Predictor Of All-cause Death Research Articles

P3780Clinical characteristics and outcomes in Japanese atrial fibrillation patients with valvular heart disease: the Fushimi AF registry

Abstract Background Previous studies have suggested that valvular atrial fibrillation (VAF), defined as atrial fibrillation (AF) patients with prosthetic valve or rheumatic mitral stenosis, increased the risks of thromboembolism. However, clinical characteristics and outcomes of VAF and non-valvular AF (NVAF) patients with other valvular heart disease (VHD) has not been fully described. Method The Fushimi AF Registry was designed to enroll all of the AF patients. In the entire cohort (4,454 patients), follow-up data including echocardiography data were available for 3,566 patients. We compared clinical characteristics and outcomes between 131 VAF patients (3.7%), 583 NVAF with VHD (NVAF-VHD: 16.3%) and 2,852 without VHD (Non-VHD: 80.0%). Result Compared with Non-VHD, patients in VAF and NVAF-VHD were older (VAF vs. NVAF-VHD vs. Non-VHD: 74.3 vs. 76.9 vs. 72.9 years, respectively; p≤0.0001), more often female (56.5% vs. 51.1% vs. 36.9%, p≤0.0001), less in body weight (54.3 vs. 54.7 vs. 60.6 kg, p≤0.0001), more persistent/permanent type (64.1% vs. 65.4% vs. 45.8%, p≤0.0001), more likely to have heart failure (61.8% vs. 53.2% vs. 23.3%, p≤0.0001), had higher CHADS2 score (2.18 vs. 2.49 vs. 1.96, p≤0.0001) and CHA2DS2-VASc score (3.71 vs. 4.02 vs. 3.26, p≤0.0001), and received oral anticoagulant prescription more frequently (78.6% vs. 63.0% vs. 55.6%, p0.0001). NVAF-VHD was more likely to have previous stroke/systemic embolism (SE) than VHD or Non-VHD (14.5% vs. 23.5% vs. 19.6%, p=0.03). VAF or NVAF-VHD had larger left atrium than Non-VHD (50.5 vs. 47.2 vs. 42.4 mm, p<0.0001). Heart rate, diabetes mellitus and previous bleeding were comparable between the groups. During the median follow-up of 1,471 days, the incidence rate of stroke/SE was not significantly different between three groups, however, NVAF-VHD showed modestly higher rate than Non-VHD (1.67 vs. 1.96 vs. 1.28 per 100 person-years, respectively, log rank p=0.054) (Figure). The incidence rates of all-cause death (4.62 vs. 5.74 vs. 3.21, p≤0.0001), cardiac death (1.07 vs. 1.01 vs. 0.44, p=0.0003), and those of hospitalization for heart failure (3.29 vs. 4.41 vs. 1.80, p≤0.0001) were higher in NVAF-VHD and VAF, than Non-VHD. After adjustment by relevant factors including the components of CHA2DS2-VASc score and oral anticoagulant use, NVAF-VHD, but not VAF, was an independent predictor for hospitalization for heart failure. Neither VAF nor NVAF-VHD was predictors for all-cause death, cardiac death or stroke/SE. Figure 1. Incidence of stroke/SE Conclusion As compared with Non-VHD, the risk of stroke/SE in VAF and NVAF-VHD was not particularly high; although NVAF-VHD had modestly higher rate than Non-VHD. VAF and NVAF-VHD were associated with higher incidence rates of all-cause death, cardiac death and hospitalization for heart failure. NVAF-VHD was an independent predictor for hospitalization for heart failure in multivariate analysis. Acknowledgement/Funding Pfizer, Bristol-Myers Squibb, Boehringer Ingelheim, Bayer Healthcare and Daiichi Sankyo

P6148Visually assessed coronary and cardiac calcium outperforms perfusion data during scintigraphy in the prediction of adverse outcomes

Abstract Background The presence and amount of calcium in the coronary arteries, but also in the heart valves and aorta, has been clearly associated with cardiovascular and all-cause mortality and this information might be prognostically useful during SPECT-CT examinations, where CT images are co-registered for attenuation correction of myocardial perfusion, but then discarded. Objectives This study sought to determine whether the assessment of calcifications of the coronary arteries, cardiac valves and thoracic aorta in the computed tomography images co-registered for attenuation correction during stress-scintigraphy (SPECT-CT) is associated with long-term mortality and cardiac events on top of other available data. Methods Baseline data were collected prospectively on 353 consecutive patients, referred for suspected coronary artery disease (CAD) with no previously known CAD who underwent stress SPECT-CT between Sept 2010 and Oct 2012. Retrospective analysis was performed on follow-up data for outcomes. Results Patients (mean age 72 years. 58% males) had a mean follow-up of 6.4 years, during which 48 died (15 from cardiovascular causes) and 10 had a non-fatal myocardial infarction (MI). Reversible myocardial perfusion defects were detected in 55 patients (15.6%), 39 of whom (11%) had more than mild defects. The presence of an overall visual calcium score >1 in the attenuation correction images was the most strong univariable (hazard ratio 8.99, p<0.0001) and multivariable (hazard ratio 4.76, p<0.0001) predictor of all-cause death or non-fatal MI on top of age, gender, irreversible myocardial perfusion defects and revascularization after the test. Multivariable models Clinical + SPECT + Overall Calcium Ischemic Cardiac Events HR CI (95%) p-value χ2 Age 1.058 1.0234 to 1.093 0.0008 Male gender 1.63 0.88 to 3.024 0.1183 Fixed perfusion defect 3.924 1.63 to 9.426 0.0022 Overall Calcium >1 4.765 2.2 to 10.32 <0.0001 71.69 Kaplan-Meier Conclusions Visual assessment of coronary or overall coronary, cardiac and aortic calcium in the CT images used for attenuation correction during SPECT-CT is feasible, reproducible and strongly associated with hard cardiac events and all-cause death, beyond clinical variables and myocardial perfusion data. This incredibly easy visual calcium assessment does not require additional costs or radiation and may heavily impact on better risk-assessment of patients with suspected CAD undergoing SPECT-CT.

