were included, 59 of whom underwent IABP implantation. Patients with rather than without IABP treatment were younger, were more often male, and had a higher body mass index and lower mean blood pressure at the onset of VSR. At 30 days, all-cause death occurred in 21 patients in the IABP group (35.59%) and 31 patients in the group without IABP (93.94%). After adjustment for age, sex, left atrial diameter, left ventricular diameter, perforation diameter and ventricular aneurysm, IABP support was found to be an independent protective predictor of 30-day all-cause mortality (hazard ratio: 0.22; 95% confidence interval: 0.12 to 0.42; P &lt; 0.001). Conclusions: IABP support was associated with lower 30-day mortality in patients with VSR after AMI. Patients with postinfarction VSR with hemodynamic instability or cardiogenic shock could receive IABP treatment as a bridge to surgical repair.

Predictive values of age shock index and age modified shock index for in-hospital mortality in patients with ST-segment elevation myocardial infarction

Abstract Background and Purpose This study aimed to evaluate the predictive values of admission age shock index (age SI) and age modified shock index (age MSI) for short-term outcomes in patients with ST-segment elevation myocardial infarction (STEMI). Methods 7324 patients with STEMI were included in the present study. Shock index (SI), modified shock index (MSI), age SI, age MSI and the TIMI score were calculated on admission. The primary outcome was all-cause mortality and the secondary outcomes were recurrent MI, cardiogenic shock and major adverse cardiovascular events (MACEs) during 30-day follow-up. Univariate and multivariate Cox regression were performed to evaluate the association between age SI, age MSI and outcomes. Predictive values of SI, MSI, age SI, age MSI and the TIMI score were evaluated and compared through analysis of the receiver operating characteristic (ROC) curves and integrated discrimination improvement (IDI). Results According to the ROC curve, the best cutoff of age SI for 30-day all-cause mortality were 50.0. Patients with elevated age SI had more comorbidities, received less evidence-based treatments and carried worse 30-day mortality. Multivariate Cox regressions demonstrated that age SI and age MSI were independent predictors of 30-day all-cause mortality and MACEs. The predictive values of age MSI for 30-day mortality were comparable to that of the TIMI score (c statistic: 0.743 vs. 0.758, z=1.740, p=0.082; IDI: 0.011, p=0.055) and better than that of SI (c statistic: 0.743 vs. 0.660, z=14.317, p&amp;lt;0.001; IDI: 0.046, p&amp;lt;0.001). The prognostic performance of age MSI was slightly inferior to that of the TIMI score (c statistic: 0.741 vs. 0.758, z=2.060, p=0.039; IDI: -0.001, p=0.846). Conclusion Age SI and age MSI were independent predictors for 30-day all-cause mortality and MACEs in patients with STEMI. The predictive value of age SI was comparable with the TIMI score but better than SI. Age SI and age MSI are practical risk stratification tools for STEMI.Figure.Receiver operating characterisTable.Discrimination and Calibration

Predictors of all-cause 30-days mortality in acute decompensated heart failure patients in the emergency department setting

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Grants from Region Östergötland County Medical Research Council of South East Sweden. Introduction The use of NT-proBNP is well established in the management of heart failure (HF), and as predictor of mortality in HF patients. However, on short-term mortality in acute decompensated heart failure the evidence is scarce. Purpose We aimed to evaluate NT-proBNP as an independent predictor of 30-day all-cause mortality in acute decompensated heart failure patients, seeking emergency medical care. Methods This was an observational study including all visits to Vrinnevisjukhuset hospital emergency department during two years, where the patient was above 18 years of age, and the main diagnosis was set to HF. Appropriate data for each visit were collected from the patients’ medical records retrospectively. The Cox proportional hazards model was applied to estimate hazard ratios (HR) for 30-day mortality. Results From the 459 emergency department visits included in the study 59 patients (12,9%) reached the primary end point of all-cause mortality in 30 days. Age, body mass index (BMI), mean arterial pressure (MAP), sodium, potassium, NT-proBNP, and the presence of atrial fibrillation or flutter were variables achieving P&amp;lt;0.1 on univariate Cox proportional hazards analysis and were subsequently introduced to the multivariate model. Age (HR: 1,05; p=0,008), sodium (HR: 0,925; p=0,012), potassium (HR: 1,95; p=0,002) and MAP (HR: 0,978; p=0,009) was found to be the only independent predictors of 30-day all-cause mortality. Conclusions Our study indicates that for short-term prediction of mortality, other markers than NT-proBNP are of significance. Measurement of serum potassium might be a better tool for clinicians in identifying patients at highest risk of short-term mortality.

