Predictor Of Mortality Research Articles

Right ventricular to pulmonary artery coupling in patients with different types of aortic stenosis undergoing TAVI.

Right ventricular (RV) dysfunction in patients undergoing transcatheter aortic valve implantation (TAVI) for aortic stenosis (AS) has long been disregarded. We aimed to assess the predictive value of RV to pulmonary artery coupling (RV/PAc), defined as tricuspid annular plane systolic excursion to systolic pulmonary artery pressure, on mortality in different flow types of AS after TAVI. All patients undergoing TAVI for AS at our centre between 2018 and 2020 were assessed; 862 patients were analysed. The cohort was dichotomized using a ROC analysis (cut-off 0.512mm/mmHg), into 429 patients with preserved and 433 patients with reduced RV/PAc. Reduced RV/PAc was associated with male sex and a higher rate of comorbidities. Short-term VARC-3 endpoints and NYHA classes at follow-up were comparable. Reduced RV/PAc was associated with higher 2-year all-cause mortality (35.0% [30.3-39.3%] vs. 15.4% [11.9-18.7%], hazard ratio 2.5 [1.9-3.4], p < 0.001). Cardiovascular mortality was almost tripled. Results were consistent after statistical adjustment and in a multivariate model. Sub-analyses of AS flow types revealed lower RV/PAc in classical and paradoxical low-flow low-gradient AS, with the majority having reduced RV/PAc (74% and 59%). RV/PAc retained its predictive value in these subgroups. RV dysfunction defined by low RV/PAc is a strong mortality predictor after TAVI independent of flow group. It should be incorporated in future TAVI risk assessment.

Clinical usefulness of NT-proBNP as a prognostic factor for septic shock patients presenting to the emergency department

Plasma N-terminal prohormone of brain natriuretic peptide (NT-proBNP) level is primarily used as a biomarker for left ventricular (LV) dysfunction. It is influenced by various conditions, such as myocardial strain and situations affecting the clearance of NT-proBNP, including sepsis and shock. In this study, we investigated the appropriateness of NT-proBNP as a prognostic factor for septic shock. Patients with septic shock who visited the emergency department of the Ewha Womans’ University Mokdong Hospital between January 1, 2018, and December 31, 2020, were classified into the survival group (those who survived in the hospital and were discharged) and the death group (those who died in the hospital). The effectiveness of NT-proBNP, lactate, and blood urea nitrogen as predictive factors of in-hospital mortality was evaluated using the area under the receiver operating characteristic (AUROC) curve. The AUROC curve was 0.678 and 0.648 for lactate and NT-proBNP, respectively, with lactate showing the highest value. However, there was no significant difference between lactate and NT-proBNP levels in the comparison of their AUROC curve (p = 0.6278). NT-proBNP could be a useful predictor of in-hospital mortality in patients with septic shock who present to the emergency department.

Neutrophil to Lymphocyte Ratio on Admission to Predict Mortality of COVID-19 Elderly Patients

Severe Acute Respiratory Syndrome Corona Virus Disease-2 (SARS-COV-2) is the cause of COVID-19, which led to a global pandemic and high mortality rate, especially in elderly patients. The declining immune system in elderly patients and comorbid diseases lead to more severe symptoms and an increased mortality rate. Many studies have shown that a high Neutrophil-Lymphocyte Ratio (NLR) value can predict the severity and mortality of COVID-19. However, studies on NLR in elderly patients in Indonesia have rarely been conducted. This study aimed to determine the role of NLR on admission as a mortality predictor in COVID-19 elderly patients who underwent in-hospital treatment. This research is an analytical observational study with a retrospective cohort method conducted in Bethesda Hospital, Yogyakarta, Indonesia. The research subjects were selected from July 2020 to October 2021 according to inclusion and exclusion criteria. Inclusion criteria were all elderly COVID-19 patients with an age limit of &gt; 60 years old who had complete hemogram data on admission, demographic data, diagnostic criteria, types of comorbid diseases, and patient outcomes (survivor or non-survivor). The exclusion criteria were elderly COVID-19 patients with incomplete Electronic Medical Records (EMR). This study found 122 elderly patients with COVID-19 with a mortality rate of 30.33%. The result showed that NLR on admission significantly increased significantly in the non-survivor group compared to the survivor group. Multivariate Cox regression analysis presented severity (RR: 5.181; CI 1.662-16.154; p=0.005), comorbid diabetes mellitus (RR: 2.829; CI: 1.115-7.178), NLR &gt; 6.04 (RR: 6.356; CI: 2.428-16.639) and other comorbid, namely thyroid, autoimmune, cancer, and anemia (RR: 15.836; CI: 1.841-136.234; p=0.012) as factors of mortality in hospitalized elderly patients.