P303Prognostic value of diastolic wall strain in patients with asymptomatic severe aortic stenosis

Abstract Background Diastolic wall strain (DWS) has been reported to be associated with left ventricular (LV) stiffness and worse clinical outcomes. We sought to assess the utility of this new index for prediction of prognosis in asymptomatic patients with severe aortic stenosis (AS). Methods Asymptomatic severe AS patients [peak flow velocity (PFV) ≥4.0m/s, mean pressure gradient (mPG) ≥40mmHg, aortic valve area (AVA) ≤1.0cm2, or indexed AVA ≤0.6cm2/m2)] diagnosed between July 2007 and April 2016 were included in this study. Patients with significant mitral valve disease, posterior wall motion abnormality, prior cardiac surgery, hypertrophic cardiomyopathy, and LV ejection fraction <50% were excluded. DWS was calculated with a validated formula [DWS = (posterior wall thickness at end-systole − posterior wall thickness at end-diastole)/posterior wall thickness at end-systole]. All study patients were prospectively followed up to last visit or death until November 2017, and predictive value of all-cause death was assessed using Cox-proportional hazards modeling. Patients who underwent aortic valve replacement (AVR) during the study period were censored on the date of surgery. Results A total of 184 asymptomatic severe AS, 138 (age 76±9year-old, men 41%, PFV 3.9±1.0m/s, mPG 38±19mmHg, AVA 0.83±0.18cm2, indexed AVA 0.56±0.13cm2/m2) met all study criteria. Of whom, 43 (31%) underwent AVR and 28 (20%) died during a mean follow-up of 25±28months. In a multivariable model after adjusting for clinical and echocardiographic variables, advancing age (per10yrs; HR=2.19, 95% CI=1.19–4.03, P<0.05), history of hemodialysis (HR=4.31, 95% CI=1.30–14.35, P<0.05), and low-DWS (DWS <0.30) (HR=2.83, 95% CI=1.25–6.40, P<0.05) were independent predictors of all-cause death. In the Kaplan-Meier estimates of cumulative survival stratified by DWS status were shown (Figure). The Kaplan-Meier estimates of survival Conclusion Low-DWS provides prognostic information in patients with asymptomatic severe AS.

P6436Soluble urokinase plasminogen activator receptor and functionally relevant coronary artery disease: a prospective cohort study

Abstract Background The urokinase system is pivotal in the pathogenesis of atherosclerosis. Therefore, soluble urokinase plasminogen activator receptor (suPAR) concentrations may help in the detection of functionally relevant coronary artery disease (fCAD). Purpose To evaluate suPAR as diagnostic marker for fCAD. Methods Among consecutive patients with symptoms suggestive of fCAD, fCAD was adjudicated blinded to suPAR concentrations in two domains: first, diagnosis of fCAD according to myocardial perfusion single photon emission tomography (MPI-SPECT) and coronary angiography; second, fCAD according to cardiovascular death, non-fatal acute myocardial infarction (AMI) and all-cause death during 2-year follow-up. Results Among 968 patients, symptoms were adjudicated to be causally related to fCAD in 26% (255/968). SuPAR concentrations were higher in patients with fCAD as compared to those without (3.45 ng/mL versus 3.20 ng/mL, p=0.007), but overall had only low diagnostic accuracy (area under the curve [AUC]: 0.56, 95% CI 0.52–0.60) and were not independent predictors of fCAD after multivariable adjustment. Circulating suPAR concentrations were modestly correlated with high-sensitivity cardiac troponin (hs-cTn) T (Spearman's rho 0.393, p<0.001), NT-proBNP (Spearman's rho 0.327, p<0.001) and age (Spearman's rho 0.364, p<0.001), but only weakly correlated with the extent of coronary atherosclerosis as quantified by perfusion defects (Spearman's rho 0.123, p<0.001). Prognostically, suPAR concentrations had moderate-to-high accuracy in the prediction of cardiovascular death (AUC 0.72, 95% CI 0.62–0.81) and all-cause death (AUC 0.72, 95% CI 0.65–0.79) at 2-years, and remained a significant predictor for all-cause death after multivariable adjustment (p=0.001). SuPAR concentrations did not predict non-fatal AMI. Conclusions SuPAR is an independent predictor of death, but not helpful in the detection of fCAD. Acknowledgement/Funding European Union, Swiss National Science Foundation, the Swiss Heart Foundation, the Cardiovascular Research Foundation Basel, the University of Basel,

P841Derivation and validation of novel score system for predicting all-cause death and myocardial infarction in coronary artery ectasia