Admission lactate level and the GRACE 2.0 score are independent and additive predictors of 30-day mortality of STEMI patients treated with primary PCI-Results of a real-world registry.

In many of the risk estimation algorithms for patients with ST-elevation myocardial infarction (STEMI), heart rate and systolic blood pressure are key predictors. Yet, these parameters may also be altered by the applied medical treatment / circulatory support without concomitant improvement in microcirculation. Therefore, we aimed to investigate whether venous lactate level, a well-known marker of microcirculatory failure, may have an added prognostic value on top of the conventional variables of the "Global Registry of Acute Coronary Events" (GRACE) 2.0 model for predicting 30-day all-cause mortality of STEMI patients treated with primary percutaneous coronary intervention (PCI). In a prospective single-center registry study conducted from May 2020 through April 2021, we analyzed data of 323 cases. Venous blood gas analysis was performed in all patients at admission. Nested logistic regression models were built using the GRACE 2.0 score alone (base model) and with the addition of venous lactate level (expanded model) with 30-day all-cause mortality as primary outcome measure. Difference in model performance was analyzed by the likelihood ratio (LR) test and the integrated discrimination improvement (IDI). Independence of the predictors was evaluated by the variance inflation factor (VIF). Discrimination and calibration was characterized by the c-statistic and calibration intercept / slope, respectively. Addition of lactate level to the GRACE 2.0 score improved the predictions of 30-day mortality significantly as assessed by both LR test (LR Chi-square = 8.7967, p = 0.0030) and IDI (IDI = 0.0685, p = 0.0402), suggesting that the expanded model may have better predictive ability than the GRACE 2.0 score. Furthermore, the VIF was 1.1203, indicating that the measured lactate values were independent of the calculated GRACE 2.0 scores. Our results suggest that admission venous lactate level and the GRACE 2.0 score may be independent and additive predictors of 30-day all-cause mortality of STEMI patients treated with primary PCI.

A diagnostic algorithm for early diagnosis and management of acute invasive fungal sinusitis

PurposeTo define different risk groups of patients suspected of having acute invasive fungal sinusitis (AIFS) and develop a goal-directed diagnostic approach. Materials and methodsForty patients with suspected AIFS biopsied from 2010 to 2020 were included in this study. Patients diagnosed with chronic invasive fungal sinusitis or without biopsy results were excluded. A recursive partitioning analysis (RPA) model was performed to define patient cohorts with the highest risk of having a positive biopsy for AIFS. ResultsThere were a total of 26 patients with biopsy-proven AIFS. Patient characteristics significantly associated with an increased likelihood of a positive biopsy for AIFS on bivariate analysis included facial pain (p = 0.047), platelet count <50,000 cells/mm3 (p = 0.028), and abnormal CT findings, most commonly, bilateral sinus opacification (p = 0.003). The RPA model identified three risk factors for predicting a patient's probability of having a positive biopsy for AIFS, resulting in four-terminal nodes. In the twenty-six patients who had biopsy-proven AIFS, the post-operative 30-day all-cause mortality was 50 % (13/26) and overall mortality was 88.5 % (23/26). Predictors of 30-day all-cause mortality included prolonged interval between biopsy and operative start time (p = 0.042) and earlier initiation of antifungals prior to the operative start time (p = 0.042). ConclusionOur findings indicate that patients with a fever of unknown origin, low platelet count, and/or ANC are at an increased risk of being diagnosed with biopsy-proven AIFS. Using these risk factors, we propose a diagnostic approach that may expedite the treatment of patients with AIFS; however, future prospective studies are needed for validation.