Cell-free DNA in patients with sepsis: long term trajectory and association with 28-day mortality and sepsis-associated acute kidney injury

IntroductionOutcome-prediction in patients with sepsis is challenging and currently relies on the serial measurement of many parameters. Standard diagnostic tools, such as serum creatinine (SCr), lack sensitivity and specificity for acute kidney injury (AKI). Circulating cell-free DNA (cfDNA), which can be obtained from liquid biopsies, can potentially contribute to the quantification of tissue damage and the prediction of sepsis mortality and sepsis-associated AKI (SA-AKI).MethodsWe investigated the clinical significance of cfDNA levels as a predictor of 28-day mortality, the occurrence of SA-AKI and the initiation of renal replacement therapy (RRT) in patients with sepsis. Furthermore, we investigated the long-term course of cfDNA levels in sepsis survivors at 6 and 12 months after sepsis onset. Specifically, we measured mitochondrial DNA (mitochondrially encoded NADH-ubiquinone oxidoreductase chain 1, mt-ND1, and mitochondrially encoded cytochrome C oxidase subunit III, mt-CO3) and nuclear DNA (nuclear ribosomal protein S18, n-Rps18) in 81 healthy controls and all available samples of 150 intensive care unit patients with sepsis obtained at 3 ± 1 days, 7 ± 1 days, 6 ± 2 months and 12 ± 2 months after sepsis onset.ResultsOur analysis revealed that, at day 3, patients with sepsis had elevated levels of cfDNA (mt-ND1, and n-Rps18, all p&amp;lt;0.001) which decreased after the acute phase of sepsis. 28-day non-survivors of sepsis (16%) had higher levels of cfDNA (all p&amp;lt;0.05) compared with 28-day survivors (84%). Patients with SA-AKI had higher levels of cfDNA compared to patients without AKI (all p&amp;lt;0.05). Cell-free DNA was also significantly increased in patients requiring RRT (all p&amp;lt;0.05). All parameters improved the AUC for SCr in predicting RRT (AUC=0.88) as well as APACHE II in predicting mortality (AUC=0.86).ConclusionIn summary, cfDNA could potentially improve risk prediction models for mortality, SA-AKI and RRT in patients with sepsis. The predictive value of cfDNA, even with a single measurement at the onset of sepsis, could offer a significant advantage over conventional diagnostic methods that require repeated measurements or a baseline value for risk assessment. Considering that our data show that cfDNA levels decrease after the first insult, future studies could investigate cfDNA as a “memoryless” marker and thus bring further innovation to the complex field of SA-AKI diagnostics.

Dialysis parameters associated with SARS-CoV-2 infection and prognosis in end-stage kidney disease

Background The Covid-19 pandemic has affected patients with end-stage kidney disease (ESKD). Whether dialysis parameters have a prognostic value in ESKD patients with Covid-19 remains unclear. Materials and Methods We retrospectively evaluated clinical characteristics, blood pressure (BP) and dialysis parameters in ESKD patients undergoing maintenance outpatient hemodialysis, with (Covid-ESKD) and without (No-Covid-ESKD) Covid-19, at four Brazilian hemodialysis facilities. The Covid-ESKD (n = 107; 54% females; 60.8 ± 17.7 years) and No-Covid-ESKD (n = 107; 62% females; 58.4 ± 14.6 years) groups were matched by calendar time. The average BP and dialysis parameters were calculated during the pre-infection, acute infection, and post-infection periods. The main outcomes were Covid-19 hospitalization and all-cause mortality. Results Covid-ESKD patients had greater intradialytic and postdialysis systolic BP and lower predialysis weight, postdialysis weight, ultrafiltration rate, and interdialytic weight gain during acute-illness compared to 1-week-before-illness, while these changes were not observed in No-Covid-ESKD patients. After 286 days of follow-up (range, 276–591), there were 18 Covid-19-related hospitalizations and 28 deaths among Covid-ESKD patients. Multivariable logistic regression analysis showed that increases in predialysis systolic BP from 1-week-before-illness to acute-illness (OR, 95%CI = 1.06, 1.02–1.10; p = .004) and Covid-19 vaccination (OR, 95%CI = 0.16, 0.04–0.69; p = .014) were associated with hospitalization in Covid-ESKD patients. Multivariable Cox-regression analysis showed that Covid-19-related hospitalization (HR, 95%CI = 5.17, 2.07–12.96; p < .001) and age (HR, 95%CI = 1.05, 1.01–1.08; p = .008) were independent predictors of all-cause mortality in Covid-ESKD patients. Conclusion Acute Covid-19 illness is associated with variations in dialysis parameters of volume status in patients with ESKD. Furthermore, increases in predialysis BP during acute Covid-19 illness are associated with an adverse prognosis in Covid-ESKD patients.