Abstract Background Coronary artery ectasia (CAE) bears high risk of death and myocardial infarction. Risk stratification in CAE patients is crucial for their management, but there were no risk score systems intended for risk evaluation of CAE patients so far. Methods In a retrospective cohort of 595 patients with CAE, we collected the baseline characteristics (clinical history, biomarkers and quantitative coronary angiography variables). Follow-up were conducted and the end-point event was the composite of all-cause death and non-fatal myocardial infarction. The candidate predictors of end-point event were analyzed using Cox proportional hazards regression models to derive a risk score in the form of nomogram. The predictive performance and discriminative ability of the novel nomogram were determined by concordance index (C-index) and calibration curve, that were validated internally. Risk stratification by nomogram-predicted risk score was further evaluated. Results During a median follow-up time of 62.3 months, 26 all-cause deaths and 37 non-fatal myocardial infarctions were identified. The final risk-prediction model named ABCD-CAE score included four items: age (A), Brain natriuretic peptide (B), high sensitivity C-reactive protein (C) and maximum Dilated area of ectatic lesions (D). The nomogram yielded a C-index for end-point event of 0.72 (95% confidence interval, 0.64 - 0.79). The calibration curve demonstrated that there is good agreement between prediction by nomogram and actual observation of end-point events. Compared with the low-risk group (score ≤100), the risk of composite events was significantly increased in the intermediate-risk group (score: 100–130) and high-risk group (score >130) [hazard ratio (95% confidence interval): 2.23 (1.23–4.06), P=0.008 and 7.02 (3.81–12.97), P<0.001 respectively]. ABCD-CAE nomogram for risk prediction Conclusions The ABCD-CAE score is a simple four-item risk score, that provides a clinically useful tool for the risk prediction of all-cause death and myocardial infarction in patients with CAE. This user-friendly tool might support clinical decision making for the management of CAE.

P2607Quick nutritional assessment and prognosis in outpatients with heart failure with mid-range ejection fraction

Abstract Background Nutritional status is an important prognostic factor in patients with heart failure (HF) beyond body mass index, although its prognostic value in patients with mid-range left ventricular ejection fraction (HFmrEF) is not completely elucidated. In a pilot study we observed that the Mini Nutritional Assessment Short Form (MNA-SF) was the best approach for the screening of nutritional status in HF outpatients over others screening tools. Purpose To assess the prognostic role of malnutrition or risk of malnutrition in HFmrEF outpatients after the implementation of the MNA-SF screening tool in a routine way in a multidisciplinary HF. Methods The MNA-SF screening tool was administered during the global nurse evaluation of patients. The scoring ranges from 0 to 14, being 0 to7 as malnutrition status, 8 to 11 as at risk of malnutrition and 12 to 14 as normal nutritional status. For the present study those patients with malnutrition and at risk of malnutrition were merged and considered abnormal nutritional status. All-cause death was the primary end-point. Univariate and multivariate (backward conditional stepwise) Cox regression analyses were performed. Results Since October 2016 to November 2017, 153 HFmrEF patients were studied (mean age 68.8±11.7 years, 72.5% men, body mass index 28.4±4.4, LVEF 44% ± 3, NYHA class I 5.9%, II 86.3%, and III 7.8%). According to the MNA-SF 25 patients were (16.3%) fulfilled criteria of malnutrition (4) or where at risk of malnutrition (21). During a mean follow-up of 17.4±6.1 months, 23 patients died (15%). In the univariate analysis, nutritional abnormal status was significantly associated with all-cause death (HR 2.93 [1.23–7], p=0.02). In the multivariate analysis which included age, sex, NYHA functional class, body mass index, ischemic aetiology of HF and years of duration of HF, abnormal nutritional status remained significantly associated with all-cause mortality (HR 3.64 [1.39–9.54], p=0.009), together with NYHA functional class (HR 7.93 [2.69–23.4], p<0.001) and years of HF duration (HR 1.10 [1.04–1.16], p=0.001). Conclusions Nutritional status assessed with the screening MNA-SF was an independent predictor of all-cause death in ambulatory patients with HFmrEF – beyond BMI – together with NYHA functional class and HF duration.

P5314Albumin is a prognostic marker of long-term outcomes in patients with triple-vessel coronary artery Disease: a large data from China