Neutrophil-to-Lymphocyte Ratio and Outcomes in Patients Admitted for Acute Heart Failure (As Seen in the BLAST-AHF, Pre-RELAX-AHF, and RELAX-AHF Studies)

Previous studies have suggested that the neutrophil-to-lymphocyte ratio (NLR) is a novel yet readily evaluable inflammatory biomarker that may be useful for determining cardiovascular prognosis during acute episodes. The study investigated the role of NLR in predicting cardiovascular (CV) outcomes in patients with acute heart failure (HF). Individual patient data from the BLAST-AHF (phase 2b study of the biased ligand of the angiotensin 2 type 1 receptor, TRV027), Pre-RELAX-AHF (phase 2b study of recombinant human relaxin-2, serelaxin), and RELAX-AHF (phase 3 study of serelaxin) randomized, placebo-controlled studies for patients with acute HF were pooled for analysis. Dyspnea visual analog scale area under the curve through day 5, worsening HF through day 5, 30-day all-cause mortality, 60-day HF/renal failure rehospitalizations or CV death, 180-day all-cause mortality, and 180-day CV death were assessed. There were several differences in the baseline characteristics of the patients divided by NLR tertile, with patients in the higher NLR having worse clinical characteristics. NLR was an independent predictor of 30-day all-cause mortality (adjusted hazard ratio [HR] per log₂ NLR increment: 1.66 [1.22 to 2.25], p=0.001), 60-day HF/renal failure rehospitalizations or CV death: 1.33 [1.12 to 1.57], p=0.001), 180-day all-cause mortality (adjusted HR 1.27 [1.08 to 1.50], p=0.003), and 180-day CV death (adjusted HR 1.24 [1.04 to 1.49], p=0.018). NLR, a readily available inflammatory biomarker, was associated with independent risk for short- and long-term adverse outcomes in acute HF, surpassing traditional markers, such as natriuretic peptides.

Frailty is Associated With Poor Outcomes Following Emergency Laparotomy: What's Next?

Background and objectiveThe Clinical Frailty Scale (CFS) is a rapid assessment tool to identify vulnerable and frail patients. We sought to evaluate the association between preoperative CFS scores and outcomes following emergency laparotomy in a dense, rural, and healthcare-deprived region of the UK inhabited by a multi-comorbid population.MethodsWe retrospectively reviewed regional National Emergency Laparotomy Audit (NELA) data across United Lincolnshire Hospitals NHS trust to identify all patients aged 65 years and above who underwent emergency laparotomy between December 2018 and March 2021. We also conducted a comprehensive multi-database literature search of Medline, Embase, and Cochrane to synthesise contemporaneous topical evidence.ResultsA total of 191 patients were assessed using the CFS before they underwent emergency laparotomy. Among 90 (47.1%) individuals categorised as vulnerable or frail (CFS score ≥4), there was no significant difference in age, gender, or length of stay related to the procedure compared with fit patients. However, vulnerable and frail patients were significantly more likely to die (84.8% vs. 39.2%, p<0.0001). Regression analysis identified a vulnerable or frail score to be a significant predictor of 30-day all-cause mortality (OR: 9.327; 95% CI: 3.101-28.054; p<0.0001). A total of six relevant papers were identified in the literature, all indicating a significant association between mortality as well as prolonged length and stay with clinical vulnerability and frailty.ConclusionsThe CFS is a practical and effective tool for assessing preoperative vulnerability and frailty among patients undergoing emergency laparotomy and can be used to predict mortality and morbidity after surgery.

Predictors of all-cause mortality among patients hospitalized with influenza, respiratory syncytial virus, or SARS-CoV-2.

BackgroundShared and divergent predictors of clinical severity across respiratory viruses may support clinical and community responses in the context of a novel respiratory pathogen.MethodsWe conducted a retrospective cohort study to identify predictors of 30‐day all‐cause mortality following hospitalization with influenza (N = 45,749; 2010‐09 to 2019‐05), respiratory syncytial virus (RSV; N = 24 345; 2010‐09 to 2019‐04), or severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2; N = 8988; 2020‐03 to 2020‐12; pre‐vaccine) using population‐based health administrative data from Ontario, Canada. Multivariable modified Poisson regression was used to assess associations between potential predictors and mortality. We compared the direction, magnitude, and confidence intervals of risk ratios to identify shared and divergent predictors of mortality.ResultsA total of 3186 (7.0%), 697 (2.9%), and 1880 (20.9%) patients died within 30 days of hospital admission with influenza, RSV, and SARS‐CoV‐2, respectively. Shared predictors of increased mortality included older age, male sex, residence in a long‐term care home, and chronic kidney disease. Positive associations between age and mortality were largest for patients with SARS‐CoV‐2. Few comorbidities were associated with mortality among patients with SARS‐CoV‐2 as compared with those with influenza or RSV.ConclusionsOur findings may help identify patients at greatest risk of illness secondary to a respiratory virus, anticipate hospital resource needs, and prioritize local prevention and therapeutic strategies to communities with higher prevalence of risk factors.