A mortality indicator in acute pulmonary embolism: the inferior vena cava contrast reflux score feasibility

Objective: Acute pulmonary embolism (APE) is frequently associated with high morbidity and mortality rates. Numerous studies have investigated the prognostic significance of cardiovascular computed tomography (CT) parameters. This study aimed to investigate potential CT scan predictors of 24-hour mortality in APE and to evaluate the value of the inferior vena cava (IVC) reflux score calculated on CT scan in predicting mortality. Methods: This study was a single-center, retrospective study. Approval from the local ethics committee (decision no. 2023/76) was obtained before patients’ data scanning. Patients who were admitted to the emergency department (ED) of a tertiary education and research hospital in Turkey between January 1, 2019, and December 31, 2021, who were diagnosed with APE at CT scan in the ED and whose treatment was started, and who did not meet the exclusion criteria were included in the study. The relationship between CT scan findings and early and late mortality was evaluated. Results: The study population comprised 226 patients, meeting the inclusion and exclusion criteria. Of the 226 patients, a total of 39 (17.3%) patients died, 16 (7.1%) within the first 24 hours. In evaluating CT scan parameters, the inferior vena cava (IVC) reflux score showed a statistically significant difference between the groups with and without mortality (24-hour P=0.001; 30-day P=0.001). Patients who died within the first 24-hour and 30-day after admission showed a reflux grade 3 into IVC more often than survivors (24-hour odds ratio (OR): 14.57, 95% confidence interval (CI): 3.64,58.1; P=0.001); 30-day (OR: 6.54, 95% CI: 2.51,16.98; P=0.001). However, other CT parameters were evaluated, and no statistical relationship was found between the groups with and without mortality. Conclusion: The cardiovascular CT scan findings may not be suitable for use as predictors of mortality. However, the IVC reflux score may be a good indicator of both early and late mortality.

Predicting early mortality and severe intraventricular hemorrhage in very-low birth weight preterm infants: a nationwide, multicenter study using machine learning

Our aim was to develop a machine learning-based predictor for early mortality and severe intraventricular hemorrhage (IVH) in very-low birth weight (VLBW) preterm infants in Taiwan. We collected retrospective data from VLBW infants, dividing them into two cohorts: one for model development and internal validation (Cohort 1, 2016–2021), and another for external validation (Cohort 2, 2022). Primary outcomes included early mortality, severe IVH, and early poor outcomes (a combination of both). Data preprocessing involved 23 variables, with the top four predictors identified as gestational age, birth body weight, 5-min Apgar score, and endotracheal tube ventilation. Six machine learning algorithms were employed. Among 7471 infants analyzed, the selected predictors consistently performed well across all outcomes. Logistic regression and neural network models showed the highest predictive performance (AUC 0.81–0.90 in both internal and external validation) and were well-calibrated, confirmed by calibration plots and the lowest two mean Brier scores (0.0685 and 0.0691). We developed a robust machine learning-based outcome predictor using only four accessible variables, offering valuable prognostic information for parents and aiding healthcare providers in decision-making.

Metabolic predictors of COVID-19 mortality and severity: a survival analysis

IntroductionThe global healthcare burden of COVID-19 pandemic has been unprecedented with a high mortality. Metabolomics, a powerful technique, has been increasingly utilized to study the host response to infections and to understand the progression of multi-system disorders such as COVID-19. Analysis of the host metabolites in response to SARS-CoV-2 infection can provide a snapshot of the endogenous metabolic landscape of the host and its role in shaping the interaction with SARS-CoV-2. Disease severity and consequently the clinical outcomes may be associated with a metabolic imbalance related to amino acids, lipids, and energy-generating pathways. Hence, the host metabolome can help predict potential clinical risks and outcomes.MethodsIn this prospective study, using a targeted metabolomics approach, we studied the metabolic signature in 154 COVID-19 patients (males=138, age range 48-69 yrs) and related it to disease severity and mortality. Blood plasma concentrations of metabolites were quantified through LC-MS using MxP Quant 500 kit, which has a coverage of 630 metabolites from 26 biochemical classes including distinct classes of lipids and small organic molecules. We then employed Kaplan-Meier survival analysis to investigate the correlation between various metabolic markers, disease severity and patient outcomes.ResultsA comparison of survival outcomes between individuals with high levels of various metabolites (amino acids, tryptophan, kynurenine, serotonin, creatine, SDMA, ADMA, 1-MH and carnitine palmitoyltransferase 1 and 2 enzymes) and those with low levels revealed statistically significant differences in survival outcomes. We further used four key metabolic markers (tryptophan, kynurenine, asymmetric dimethylarginine, and 1-Methylhistidine) to develop a COVID-19 mortality risk model through the application of multiple machine-learning methods.ConclusionsMetabolomics analysis revealed distinct metabolic signatures among different severity groups, reflecting discernible alterations in amino acid levels and perturbations in tryptophan metabolism. Notably, critical patients exhibited higher levels of short chain acylcarnitines, concomitant with higher concentrations of SDMA, ADMA, and 1-MH in severe cases and non-survivors. Conversely, levels of 3-methylhistidine were lower in this context.

Association of inflammatory markers based on routine blood with prognosis in patients underwent percutaneous coronary intervention.