Abstract Background Hypoalbuminemia was reported to be associated with poor prognosis in severe diseases. Triple-vessel coronary artery disease (TVD) has high risk of death. We aimed to evaluate the predictive value of hypoalbuminemia in TVD patients. Methods A total of 8,943 consecutive TVD patients were enrolled from April 2004 to February 2011. The primary endpoint was all-cause death and the secondary endpoints were major adverse cardiovascular and cerebrovascular events (MACCE; a composite of all-cause death, myocardial infarction or stroke). Patients were divided into two groups according to normal serum albumin level (<4.0 g/dL and ≥4.0 g/dL). Results During the median of follow-up 7.5 years, 1365 deaths and 2354 MACCE occurred. Multivariate Cox regression indicated that hypoalbuminaemia (<4.0 g/dL) was an independent predictor of all-cause death (HR 1.30, 95% CI 1.14–1.50, P<0.001) and MACCE (HR 1.19, 95% CI 1.07–1.32, P<0.001). Adjustment of the all-cause death risk estimated by albumin improved the predictive value of SYNTAX score (AUC from 0.585 to 0.602, P=0.002; IDI=0.005, P<0.001; NRI=0.205, P<0.001). For SYNTAX II score, improvement was shown for NRI and IDI but not for AUC (SYNTAX II for PCI: IDI=0.003, P<0.001; NRI=0.205, P<0.001; AUC from 0.711 to 0.713, P=0.257; SYNTAX II for CABG: IDI=0.002, P<0.001; NRI=0.205, P<0.001; AUC from 0.696 to 0.698, P=0.120). Predictive value for all-cause death using the AUC, NRI and IDI AUC (95% CI) P value NRI (95% CI) P value IDI (95% CI) P value SYNTAX 0.585 (0.568–0.602) Ref. Ref. – Ref. – SYNTAX + albumin 0.602 (0.586–0.619) 0.002 0.205 (0.145–0.264) <0.001 0.005 (0.004–0.007) <0.001 SYNTAX II (for PCI) 0.711 (0.696–0.726) Ref. Ref. – Ref. – SYNTAX II (for PCI) + albumin 0.713 (0.698–0.728) 0.257 0.205 (0.145–0.264) <0.001 0.003 (0.001–0.004) <0.001 SYNTAX II (for CABG) 0.696 (0.680–0.711) Ref. Ref. – Ref. – SYNTAX II (for CABG) + albumin 0.698 (0.683–0.714) 0.120 0.205 (0.145–0.264) <0.001 0.002 (0.001–0.004) <0.001 Multi-factor adjusted KM analysis in TVD Conclusions For TVD patients, hypoalbuminaemia was a strong independent prognostic factor for long-term outcomes of death and MACCE. Albumin improved the prediction of death with the SYNTAX score and the SYNTAX II score. Acknowledgement/Funding CAMS Innovation Fund for Medical Sciences (2016-I2M-1-002), Beijing Natural Science Foundation (7181008)

P1885Cha2ds-2vasc score lacks of ability to predict mortality in patients attending the emergency department with atrial fibrillation in the presence of troponin i

Abstract Background CHA2DS2-VASc score has been used as a surrogate marker for predicting outcomes beyond thromboembolic risk in patients with atrial fibrillation (AF). Likewise, cardiac troponin I (cTnI) is a predictor of mortality in AF. Purpose This study aimed to investigate the association of cTnI and CHA2DS2-VASc score with long-term prognosis in patients admitted to the emergency department with AF. Methods A retrospective cohort study conducted between January 2012 and December 2013, enrolling patients admitted to the emergency department with AF and having documented cTnI measurements. CHA2DS2-VASc score was estimated. Primary endpoint was 5-year all-cause mortality, readmission for heart failure (HF), readmission for myocardial infarction (MI) and the composite end point of major adverse cardiac events defined as death, readmission for HF or readmission for MI (MACE). Results A total of 578 patients with AF were studied, of whom 252 patients had elevated levels of cTnI (43.6%) and 334 patients had CHA2DS2-VASc score >3 (57.8%). Patients with elevated cTnI tended to be oldercompared with those who did not have cTnI elevation and were more frequently comorbid and of higher ischemic risk, including hypertension, prior MI, prior HF, chronic renal failure and peripheral artery disease. The overall median CHA2DS2-VASc score was higher in those with cTnI elevation compared to those patients elevated cTnI levels (4.2 vs 3.3 points, p<0.001). Main diagnoses at hospital discharge were tachyarrhythmia 30.3%, followed by heart failure 17.7%, respiratory infections 9.5% and acute coronary syndrome 7.3%. At 5-year follow-up, all-cause death was significantly higher for patients with cTnI elevation compared with those who did not have cTnI elevation (56.4% vs. 27%; logrank test p<0.001). Specifically, for readmissions for HF and readmissions for MI there were no differences in between patients with or without cTnI elevation. In addition, MACE was reached in 165 patients (65.5%) with cTnI elevation, compare to 126 patients (38.7%) without cTnI elevation (p<0.001). On multivariable Cox regression analysis, cTnI elevation was an independent predictor of all-cause death (hazard ratio, 1.67, 95% confidence interval [CI]: 1.24–2.26, p=0.001) and of MACE (hazard ratio 1.47, 95% confidence interval 1.15–1.88; P=0.002), but it did not reach statistical significance for readmissions for MI and readmissions for HF. CHA2DS2-VASc score was a predictor on univariate Cox regression analysis for each endpoint, but it did not reach significance on multivariable Cox regression analysis for any endpoint. Conclusions cTnI is independently associated with long-term all-cause mortality in patients attending the emergency department with AF. cTnI compared to CHA2DS2-VASc score is thus a biomarker with predictive capacity for mortality in late follow-up, conferring utility in the risk stratification of patients with atrial fibrillation.

P1653Admission high-sensitivity troponin T and NT-proBNP for outcome prediction in acute heart failure