Clinical profile and predictors of 30-day all-cause mortality of ST-elevation myocardial infarction (STEMI) patients receiving fibrinolytic therapy in an Asian population

BackgroundFibrinolysis remains the primary reperfusion strategy for ST-elevation myocardial infarction (STEMI) in many Asian countries. The outcomes and factors affecting mortality in STEMI fibrinolysis in the Asian population are lacking despite being widely used. ObjectivesThis study aimed to assess the clinical profile of patients and predictors affecting STEMI mortality in an Asian population. MethodsThis single-center retrospective study analyzed data from STEMI patients who received fibrinolytic therapy from 2016 to 2020 in a tertiary hospital. Logistic regression analysis was performed to identify the significant predictors of the 30-day all-cause mortality, the primary outcome. ResultsA total of 859 patients were included. Their mean age was 53.6 ±12.1 years and they were predominantly male (n=769, 89.4%). The majority of them had anterior involvement STEMI (n = 477, 55.5%) and presented with Killip ≥ II (n = 424, 49.4%). The 30-day all-cause mortality was 12.0% (n = 103). The final model found six predictors for 30-day mortality: age ≥75 (aOR 4.784, p < 0.001), female gender (aOR 2.869, p = 0.001), pre-existing hypertension (aOR 1.623, p = 0.046), anterior myocardial infarction (MI) (aOR 1.947, p < 0.001), Killip class (p < 0.001) and heart rate ≥100 at presentation (aOR 1.823, p = 0.016). Following fibrinolytic therapy, five predictors were found to affect 30-day mortality, i.e. failed fibrinolysis (aOR 2.094, p = 0.041), bleeding events, congestive heart failure (aOR 3.554, p = 0.046), ventricular fibrillation/ tachycardia (aOR 5.920, p < 0.001), and atrial fibrillation/ flutter (aOR 2.968, p = 0.016). ConclusionOur STEMI patients were younger and more ill at presentation. The risk predictors on 30-day all-cause mortality identified in our Asian population allow the clinicians to better triage and manage STEMI patients.

Arterial partial pressure of oxygen and diffusion function as prognostic biomarkers for acute pulmonary embolism

BackgroundRisk stratification for acute pulmonary embolism (PE) ignores the roles of respiratory function and gas exchange. We aimed to identify the role of arterial partial pressure of oxygen (PO2) and diffusion function as prognostic biomarkers. MethodsWe collected the data from hospitalised patients with acute PE. We used Spearman's correlation coefficient and Cox regression analysis to explore the clinical and prognostic values of PO2 and predicted percentage diffusing lung capacity for carbon monoxide (DLCO%pred) to predict the 30-day mortality. ResultsWe included 309 patients (mean age: 67.93 ± 13.31 years); 46.6% were men, and 12.62% were haemodynamically unstable. The 30-day all-cause mortality rates in the high-, intermediate high-, intermediate low-, and low-risk groups were 7.7%, 4.7%, 2.9%, and 0.0%, respectively (P < 0.05). PO2 (P = 0.012) and DLCO%pred (P = 0.036) were significantly different between the four risk groups. There were strong correlations between PO2, DLCO%pred, PO2*DLCO%pred, and other markers (P < 0.05), especially troponin I, N-terminal pro-brain natriuretic peptide, and systolic pulmonary artery pressure. PO2 and PO2*DLCO%pred were prognostic factors for death in haemodynamically stable patients (hazard ratio [HR] 0.618, 95% confidence interval [CI] 0.389–0.980, P = 0.041, and HR 0.501, 95% CI 0.26–0.96, P = 0.036, respectively). A lower PO2 (<8 kPa) was associated with a higher risk of mortality in all patients and in haemodynamically stable ones (HR 9.462, 95% CI 2.365–37.860, P = 0.001, and HR 6.597, 95% CI 1.102–39.495, P = 0.039, respectively). ConclusionsPO2, PO2*DLCO%pred, and PO2 < 8 kPa were predictors of 30-day all-cause mortality in all patients and haemodynamically stable ones. Trial registrationChiCTR2000030448.