Inflammation contributes to the pathophysiological processes of coronary artery disease. We evaluated the association between inflammatory biomarkers, neutrophil-to-lymphocyte ratio (NLR), red cell distribution width (RDW), systemic inflammatory index, platelet-lymphocyte ratio, and 1-year all-cause mortality in patients underwent percutaneous coronary intervention (PCI). In this retrospective cohort, we consecutively enrolled 4651 patients who underwent PCI. Baseline demographic details, clinical data, and laboratory parameters on admission were analyzed. The primary outcome was 1-year all-cause mortality after PCI. We performed Cox regression and restricted cubic spline analysis to assessed the association between the inflammatory biomarkers and the clinical outcome. The area under the curve from receiver operating characteristic analysis was determined for the ability to classify mortality outcomes. A total of 4651 patients were included. Of these, 198 (4.26%) died on follow-up. Univariate Cox regression showed that NLR (heart rate [HR]: 1.070, 95% confidence interval [CI]: 1.060-1.082, P < .001), RDW (HR: 1.441, 95% CI 1.368-1.518, P < .001), systemic inflammatory index (HR: 1.000, 95% CI 1.000-3.180, P < .001), platelet-lymphocyte ratio (HR: 3.812, 95% CI 1.901-3.364, P < .001) were significant predictors of 1-year all-cause mortality. After adjusting for other confounders in multivariate analysis, NLR (HR: 01.038, 95% CI 1.022-1.054, P < .001) and RDW (HR: 1.437, 95% CI 1.346-1.535, P < .001) remained significant predictors. Restricted cubic spline analysis showed the relationship between RDW, NLR, and 1-year all-cause mortality was linear after adjusting for the covariables (P for non-linearity < 0.001). The multivariable adjusted model led to improvement in the area under the curve to 0.83 (P < .05). Nomogram was created to predict the probability of 1 year mortality. Among the laboratory indices, RDW and NLR showed the best performance for mortality risk prediction. Multivariate predictive models significantly improved risk stratification.

Proposal and Validation of a Clinically Relevant Modification of the Japanese Association for Acute Medicine Disseminated Intravascular Coagulation Diagnostic Criteria for Sepsis.

Japanese Association for Acute Medicine (JAAM) disseminated intravascular coagulation (DIC) criteria were launched nearly 20 years ago. Following the revised conceptual definition of sepsis and subsequent omission of systemic inflammatory response syndrome (SIRS) score from the latest sepsis diagnostic criteria, we omitted the SIRS score and proposed a modified version of JAAM DIC criteria, the JAAM-2 DIC criteria. To validate and compare performance between new JAAM-2 DIC criteria and conventional JAAM DIC criteria for sepsis. We used three datasets containing adult sepsis patients from a multicenter nationwide Japanese cohort study (J-septic DIC, FORECAST, and SPICE-ICU registries). JAAM-2 DIC criteria omitted the SIRS score and set the cutoff value at ≥3 points. Receiver operating characteristic (ROC) analyses were performed between the two DIC criteria to evaluate prognostic value. Associations between in-hospital mortality and anticoagulant therapy according to DIC status were analyzed using propensity score weighting to compare significance of the criteria in determining introduction of anticoagulants against sepsis. Final study cohorts of the datasets included 2,154, 1,065, and 608 sepsis patients, respectively. ROC analysis revealed that curves for both JAAM and JAAM-2 DIC criteria as predictors of in-hospital mortality were almost consistent. Survival curves for the anticoagulant and control groups in the propensity score-weighted prediction model diagnosed using the two criteria were also almost entirely consistent. JAAM-2 DIC criteria were equivalent to JAAM DIC criteria regarding prognostic and diagnostic values for initiating anticoagulation. The newly proposed JAAM-2 DIC criteria could be potentially alternative criteria for sepsis management.

Staging reinterventions for remodeling of residual aortic dissection: a single-center retrospective study

ObjectiveInadequate remodeling of residual aortic dissection (RAD) following repair of Stanford A or B aortic dissections has been identified as a significant predictor of patient mortality. This study evaluates the short- to mid-term outcomes of staged reinterventions for RAD at a single center with prospective follow-up.MethodsData were retrospectively collected from patients with RAD who underwent staged reinterventions or received none-surgery treatment in the Cardiovascular Surgery Department of our hospital between July 2019 and December 2021. The cohort included 54 patients with residual distal aortic dissection post-primary surgery, comprising 28 who underwent open surgery and 26 who received thoracic endovascular aortic repair (TEVAR). Patients were divided into two groups: those who underwent staged stent interventions for distal dissection [staged reintervention (SR) group] and those who did not undergo surgery (non-surgery group). For the SR group, second or third staged stent interventions were performed. The study assessed distal remodeling of aortic dissection between the groups, focusing on endpoints such as mortality (both general and aortic-specific), occurrences of visceral branch occlusion, necessity for further interventions, and significant adverse events. Morphological changes were analyzed to determine the therapeutic impact.ResultsThe study encompassed 54 participants, with 33 in the SR group and 21 in the non-surgical control group. Baseline demographics and clinical characteristics were statistically comparable across both groups. During an average follow-up of 31.5 ± 7.0 months, aortic-related mortality was 0% in both groups; all-cause mortality was 3% (one case) and 5% (one case) in the SR and control groups, respectively, with no statistically significant difference noted. In the SR group, a single patient experienced complications, including renal artery thrombosis, leading to diminished blood flow. An increased true lumen (TL) area and a decreased false lumen area at various aortic planes were observed in the SR group compared to the control group.ConclusionThe staged reintervention strategy for treating RAD is safe and provides promising early results.