Abstract Background High-sensitivity troponin T (hs-TnT) reflects the severity of ongoing myocardial damage and holds independent prognostic significance in chronic heart failure (HF). In acute HF (AHF), its additive prognostic value over natriuretic peptides is unclear. Methods Individual data of 1571 AHF patients with admission hs-TnT were collected from 3 cohorts. Results Patients were aged 78±10 years, and 51% were men. Median hs-TnT and N-terminal fraction of pro-B-type natriuretic peptide (NT-proBNP) concentrations were 43 ng/L (interquartile interval 26–69) and 5660 (2693–12466), respectively. Patients experiencing in-hospital death (n=187, 13%) had significantly higher hs-TnT and NT-proBNP on admission (both p<0.001). The risk of in-hospital death increased by 45% per each doubling of hs-TnT (HR 1.45, 95% confidence interval - CI 1.31–1.59, p<0.001), and by 32% per each doubling of NT-proBNP (HR 1.32, 95% CI 1.17–1.50, p<0.001). Patients with hs-TnT ≥43 ng/L and NT-proBNP ≥5660 ng/L had a 2.7-fold higher risk of in-hospital death (relative risk - RR 2.7, 95% CI 1.7–4.5). Among the 1262 patients discharged, 1024 deaths occurred over a median 11-month follow-up (4–22). In a model including NT-proBNP, hs-TnT ≥43 ng/L was a strong, independent predictor of all-cause death at 6, 12 and 24 months, and the composite of cardiovascular death or HF hospitalization at 6 and 24 months. hs-TnT ≥43 ng/L also improved risk reclassification. Conclusions The risk of in-hospital death is almost 3 folds higher with admission hs-TnT ≥43 ng/L and NT-proBNP ≥5660 ng/L, and hs-TnT ≥43 ng/L holds strong independent prognostic significance for post-discharge outcome.

192 Interleukin-6 and C-Reactive Protein Predict all Cause Death and Poor Functional Outcome after Non-Severe Stroke and Transient Ischaemic Attack

Abstract Background Inflammation plays a role in the development of ischaemic cerebrovascular events. High sensitivity C-reactive protein (CRP) is known to predict recurrent events. Little data exists for more upstream serum markers of inflammation. Methods BIO-STROKE and BIO-TIA were multicentre prospective biomarker and imaging studies of patients with non-severe stroke, TIA and controls. Exclusion criteria were malignancy, infection, recent trauma / surgery, recurrent stroke before phlebotomy/MRI. Serum biomarkers analysed included Interleukin (IL) – 6, CRP, IL-1, IL-8, IL10, IL12p70, IFN and TNF.Plasma CRP and IL-6 were measured by mass spectrometry. Additional biomarkers were measured using ELISA. Follow up was performed at 7, 28, 90 days and 1 year. Results 680 patients (439 strokes, 241 TIAs) and 68 controls were included in the analysis. The median age was 70 for cases. Carotid stenosis was present in 23.6% of cases. Median CRP was 3.75mg/L, 2.36mg/l and 1.87mg/L in the stroke, TIA and control groups (p=<0.001). Median IL-6 was 5.86pg/ml (stroke), 4.25pg/ml (TIA), 3.06pg/ml (control) (p=<0.001). On multivariate cox regression analysis baseline IL6 and CRP were independent predictors of all cause death at 1 year with a HR of 1.005 (95% CI 1.002-1.007, p<0.001).and 1.005(95% CI 1.002-1.007, p<0.001) per unit increase. Both IL6 and CRP were associated with vascular death at 1 year. In adjusted analyses, IL6 and CRP were associated with poor functional outcome at 1 year (OR of 1.02(CI 1.01 -1.03) and 1.02(CI 1.01-1.03) per unit increase, for IL6 and CRP respectively). On adjusted analysis, when IL6 was analysed as quartiles, there was a strong association with death at 1 year with an OR 1.87 (95% CI 1.19-2.93).CRP, analysed as quartiles, demonstrated an OR for death at 1 year of 1.64 (1.10-2.46). Conclusion IL-6 and CRP may be a useful prognostic factor for the prediction of outcome and death after stroke at 1 year follow up.

Pericardiectomy for constrictive pericarditis: a risk factor analysis for early and late failure.

Predictors of early and late failure of pericardiectomy for constrictive pericarditis (CP) have not been established. Early and late outcomes of a cumulative series of 81 (mean age 60years; mean EuroSCORE II, 3.3%) consecutive patients from three European cardiac surgery centers were reviewed. Predictors of a combined endpoint comprising in-hospital death or major complications (including multiple transfusion) were identified with binary logistic regression. Non-parametric estimates of survival were obtained with the Kaplan-Meier method. Predictors of poor late outcomes were established using Cox proportional hazard regression. There were 4 (4.9%) in-hospital deaths. Preoperative central venous pressure > 15mmHg (p = 0.005) and the use of cardiopulmonary bypass (p = 0.016) were independent predictors of complicated in-hospital course, which occurred in 29 (35.8%) patients. During follow-up (median, 5.4years), preoperative renal impairment was a predictor of all-cause death (p = 0.0041), cardiac death (p = 0.0008), as well as hospital readmission due to congestive heart failure (p = 0.0037); while partial pericardiectomy predicted all-cause death (p = 0.028) and concomitant cardiac operation predicted cardiac death (p = 0.026), postoperative central venous pressure < 10mmHg was associated with a low risk both of all-cause and cardiac death (p < 0.0001 for both). Ten-year adjusted survival free of all-cause death, cardiac death, and hospital readmission were 76.9%, 94.7%, and 90.6%, respectively. In high-risk patients with CP, performing pericardiectomy before severe constriction develops and avoiding cardiopulmonary bypass (when possible) could contribute to improving immediate outcomes post-surgery. Complete removal of cardiac constriction could enhance long-term outcomes.