Abstract 9418: Contrast Volume to Estimated Glomerular Filtration Rate Ratio as a Predictor for 30-Day All-Cause Mortality After Transcatheter Aortic Valve Implantation

Introduction: Contrast-induced acute kidney injury (AKI) has been proven to be associated with early mortality and adverse events. However, in the setting of transcatheter aortic valve implantation (TAVI), previous literature has failed to establish a correlation between the absolute volume of contrast media administered and mortality. Objective: We aimed to investigate the impact of contrast volume administered normalised to estimated glomerular filtration rate ratio (V/eGFR) on 30-day all-cause mortality in TAVI patients. Secondary outcomes were AKI and new renal replacement therapy (RRT). Methods: We retrospectively analysed a cohort of 1150 patients who underwent TAVI at our unit between 2015-2018. Results: Follow-up was complete for all patients. There were 23 deaths within the follow-up period. Receiver operating curve (ROC) analysis showed fair discrimination for 30-day all-cause mortality at a V/eGFR ratio of 3.6 (C-statistic 0.68). 69.7% (n=801) of patients had a V/eGFR of &lt;3.6 and 30.3% (n=349) had a V/eGFR of ≥3.6. In multivariate Cox proportional hazards analysis, V/eGFR as a cut point ≥3.6 was the strongest predictor of 30-day all-cause mortality (hazards ratio 4.35, 95% confidence interval [1.74-10.89], p=0.002). Other independent predictors were procedural urgency (3.40 [1.46-7.92]) and being under general anaesthesia (4.23 [1.62-11.08]). In Kaplan-Meier analysis, patients with V/eGFR ≥3.6 had a significantly greater 30-day mortality than those &lt;3.6 (log rank test p&lt;0.0001). A similar V/eGFR cut point of 3.6 was found to be an excellent predictor for new RRT (C-statistic 0.82), and 3.3 for AKI (C-statistic 0.60). Conclusions: In conclusion, a V/eGFR ≥3.6 after TAVI was found to be a strong predictor of 30-day mortality. The maximum contrast volume which can be safely administered in each patient without significantly increasing the risk of mortality can be calculated using this ratio. Future studies are indicated to validate our findings.

Management and 30-Day Mortality of Acute Coronary Syndrome in a Resource-Limited Setting: Insight From Ethiopia. A Prospective Cohort Study.

Background: Despite the fact that the burden, risk factors, and clinical characteristics of acute coronary syndrome (ACS) have been studied widely in developed countries, limited data are available from sub-Saharan Africa. Therefore, this study aimed at evaluating the clinical characteristics, treatment, and 30-day mortality of patients with ACS admitted to tertiary hospitals in Ethiopia.Methods: A total of 181 ACS patients admitted to tertiary care hospitals in Ethiopia were enrolled from March 15 to November 15, 2018. The clinical characteristics, management, and 30-day mortality were evaluated by ACS subtype. The Cox proportional hazards model was used to determine the predictors of 30-day all-cause mortality. A p-value < 0.05 was considered statistically significant.Results: The majority (61%) of ACS patients were admitted with ST-segment elevation myocardial infarction (STEMI). The mean age was 56 years, with male predominance (62.4%). More than two-thirds (67.4%) of patients presented to hospital after 12 h of symptom onset. Dyslipidemia (48%) and hypertension (44%) were the most common risk factors identified. In-hospital dual antiplatelet and statin use was high (>90%), followed by beta-blockers (81%) and angiotensin-converting enzyme inhibitors (ACEIs; 72%). Late reperfusion with percutaneous coronary intervention (PCI) was done for only 13 (7.2%), and none of the patients received early reperfusion therapy. The 30-day all-cause mortality rate was 25.4%. On multivariate Cox proportional hazards model analysis, older age [hazard ratio (HR) = 1.03, 95% CI = 1.003–1.057], systolic blood pressure (HR = 0.99, 95% CI = 0.975–1.000), serum creatinine (HR = 1.32, 95% CI = 1.056–1.643), Killip class > II (HR = 4.62, 95% CI = 2.502–8.523), ejection fraction <40% (HR = 2.75, 95% CI = 1.463–5.162), and STEMI (HR = 2.72, 95% CI = 1.006–4.261) were independent predictors of 30-day mortality.Conclusions: The 30-day all-cause mortality rate was unacceptably high, which implies an urgent need to establish a nationwide program to reduce pre-hospital delay, promoting the use of guideline-directed medications, and increasing access to reperfusion therapy.