The Jarring Reality: Adolescent and Pediatric Gunshot Trauma on the Rise in a Major Urban Institution.

Firearms are the leading cause of death in the pediatric population, and the incidence of firearm injury is on the rise in the United States. The purpose of this study was to examine the incidence of pediatric gunshot wounds (GSWs) in New Orleans from 2012 to 2023 and evaluate factors that contribute to mortality. A retrospective analysis of pediatric GSWs was conducted using the trauma database at a Level I trauma center in New Orleans, Louisiana. All patients aged 0 to 18 years with a GSW between January 1, 2012, and January 1, 2023, were evaluated. Demographic data, Injury Severity Score (ISS), hospital length of stay (LOS), discharge disposition, intent of injury, mortality, firearm type, orthopaedic injuries, and related surgical procedures were extracted from the database. Linear regression was used to assess the trend of GSWs over time, and logistic regression was used to identify variables that predicted mortality. Statistical significance was defined as α = 0.05. Geographic information system (GIS) mapping was conducted using the ZIP code location of injury to identify geographic areas with the greatest number of GSWs. A significant increasing trend was observed in the number of pediatric GSWs when adjusted for changes in population (P = 0.014), and the number of GSWs increased 43.2% over the duration of the study. Higher ISS, shorter length of stay, and self-inflicted intent of injury were notable predictors of mortality. Three hundred fifty-four patients (31.4%) had at least one orthopaedic injury, and of the survivors, 365 patients (35.6%) required at least one surgical procedure in the operating room during their admission. The number of GSWs in the pediatric population in New Orleans presenting at a large level 1 trauma center demonstrated a statistically significant increasing trend over the past 11 years. ISS and self-inflicted intent were predictive of mortality within this pediatric patient population.

Respiratory support modalities in cardiogenic shock: insights from a prospective multicenter registry

Abstract Funding Acknowledgements None. Background Respiratory support is a vital component of the comprehensive management of cardiogenic shock (CS). However, there is a lack of data comparing the application of different respiratory support modalities in CS patients. Purpose Aim of this study was to examine the use of low-flow oxygen (LFO), non-invasive ventilation (NIV), and invasive mechanical ventilation (IMV) in a cohort of CS patients and assess their effects on 60-day mortality. Methods We analyzed a cohort of CS patients enrolled in a multicenter prospective registry from twelve cardiac intensive care units from March 2020 to August 2022. Patients were categorized according to the maximum intensity of respiratory support during intensive care unit stay into three groups: LFO, NIV, and IMV. Clinical characteristics and mortality were compared between groups. Results A total of 375 patients were included in our analysis. The median age of the population was 65 years, with 77% being males. During their ICU stay, 139 patients (37%) received LFO, 61 (16%) were treated with NIV, and 175 (47%) underwent IMV. Patients treated with IMV presented more frequently with cardiac arrest (41% vs 8% in the LFO group and 5% in the NIV group, p = 0.00). Patients treated with LFO and NIV had a higher prevalence of CS related to acute decompensated heart failure (40% and 57% vs 21% in the IMV group, p = 0.00); moreover, they presented with less severe respiratory distress, milder tissue hypoperfusion, and better SCAI class upon admission. At sixty days follow-up 128 patients (34%) died: 41% in the IMV group, 28% in the LFO group and 26% in the NIV group (p = 0.02). Multivariate analysis revealed that NIV was independently associated with improved survival (OR 0.47, 95% CI 0.22-0.99, p = 0.05), while age, lactate levels, and glomerular filtration rate were predictors of mortality. A tendency towards improved survival with NIV was observed even after excluding patients with cardiac arrest. Conclusions Compared to previous registries, our study highlights a significant shift in the management of CS, marked by a growing preference for NIV. Notably, this approach, when employed in well-selected patients in the early stages of CS, correlates with lower mortality rates. These findings underscore the significance of personalized treatment strategies for CS patients, considering their clinical presentation, the degree of respiratory distress, and tissue perfusion.60-day survival curvesMultivariate regression analysis

Global longitudinal strain as a predictor of mortality in patients with cardiogenic shock