Prognostic impact of chronic obstructive pulmonary disease on adverse prognosis in hospitalized heart failure patients with preserved ejection fraction – A report from the JASPER registry

BackgroundThe prognostic impact of chronic obstructive pulmonary disease (COPD) on heart failure (HF) with preserved ejection fraction (HFpEF) patients and its clinical characteristics have not yet been fully examined. MethodsThe Japanese Heart Failure Syndrome with Preserved Ejection Fraction (JASPER) registry is a nationwide, observational, prospective registration of consecutive Japanese hospitalized HFpEF patients with left ventricular ejection fraction (LVEF) of ≥50%. Among 535 patients enrolled in the registry, 10 lacking COPD data, and seven who died during the first hospitalization, were excluded. Finally, 518 patients were enrolled in this analysis. We divided these patients into two groups: the COPD group (n=40, 7.7%) and the non-COPD group (n=478, 92.3%). This analysis had two primary endpoints: (1) all-cause death and (2) all-cause death or rehospitalization for HF. ResultsThe COPD group showed a higher prevalence of male sex (70.0% vs. 48.1%, p=0.008), history of prior hospitalization for HF (63.2% vs. 35.1%, p=0.001), smoking history (71.8% vs. 43.3%, p=0.001), and a higher usage of loop diuretics (70.0% vs. 50.0%, p=0.015). In the follow-up period after discharge (median 733 days), there were 82 all-cause deaths and 127 rehospitalizations for HF. In the Kaplan–Meier analysis, the COPD group showed higher all-cause death and reached the composite endpoint more often than in the non-COPD group (all-cause death, log-rank 0.035; all-cause death or rehospitalization for HF, log-rank 0.025). In the Cox proportional hazard analysis, COPD was a predictor of all-cause death (hazard ratio 1.957, 95% confidence interval 1.037–3.694, p=0.038) and the composite endpoint (hazard ratio 1.694, 95% confidence interval 1.064–2.697, p=0.026). ConclusionsCOPD is associated with adverse prognosis in hospitalized patients with HFpEF.

Serum bilirubin improves the risk predictions of cardiovascular and total death in diabetic patients

BackgroundBilirubin is a potential endogenous inhibitor of atherosclerosis. We investigated the association of bilirubin and cardiovascular (CV) and all-cause mortality including potential improvements in bilirubin risk reclassification in asymptomatic diabetic patients. MethodsWe enrolled 2936 asymptomatic diabetic subjects. The serum bilirubin was measured, and future CV and all-cause death were the primary endpoints. ResultsThe follow-up period was 5.4 ± 3.0 y. There were 218 deaths including 95 cardiovascular deaths. The occurrence of CV death and all-cause death were negatively correlated with increasing serum bilirubin quintiles and actual bilirubin values. Serum bilirubin was negatively associated with incident cardiovascular death (hazard ratio: 0.26, 95% CI, 0.11–0.61, p = .01) and all-cause death (hazard ratio: 0.30, 95% CI, 0.17–0.51, p ≤.001). The addition of bilirubin for cardiovascular death increased the C-statistic from 0.713 (95% CI, 0.664–0.762) to 0.729 (95% CI, 0.681–0.776) (P = .008) and showed an integrated discrimination improvement (IDI) of 0.012 (P < .0171) with 8.57% improvement in net reclassification analysis (P = .0224). These results suggest additional predictive value is possible via total bilirubin levels for future CV deaths in diabetic patients. In terms of all-death, the addition of bilirubin significantly increased the C-statistic (from 0.769 to 0.78, P = .0064)—a 3.52% net reclassification improvement (P = .0307). It did not improve the IDI (p = .1505). ConclusionsHigher serum concentrations of bilirubin are associated with a decreased risk of developing CV and all-cause death in diabetic patients. Bilirubin improved the risk prediction of cardiovascular death but provided only a slightly better prediction of all-cause death than conventional risk factors.

Predictive Value of CHA2DS2-VASc Score for Ischemic Events in Patients Undergoing Percutaneous Coronary Intervention.

We evaluated the association of preprocedure CHA2DS2-VASc (congestive heart failure, hypertension, age, diabetes mellitus, stroke, vascular disease, and sex) score with ischemic events in patients undergoing percutaneous coronary intervention (PCI). The Dryad Digital Repository enrolled 2533 patients between July 2009 and August 2011. We recorded 1-year ischemic events. Univariate and multivariable logistic regression analyses were used to analyze the association between CHA2DS2-VASc score and ischemic events. Receiver operating characteristic curves were used to evaluate the accuracy of CHA2DS2-VASc score in predicting long-term ischemic events. Long-term death (9.5 vs 2.8%), cardiac death (2.9 vs 1.4%), and nonfatal stroke (1.9 vs 0.7%) were significantly higher in the CHA2DS2-VASc score ≥2 group than the CHA2DS2-VASc score ≤1 group. The CHA2DS2-VASc score was a predictor for all-cause death (odds ratio [95% confidence interval]: 3.71 [1.89-7.30]). The risk factors for all-cause death in CHA2DS2-VASc score ≥2 patients included age, diagnosis, heart failure, older myocardial infarction, diabetes, and chronic obstructive pulmonary disease, while the risk factor for CHA2DS2-VASc score ≤1 patients was age. In conclusion, the CHA2DS2-VASc score is associated with long-term all-cause death, cardiac death, and stroke in patients undergoing PCI, and it may have a potential use for risk stratification for patients who undergo PCI.