Expert consensus on the use of human serum albumin in critically ill patients.

Expert consensus on the use of human serum albumin in critically ill patients.

Feasibility of Coronary Access in Patients With Acute Coronary Syndrome and Previous TAVR.

The aim of this study was to characterize the feasibility of coronary angiography (CA) and percutaneous coronary intervention (PCI) in acute settings among patients who have undergone transcatheter aortic valve replacement (TAVR). Impaired coronary access after TAVR may be challenging and particularly in acute settings could have deleterious consequences. In this international registry, data from patients with prior TAVR requiring urgent or emergent CA were retrospectively collected. A total of 449 patients from 25 sites with acute coronary syndromes (89.1%) and other acute cardiovascular situations (10.9%) were included. Success rates were high for CA of the right coronary artery (98.3%) and left coronary artery (99.3%) and were higher among patients with short stent-frame prostheses (SFPs) than in those with long SFPs for CA of the right coronary artery (99.6% vs 95.9%; P=0.005) but not for CA of the left coronary artery (99.7% vs 98.7%; P=0.24). PCI of native coronary arteries was successful in 91.4% of cases and independent of valve type (short SFP 90.4% vs long SFP 93.4%; P=0.44). Guide engagement failed in 6 patients, of whom 3 underwent emergent coronary artery bypass grafting and another 3 died in the hospital. Among patients requiring revascularization of native vessels, independent predictors of 30-day all-cause mortality were prior diabetes, cardiogenic shock, and failed PCI but not valve type or success of coronary engagement. CA or PCI after TAVR in acute settings is usually successful, but selective coronary engagement may be more challenging in the presence of long SFPs. Among patients requiring PCI, prior diabetes, cardiogenic shock, and failed PCI were predictors of early mortality.

Incidence and outcomes of perioperative myocardial infarction/injury diagnosed by high-sensitivity cardiac troponin I

Background Perioperative myocardial infarction/injury (PMI) diagnosed by high-sensitivity troponin (hs-cTn) T is frequent and a prognostically important complication of non-cardiac surgery. We aimed to evaluate the incidence and outcome of PMI diagnosed using hs-cTnI, and compare it to PMI diagnosed using hs-cTnT.MethodsWe prospectively included 2455 patients at high cardiovascular risk undergoing 3111 non-cardiac surgeries, for whom hs-cTnI and hs-cTnT concentrations were measured before surgery and on postoperative days 1 and 2. PMI was defined as a composite of perioperative myocardial infarction (PMIInfarct) and perioperative myocardial injury (PMIInjury), according to the Fourth Universal Definition of Myocardial Infarction. All-cause mortality was the primary endpoint.ResultsUsing hs-cTnI, the incidence of overall PMI was 9% (95% confidence interval [CI] 8–10%), including PMIInfarct 2.6% (95% CI 2.0–3.2) and PMIInjury 6.1% (95% CI 5.3–6.9%), which was lower versus using hs-cTnT: overall PMI 15% (95% CI 14–16%), PMIInfarct 3.7% (95% CI 3.0–4.4) and PMIInjury 11.3% (95% CI 10.2–12.4%). All-cause mortality occurred in 52 (2%) patients within 30 days and 217 (9%) within 1 year. Using hs-cTnI, both PMIInfarct and PMIInjury were independent predictors of 30-day all-cause mortality (adjusted hazard ratio [aHR] 2.5 [95% CI 1.1–6.0], and aHR 2.8 [95% CI 1.4–5.5], respectively) and, 1-year all-cause mortality (aHR 2.0 [95% CI 1.2–3.3], and aHR 1.8 [95% CI 1.2–2.7], respectively). Overall, the prognostic impact of PMI diagnosed by hs-cTnI was comparable to the prognostic impact of PMI using hs-cTnT.ConclusionsUsing hs-cTnI, PMI is less common versus using hs-cTnT. Using hs-cTnI, both PMIInfarct and PMIInjury remain independent predictors of 30-day and 1-year mortality.Graphic abstract

Predicting mortality in cardiogenic shock secondary to ACS requiring short-term mechanical circulatory support: The ACS-MCS score.