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Aarhus University Dagmar Marshalls Fond. Background The assessment of left ventricular (LV) function through transthoracic echocardiography (TTE) is essential for guiding diagnosis and treatment in cases of cardiogenic shock (CS). Myocardial global longitudinal strain (GLS) provides an objective and reproducible measure of systolic function, independently predicting outcomes in acute heart failure, regardless of left ventricular ejection fraction (LVEF). However, whether assessment of GLS can predict mortality in patients with CS remains unknown. Purpose In this study, we aimed to evaluate the prognostic significance of GLS in patients with CS. Methods Data from cardiac intensive care unit (CICU) patients admitted between 2007 and 2018 with CS who received vasoactive agents and/or mechanical circulatory support were analysed. GLS (as absolute values) and biplane LVEF were measured via TTE performed within 24 hours of CICU admission. Patients with CS were categorised based on the GLS quartile: mild (GLS &amp;gt;9.7%), moderate (7.0% &amp;lt; GLS &amp;lt;9.6%), severe (5.0% &amp;lt; GLS &amp;lt; 6.9%), and very severe (GLS ≤ 4.9%). CICU and in-hospital mortality were compared across GLS categories, and the relationship between GLS and mortality was assessed using multivariable logistic regression. Results The study included 626 patients with a median age of 68.6 years, a median LVEF of 31% (IQR 24 to 40%), and a median GLS of 7.0% (IQR 5.0 to 9.7%). In-hospital mortality was 29.1%. As GLS deteriorated, there was an increasing need for vasopressors (P&amp;lt;0.001). Patients with progressively lower GLS exhibited significantly higher CICU and in-hospital mortality across the GLS quartiles (Figure A; P&amp;lt;0.001). Patients in the severe (adjusted OR 2.67; p&amp;lt;0.001) and very severe category (adjusted OR 3.54; P&amp;lt;0.001) had significantly increased risk of in-hospital death compared with mild category. In multivariable analysis, every 1% decrease in GLS corresponded to a 14% higher risk of in-hospital mortality (P&amp;lt;0.001). Finally, GLS outperformed LVEF for discrimination of in-hospital mortality (P=0.002), and when both measurements were included in the same multivariable model, only GLS remained significant. When patients were divided according to whether they had GLS and/or LVEF below the median value, patients with low GLS had higher mortality irrespective of the LVEF (Figure B). Conclusion In patients with CS, GLS assessment surpasses LVEF in its prognostic value and improves risk stratification. Routine evaluation of GLS should be considered for patients with CS.Figure AFigure B

In-hospital trimethylamine N-oxide (TMAO) variation predicts major adverse cardiovascular events in myocardial infarction survivors

Abstract Funding Acknowledgements None. Background Trimethylamine N-oxide (TMAO), a gut microbiota result of the fermentation of animal foods rich in choline, L-carnitine and phosphatidylcholine (red meat, egg yolk, dairy food), is associated with alterations in lipid metabolism, increased foam cell formation, promotion of inflammation, oxidative stress, platelet aggregation and thrombosis. To date the data evaluating TMAO as a predictor of mortality and ischemic events in patients with acute myocardial infarction (AMI) based on one-time measurement of TMAO levels lead to conflicting results. TMAO levels are fluctuating and in addition to diet, genetic factors, general condition and some co-morbidities affect its circulating levels. Purpose Since, there is a need for better risk stratification of AMI patients before the hospital discharge for more personalised treatment, we evaluated in-hospital variation in TMAO levels and its impact on outcome. Methods Blood samples from 149 consecutive AMI patients were collected on admission and on discharge. The endpoint was a three-point major adverse cardiovascular events (MACE) composed as all-cause mortality, reinfarction and development of heart failure. Results The majority of AMI patients were male (77%), hospitalized for first coronary event, with mean age 64(11) years. Median circulating TMAO level was significantly higher on admission than on discharge, (7.81 [3.47 –19.98] vs 3.45 [2.3 – 4.78] μM, respectively, p&amp;lt;0.001). In order to evaluate the impact of TMAO variation during the hospital stay on outcome, we estimated TMAO cut-off value by continuous hazard ratio analysis; values above the 3.45 μM were associated with incident of MACE in a linear fashion (Fig. 1a). Subsequently, we stratified AMI patients in 2 groups: 1) LL/HL (low-low/high-low) that included 75 (50.3%) patients whose TMAO levels remained low or were high and decreased during hospitalization and 2) HH/LH (high-high/low-high) including 74 patients (49.7%) patients whose TMAO levels remained elevated or were initially low, but rose above the estimated threshold during hospitalisation (Fig. 1b). Thirty-two (21.5%) patients reached the combined endpoint during the median follow-up of 30 months. The Kaplan-Meier analysis demonstrated that patients from the HH/LH group had a higher likelihood of experiencing MACE (p=0.05) (Fig. 2a). The multivariate Cox analysis revealed that patients in the HH/LH group had over twice the risk of MACE compared to those in the LL/HL group. Furthermore, older age and worse left ventricular systolic function were identified as independent predictors of MACE during long-term follow-up (Fig. 2b). Conclusions AMI patients with permanently elevated or increasing levels of TMAO have a worse outcome. The novelty and the strength of our study is the fact that the direction of variation of TMAO during the index hospitalisation identifies patients at higher risk of MACE during 30 months follow-up.

Variables associated with mortality in patients with atrial fibrillation and ischaemic heart disease in Spain