Doses of renin-angiotensin system inhibitors but not beta-blockers predict outcome after ST-elevation myocardial infarction

ABSTRACTObjectives: In patients with ST-elevation myocardial infarction (STEMI), it is not clear whether low-dose renin-angiotensin system inhibitors and beta-blockers can result in the same benefits achievable with higher target doses. This observational study aims to investigate whether higher doses of angiotensin converting enzyme inhibitors (ACEI)/angiotensin II receptor blockers (ARB) and beta-blockers can improve outcomes in patients with STEMI.Methods: We recorded daily doses of ACEI, ARB, and beta-blockers in 331 patients with STEMI. Echocardiographic studies were performed at baseline and were repeated 6 months later. Clinical events, including all-cause death and heart failure, were followed for 2 years.Results: Patients receiving high-dose ACEI/ARB had less increase in left ventricular end-diastolic volume index (LVEDVI) at 6 months. In multivariable linear regression model, ACEI/ARB dose or beta-blocker dose was not an independent predictor of increase in LVEDVI at 6 months. Kaplan-Meier survival curves showed that doses of ACEI/ARB (p = 0.003) and beta-blockers (p = 0.027) were significant predictors of death and heart failure. In multivariable Cox regression analysis, independent predictors of all-cause death and heart failure were diabetes mellitus (p = 0.001), left ventricular ejection fraction (p = 0.026), and ACEI/ARB dose (p = 0.025). Beta-blockers dose was not a predictor of clinical events in multivariable analysis (p = 0.413).Conclusion: High-dose ACEI/ARB, but not beta-blocker, was associated with lower rate of all-cause death and heart failure in patients with STEMI.

Impact of Resting Heart Rate at 30 Days Following Transcatheter or Surgical Aortic Valve Replacement and Cardiovascular Outcomes: Insights from The PARTNER 2 Trial

ABSTRACT Background: Elevated resting heart rate (RHR) is associated with adverse cardiovascular outcomes in patients with untreated aortic valve stenosis (AS). However, the impact of RHR following transcatheter (TAVR) or surgical aortic valve replacement (SAVR) on cardiovascular outcomes is unknown. We therefore sought to determine the effect of RHR at 30 days after aortic valve replacement (AVR) on 2-year outcomes in patients with severe symptomatic AS. Methods: The study population consists of 3170 patients from the PARTNER 2 Trial and its embedded registries who underwent TAVR or SAVR for severe AS, and had available 12-lead electrocardiograms demonstrating sinus rhythm at 30 days post-procedure. Outcomes at 2 years were analyzed according to 30-day RHR modeled as a continuous variable and in groups (RHR ≥75 bpm and RHR <75 bpm). Results: By multivariable analysis, RHR ≥75 bpm at 30 days after AVR was an independent predictor of the composite endpoint of all-cause death, rehospitalization or stroke (hazard ratio [HR] 1.26, 95% confidence interval [CI], 1.05–1.52, p = 0.015) and rehospitalization (HR 1.42, 95% CI, 1.12–1.79, p = 0.004). Similarly, RHR modeled as a continuous variable (per 5 bpm) remained an independent predictor of all-cause death, rehospitalization or stroke (adjusted HR 1.07, 95% CI, 1.03–1.11, p = 0.0007), and rehospitalization (adjusted HR 1.09, 95% CI, 1.04–1.14, p = 0.0003) at 2 years. Conclusions: In patients with severe AS treated with TAVR or SAVR, resting heart rate at 30 days post-procedure was an independent predictor of the composite endpoint of all-cause death, rehospitalization or any stroke, and of rehospitalization at 2 years.

Prognostic value of the Stanniocalcin-2/PAPP-A/IGFBP-4 axis in ST-segment elevation myocardial infarction

ObjectiveThe aim of the present study was to evaluate the prognostic value of the Stanniocalcin-2/PAPP-A/IGFBP-4 axis in patients with ST-segment elevation myocardial infarction (STEMI).MethodsObservational cohort study performed in 1085 consecutive STEMI patients treated with early reperfusion between February 2011 and August 2014. Stanniocalcin-2, PAPP-A, and IGFBP-4 were measured using state-of-the art immunoassays. The primary outcome was the composite endpoint of all-cause mortality and readmission due to heart failure (HF).ResultsMedian follow-up was 3.3 years (IQR 1.0–3.7), during which 176 patients (16.2%) presented a composite endpoint. Multivariable cox regression analysis revealed that Stanniocalcin-2 (HR 2.06; 95% CI 1.13–3.75; p = 0.018), IGFBP-4 (HR 1.73; 95% CI 1.14–2.64; p = 0.010), Killip–Kimball class III–IV (HR 1.40; 95% CI 1.13–1.74; p = 0.002), NT-ProBNP (HR 1.21; 95% CI 1.07–1.37; p = 0.002), age (HR 1.06; 95% CI 1.04–1.08; p < 0.001) and left ventricular ejection fraction (HR 0.97; 95% CI 0.95–0.98; p < 0.001) were independent predictors of the composite endpoint. A model containing Stanniocalcin-2 and IGFBP-4 on top of clinical variables significantly improved C-index discrimination (p = 0.036). Stanniocalcin-2 was also identified as independent predictor of all-cause mortality (HR 2.23; 95% CI 1.16–4.29; p = 0.017) and readmission due to HF (HR 3.42; 95% CI 1.22–9.60; p = 0.020).ConclusionsIn STEMI patients, Stanniocalcin-2 and IGFBP-4 emerged as independent predictors of all-cause death and readmission due to HF. The Stanniocalcin-2/PAPP-A/IGFBP-4 axis exhibits a significant role in STEMI risk stratification.