To identify predictors of 30-day all-cause mortality for patients with cardiogenic shock secondary to acute coronary syndrome (ACS-CS) who require short-term mechanical circulatory support (ST-MCS). ACS-CS mortality is high. ST-MCS is an attractive treatment option for hemodynamic support and stabilization of deteriorating patients. Mortality prediction modeling for ACS-CS patients requiring ST-MCS has not been well-defined. The Utah Cardiac Recovery (UCAR) Shock database was used to identify patients admitted with ACS-CS requiring ST-MCS devices between May 2008 and August 2018. Pre-ST-MCS clinical, laboratory, echocardiographic, and angiographic data were collected. The primary endpoint was 30-day all-cause mortality. A weighted score comprising of pre-ST-MCS variables independently associated with 30-day all-cause mortality was derived and internally validated. A total of 159 patients (mean age, 61 years; 78% male) were included. Thirty-day all-cause mortality was 49%. Multivariable analysis resulted in four independent predictors of 30-day all-cause mortality: age, lactate, SCAI CS classification, and acute kidney injury. The model had good calibration and discrimination (area under the receiver operating characteristics curve 0.80). A predictive score (ranging 0-4) comprised of age ≥ 60 years, pre-ST-MCS lactate ≥2.5 mmol/L, AKI at time of ST-MCS implementation, and SCAI CS stage E effectively risk stratified our patient population. The ACS-MCS score is a simple and practical predictive score to risk-stratify CS secondary to ACS patients based on their mortality risk. Effective mortality risk assessment for ACS-CS patients could have implications on patient selection for available therapeutic strategy options.

Short and long-term clinical impact of transcatheter aortic valve implantation in Portugal according to different access routes: Data from the Portuguese National Registry of TAVI

IntroductionThe Portuguese National Registry of Transcatheter Aortic Valve Implantation records prospectively the characteristics and outcomes of transcatheter aortic valve implantation (TAVI) procedures in Portugal. ObjectivesTo assess the 30-day and one-year outcomes of TAVI procedures in Portugal. MethodsWe compared TAVI results according to the principal access used (transfemoral (TF) vs. non-transfemoral (non-TF)). Cumulative survival curves according to access route, other procedural and clinical variables were obtained. The Valve Academic Research Consortium-2 (VARC-2) composite endpoint of early (30-days) safety was assessed. VARC-2 predictors of 30-days and 1-year all-cause mortality were identified. ResultsBetween January 2007 and December 2018, 2346 consecutive patients underwent TAVI (2242 native, 104 valve-in-valve; mean age 81±7 years, 53.2% female, EuroSCORE-II - EuroS-II, 4.3%). Device success was 90.1% and numerically lower for non-TF (87.0%). Thirty-day all-cause mortality was 4.8%, with the TF route rendering a lower mortality rate (4.3% vs. 10.1%, p=0.001) and higher safety endpoint (86.4% vs. 72.6%, p<0.001). The one-year all-cause mortality rate was 11.4%, and was significantly lower for TF patients (10.5% vs. 19.4%, p<0.002). After multivariate analysis, peripheral artery disease, previous percutaneous coronary intervention, left ventricular dysfunction and NYHA class III-IV were independent predictors of 30-day all-cause mortality. At one-year follow-up, NYHA class III-IV, non-TF route and occurrence of life-threatening bleeding predicted mortality. Kaplan-Meier survival analysis of the first year of follow-up shows decreased survival for patients with an EuroS-II>5% (p<0.001) and who underwent non-TF TAVI (p<0.001). ConclusionData from our national real-world registry showed that TAVI was safe and effective. The use of a non-transfemoral approach demonstrated safety in the short term. Long-term prognosis was, however, adversely associated with this route, with comorbidities and the baseline clinical status.