Abstract Funding Acknowledgements None. Introduction The prevalence of atrial fibrillation (AF) and ischaemic heart disease (IHD) increases with age, conditioning a complex and relatively frequent scenario in clinical practice. Our objective was to know the variables associated with prognosis in a cohort of patients with AF and IHD in our country after a year of follow-up. Methods An observational, prospective and multicentre study that included patients with AF and IHD in Spain. Baseline, clinical, laboratory and echocardiographic characteristics were assessed, as well as the clinical management and the choice of antithrombotic treatment. We studied long-term mortality. Results 290 patients were included (mean age 77.7±9.7 years, 28% women). 84% of the patients were hypertensive, 42% diabetic, 69.7% dyslipidemic. The average comorbidity, characterized by the Charlson index, was 2.3±2. The average score on the CHADSVASC and HASBLED scales was 4.28±1.62 and 2.94±1, respectively. The clinical presentation of ischaemic heart disease was NSTEMI (45%), STEMI (22%) and stable angina (33%). 65.6% of patients underwent revascularisation, mostly percutaneously (92%). 42% of patients were discharged with triple therapy (double antiplatelet + anticoagulation), 30.1% with double therapy (antiplatelet + anticoagulation). After an average follow-up of 325±5.7 days, 35 patients (12%) died. The variables independently associated (multivariate analysis) with mortality during follow-up are shown in the Table (creatinine, leukocyte count, troponin elevation, number of diseased vessels, ventricular function, and comorbidity were mortality predictors in our study). Conclusions The presence of a series of simple variables identifies patients with AF and IHD as having a greater risk of mortality during follow-up.Variables independentily associated AF

Long-term prognostic significance of stress hyperglycemia in patients with ST-elevation myocardial infarction

Abstract Funding Acknowledgements None. Background/aim Stress hyperglycemia is defined as hyperglycemia that occurs in critically ill patients without diabetes mellitus (DM). It is associated with adverse in-hospital outcomes in patients with ST elevation myocardial infarction (STEMI). The aim of the present study is to evaluate short- and long-term prognostic impact of stress hyperglycemia in STEMI patients. Method We analysed 2505 consecutive STEMI patients treated with successful primary PCI (pPCI) without previous DM and without cardiogenic shock at admission. Successful pPCI was defined as post-procedural flow TIMI 3. Stress hyperglycemia was defined as plasma glucose level above 7.8mmol/L at any time during hospitalization. The follow-up period was 6 years. Results Stress hyperglycemia at admission was registered in 685 (27.3%) patients. Compared with patients without stress hyperglycemia, patients with stress hyperglycemia were older and presented more often with heart failure (Killip class II and III); they were more likely to have hypertension, chronic kidney disease, three vessel coronary disease (at initial angiogram) and lower predischarge left ventricular ejection fraction (EF). In-hospital, 30-day and 6-year mortality were significantly higher in patients with stress hyperglycemia vs patients without stress hyperglycemia: 7.1% vs 1.5%, 7.5% vs 1.7% and 12.5% vs 4.6% (p&amp;lt;0.001), respectively as shown in Figure 1. In Cox regression analysis stress hyperglycemia was an independent predictor for in-hospital, 30-days and 6-year mortality- HR 2.19 (95% 1.49-3.94), p=0.018, HR 1,58(95%CI 1.15-2.85), p=0.020 and HR 1.52 (95%CI 1.32-2.17), p=0.030, respectively. Conclusion In STEMI patients without diabetes mellitus treated with successful primary PCI stress hyperglycemia is an independent predictor for short- and long-term mortality (up to 6-years). These findings emphasize the importance of close monitoring of blood glucose level in STEMI patients regardless of diabetic status.

Predicting in-hospital mortality in infective endocarditis: insights from complete blood count parameters and NT-proBNP

Abstract Funding Acknowledgements None. Introduction Infective endocarditis (IE) is a rare condition with an increasing incidence rate and complexity of cases over the last few years, accompanied by a high mortality rate ranging from 18% to 25%. Recent studies have shown the utility of new outcome predictors based on complete blood count (CBC), such as red blood cell distribution width (RDW) and neutrophils/lymphocytes ratio (NLR). Drawing retrospectively from an 8-year experience, we provide a perspective from a tertiary center on predictors of in-hospital mortality based on basic laboratory test results in patients with valve-related IE. Purpose The aim of the study was to assess the clinical accuracy of CBC-based parameters as in-hospital mortality predictors. Methods From a tertiary center database (serving a stable population of 2.5 million citizens), we selected all patients hospitalized due to valve-related infective endocarditis between 2015 and 2022. We analyzed clinical data (including sex, age, IE localization, and etiological factors, number of cases, management and mortality), laboratory test results at admission (including CBC parameters, C-reactive protein - CRP, procalcitonin - PCT, N-terminal prohormone of brain natriuretic peptide - NT-proBNP, estimated glomerular filtration rate - eGFR, Creatinine - Crea, urea - UR). For three NT-proBNP, NLR, and RDW we provided a further analysis to compare their clinical accuracy. Univariable logistic regression was used to assess the impact of specific factors on mortality. To determine the optimal cutoff values for predicting mortality, we analyzed the area under the curve (AUC) from receiver operating characteristic (ROC) curves and used Youden's index. P-values &amp;lt; 0.05 were considered statistically significant. Results A total of 194 consecutive patients with confirmed IE were included in the study, the majority of whom were men (75.3%) with an overall median age of 62 years. The overall mortality rate was 27.8%. The most common localization was left-sided IE (92.3%). In 39.7% of cases, the etiological factor was unidentified, while Staphylococcus spp. were the most common bacteria among the identified cases. We identified significant impacts on mortality in most of the analyzed laboratory tests (RDW, platelet count, hemoglobin, NLR, PCT, NT-proBNP, eGFR, Crea, UR). Results showed that for every 1000pg/ml of NT-proBNP the risk of in-hospital death increases by 6%. ROC analysis was performed for the three parameters (RDW, NLR, and NT-proBNP), and each parameter showed an acceptable area under the curve - AUC (RDW: 0.69; NLR: 0.62; NT-proBNP: 0.78). Although we found the highest AUC for NT-proBNP (p&amp;lt;0.001). Conclusions Although CBC parameters are easy to assess and useful in predicting in-hospital death in IE, the accuracy of NT-proBNP is higher. The management of IE cases requires a complex approach, and NT-proBNP, which also reflects the clinical state of patients, still remains a more useful tool.In-hospital deaths ROC analysis