Predictors of adverse outcome in patients with myocardial infarction with non-obstructive coronary artery (MINOCA) disease

BackgroundMyocardial infarction (MI) with non-obstructive coronary arteries (MINOCAs) is an increasingly recognized entity. No previous study has evaluated predictors for new major adverse cardiacvascular events (MACEs) and death in patients with MINOCA. MethodsWe conducted an observational study of MINOCA patients recorded between July 2003 and June 2013 and followed until December 2013 for outcome events. Out of 199,163 MI admissions, 9092 consecutive unique patients with MINOCA were identified. The mean age was 65.5 years and 62% were women. MACE was defined as all-cause mortality, rehospitalization for acute MI, ischemic stroke and heart failure. Hazard ratio and 95% confidence interval (HR; 95% CI) was calculated using Cox-regression. ResultsA total of 2147 patients (24%) experienced a new MACE and 1254 patients (14%) died during the mean follow-up of 4.5 years. Independent predictors for MACE after adjustment, were older age (1.05; 1.04–1.06), diabetes (1.44; 1.21–1.70), hypertension (1.25; 1.09–1.43), current smoking (1.38; 1.15–1.66), previous myocardial infarction (1.38; 1.04–2.82), previous stroke (1.69; 1.35–2.11), peripheral vascular disease (1.55; 1.97–2.23), chronic obstructive pulmonary disease (1.63; 1.32–2.00), reduced left ventricular ejection fraction (2.00; 1.54–2.60), lower level of total cholesterol (0.88; 0.83–0.94) and higher level of creatinine (1.01; 1.00–1.03). Independent predictors for all cause death were age, current smoking, diabetes, cancer, chronic obstructive pulmonary disease, previous stroke, reduced left ventricular fraction, lower level of total cholesterol and higher levels of creatinine and CRP. ConclusionsThe clinical factors predicting new MACE and death of MINOCA patients seem to be strikingly similar to factors previously shown to predict new cardiovascular events in patients with MI and obstructive coronary artery disease.

Correlation between Nutritional Status and Mortality in Patients with Heart Failure

Objective To investigate the nutritional status of patients with heart failure and its effect on all-cause mortality. Methods A total of 351 patients with chronic heart failure, who were consecutively admitted to the East Hospital of Shanghai from March 2013 to November 2015, were put into the heart failure with reduced left ventricular ejection fraction(HFrEF) group. They were compared to 222 controls who were admitted during the same period for preclinical heart failure. After a median follow-up time of 606 days, 108 patients of the HFrEF group died, compared to 11 of the controls. Logistic regression was used to analyze correlations of all-cause mortality with the patients' body mass index (BMI), serum albumin and other factors. Results Compared to the controls, patients with chronic heart failure had lower BMI[(22.71±3.95)kg/m2vs.(24.23±3.66)kg/m2,t=4.331, P=0.000], total cholesterol[(3.81±0.99)mmol/L vs.(4.03±0.96)mmol/L, t=2.638, P=0.009], albumin[(38.18±5.03)g/L vs.(40.18±6.12)g/L, t=3.874, P=0.000] and prealbumin[(187.67±61.83)mg/L vs.(211.94±65.44)mg/L, t=3.937, P=0.000]. Within the HFrEF group, patients with lower BMI had higher mortality (36.0% vs. 22.4%, P=0.008). Logistic regression suggested BMI, age were independent predictors of all-cause death. Conclusions Patients with chronic heart failure had high incidence of malnutrition, and those with BMI<22 kg/m2 had higher risk of mortality. Serum albumin and BMI not only reflected nutritional status of the patients but had significant implications on prognosis. Key words: HFrEF; Nutritional status; All-cause death

Impact of chronic obstructive pulmonary disease and frailty on long-term outcomes and quality of life after transcatheter aortic valve implantation

BackgroundAssociation between chronic obstructive pulmonary disease (COPD) and long-term mortality as well as the quality of life (QoL) in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI) is still unclear.AimWe sought to evaluate the impact of COPD on mortality and QoL of patients with AS undergoing TAVI.MethodsA total of 148 consecutive patients who underwent TAVI were enrolled and stratified by history of COPD.ResultsOf 148 patients enrolled, 19 (12.8%) patients had a history of COPD. Patients with COPD were high-risk patients with higher prevalence of incomplete revascularization and frailty features. At follow-up of 15.8 months, all-cause mortality in patients with COPD was over four times higher than in patients without COPD [17.8% vs. 52.6%; p = 0.002—age/gender-adjusted OR (95% CI) 4.73 (1.69–13.24)]. On the other hand, in Cox regression model, the only independent predictors of all-cause death at long-term follow-up were: incomplete coronary revascularization [HR (95% CI) 5.45 (2.38–12.52); p = 0.001], estimated glomerular filtration rate [per 1 ml/min/1.73 m2 increase: 0.96 (0.94–0.98); p = 0.001], and previous stroke/transient ischemic attack [2.86 (1.17–7.00); p = 0.021]. Also, the difference in mortality between patients with and without COPD was not significant after adjustment for the most of frailty indices. Importantly, groups were comparable in terms of QoL at baseline and 12 months.ConclusionCOPD may pose an important factor affecting long-term outcomes of patients with severe AS undergoing TAVI. However, its effects might be partially related to coexisting comorbidities and frailty.