Impact of clinical frailty scale on short and long term outcome in patients with acute coronary syndrome

Abstract Funding Acknowledgements None. Background As recently outlined in the European Society of Cardiology (ESC) guidelines on acute coronary syndrome (ACS), scarce data still exits about the prognostic role of frailty to guide clinical decision-making for patients with ACS. Purpose To assess the potential predictive value of frailty both for short, and long term all-cause mortality, in a contemporary ACS population. Methods All consecutive admissions due to ACS, from 01/01/2019 to 31/12/2021, were retrospectively reviewed from an internal database of a tertiary cardiac center in Salerno (Italy). Logistic and Cox proportional regression analysis were performed in order to assess the contribution of frailty on 30-days and long term mortality. Frailty was assessed using the Clinical Frailty Scale (CFS) and patients were classified as non frail (CFS 1-4), and frail (CFS 5-9). Both logistic and Cox regression analysis were adjusted for age, gender, GRACE risk score, comorbidity burden, defined by the Charlson comorbidity score (CCS), and all other relevant covariates associated with outcomes of interest in the univariate analysis. In order to estimate the survival rates during the follow-up, a Kaplan Meyer analysis was carried out and differences between the CFS groups were assessed using the log-rank test. Robustness of the results were assessed through an internal validation procedure with bootstrapping. All statistical analyses were performed using SPSS software version 25.0 (SPPS Inc., Chicago, Illinois) and R version 4.0.5 (R Foundation for Statistical Computing, Vienna, Austria). A p-value of less than 0.05 was considered significant. Results 1366 patients were identified. The median age was 68 (58-77). Of these patients, 1087 (79,6%) were classified as non-frail (CFS 1-4), and 279 (20,4%) as frail (CFS 5-9). 120 (8,8%) and 140 (11,2%) deaths occurred, respectively, during the first 30 days from admission, and during long term follow-up (median follow-up time: 15 months; IQR: 10-24). After multivariate regression analysis the CFS was associated with both short and long-term mortality (OR: 1,6, 95% CI: 1,34-1,91; p&amp;lt;0,001 and HR: 1,37, 95% CI: 1,18-1,58; p&amp;lt;0,001, Fig. 1). Patients with CFS ≥ 5 showed significant higher mortality rate during long term follow-up (p&amp;lt;0.001; Fig.2). Conclusions The CFS is a strong predictor of both short and long-term mortality in patients affected by ACS also after comprehensive adjustment for baseline differences in other risk factors.Fig. 2

The impact of frailty on clinical outcomes of older patients undergoing enhanced recovery after lumbar fusion surgery: A prospective cohort study.

Frailty is recognized as a surrogate for physiological age and has been established as a valid and independent predictor of postoperative morbidity, mortality, and complications. ERAS can enhance surgical safety by minimizing stress responses in frail patients, enabling surgeons to discharge patients earlier. However, the question of whether and to what extent the frailty impacts the post-ERAS outcomes in older patients remains. An evidence-based ERAS program was implemented in our center from January 2019. This is a prospective cohort study of patients aged ≥75 years who underwent open transforaminal lumbar interbody fusion (TLIF) for degenerative spine disease from April 2019 to October 2021. Frailty was assessed with the Fried frailty scale (FP scale), and patients were categorized as non/prefrail (FP 0-2) or frail (FP ≥ 3). The preoperative variables, operative data, postoperative outcomes and follow-up information were compared between the two groups. Univariate and multivariate logistic regression analyses were used to identify risk factors for 90-day major complications and prolonged length of hospital stay (LOS) after surgery. A total of 245 patients (age of 79.8 ± 3.4 yr) who had a preoperative FP score recorded and underwent scheduled TLIF surgery were included in the final analysis. Comparisons between non-frail and prefrail/frail patients revealed no significant difference in age, sex, and surgery-related variables. Even after adjusting for multiple comparisons, the association between Fried frailty and ADL-dependency, IADL-dependency, and malnutrition remained significant. Preoperative frailty was associated with increased rates of postoperative adverse events. A higher CCI grade was an independent predictor for 90-day major complications, while Fried frailty and MNA-SF scores <12 were predictive of poor postoperative recovery. Frail older patients had more adverse post-ERAS outcomes after TLIF compared to non/prefrail older patients. Continued research and multidisciplinary collaboration will be essential to refine and optimize protocols for surgical care in frail older adults.