Predictor Of Outcome In Patients Research Articles

Three-dimensional right ventricular ejection fraction: a strong predictor of outcomes in patients undergoing cardiac surgery, a multicenter study.

Abstract Background Cardiac surgery is the cornerstone of treatment of several heart conditions.1 Risk stratification before surgery is crucial to patient’ prognostic, but commonly used scores do not include right ventricular (RV) function.2 Purpose To evaluate if 3D RV ejection fraction (RVEF) is independently associated with in-hospital outcomes in patients undergoing cardiac surgery after adjusting for the EuroSCORE. Methods Prospective multicenter (3 centers in 2 countries) cohort study of adult patients undergoing cardiac surgery. A comprehensive transesophageal echocardiogram was performed in the operating room before the surgery to capture dedicated acquisitions of the RV. The images were analyzed offline in TOMTEC imaging system. The primary outcome was a composite of in-hospital mortality or need of temporary ventricular assistance device after surgery. Exploratory endpoints were time on mechanical ventilation and time on inotropes after the surgery. Univariate and multivariable Cox regression model was used to analyze the association of RVEF with the primary outcome after adjusting for the EuroSCORE. Results We included 248 patients. The median age was 60 y/o and 43% were female. Aortic valve repair or replacement and CABG were the most common procedures. Sixty nine percent had normal RVEF (RVEF ≥45%) and 31% low RVEF (RVEF <45%). Baseline demographic characteristics were similar between groups except for atrial fibrillation, which was more common in the low RVEF group. Left ventricular ejection fraction was lower in patients with low RVEF (50 ± 14 vs. 54 ± 12, p=0.041). The volume of the atria and the RV size were higher in patients with low RVEF (p<0.04 for all). RV function parameters (TAPSE, FAC and RVFWLS) were lower in the group of low RVEF (p<0.001 for all). The group with low RVEF showed higher PASP (42 ± 19 vs. 53 ± 27 mmHg, p=0.003) and lower RV–pulmonary artery coupling [0.54 (IQR 0.33 – 0.78 mm/mmHg) vs. 0.34 (IQR 0.24 – 0.53 mm/mmHg), p<0.001]. The primary outcome occurred in 28 patients (11%). Table 1 illustrates the univariate and multivariable association of RVEF as a continuous variable as well as other parameters with the primary outcome. When analyzing groups of low vs high RVEF (binary variable), patients with low RVEF showed higher risk of the primary outcome [HR 2.46 (95% CI 1.10, 5.50), p=0.028]. At 30 days, the survival free of the primary endpoint was 72±8% vs. 93±3% (p<0.001) in low vs normal RVEF, respectively (Figure 2, panel A). Further, RVEF was associated with shorter time on mechanical ventilation (r= -0.27, p<0.001) and shorter time on inotropes (r= -0.20, p=0.01); (Figure 2, panel B and C). Conclusion Three-dimensional RVEF is a strong predictor of outcomes in patients undergoing cardiac surgery. This multicenter study suggests that including RV function in the evaluation of patients undergoing surgery might improve stratification. Table 1. Figure 1.

Score-based or left atrial strain based assessment of heart failure with preserved ejection fraction in transcatheter aortic valve replacement

Abstract Background Heart failure with preserved ejection fraction (HFpEF) has recently been proposed as important comorbid condition in patients undergoing transcatheter aortic valve replacement (TAVR) for aortic stenosis (AS). The H2FPEF-score and the HFA-PEFF-score are used to diagnose HFpEF, but their use might be hampered by lack of specificity in TAVR-populations. Left atrial reservoir strain (LARS) emerged as a powerful predictor of outcomes in patients with AS irrespective of ejection fraction (EF). Purpose To assess the prognostic value of the H2FPEF-score, the HFA-PEFF-score and of LARS for the prediction of outcomes after TAVR. Methods All consecutive patients undergoing TAVR with an LVEF was ≥50% between 01/2018 and 12/2018 were included if discharge echo and follow-up were available. The primary endpoint was all-cause death and readmission for decompensated HF. HFpEF was defined as an H2FPEF-score of ≥6 or an HFA-PEFF-score of ≥5 points. LARS was derived from 2-D-speckle-tracking and patients were divided in two groups according to LARS-median. Results Overall, 499 patients were available (Age 80 years (IQR 77-84)), including 58% woman. The H2PEFF-score was available in 92% and classified 204 patients (45%) as HFpEF with significant prediction of the primary endpoint (log-rank p=0.04). The HFA-PEFF-score was available in 91% and classified 414 patients (91%) as HFpEF with, but lacked prognostic significance (log-rank p=0.47). LARS was available in 100% of patients (median 13.9% [IQR 9.2-19.0%]). Patients with LARS ≤13.9% experienced worse outcomes (log-rank p<0.001). Conclusion H2PEFF-score and LARS might be used for risk-prediction post TAVR with LARS being applicable for more patients in our cohort.

Clinical utility of ischaemic late gadolinium enhancement granularity in ischaemic cardiomyopathy patients with reduced left ventricular ejection fraction

Abstract Background Although the presence and extent of ischaemic late gadolinium enhancement (LGE) assessed by cardiovascular magnetic resonance (CMR) are robust predictors of outcomes in patients with ischaemic cardiomyopathy (ICM), the prognostic significance of other ischaemic-LGE parameters is not well established, and no integrated score exists. Purpose This study aims to evaluate the additional prognostic value of a model that assesses the granularity of ischaemic-LGE over traditional factors in predicting mortality in ICM patients. The granularity includes ischaemic-LGE extent, transmurality, location, and associated midwall-LGE (Figure 1). A simplified score based on these parameters will be implemented to facilitate its use in clinical practice. Methods This study is a bi-centric retrospective analysis of a prospective observational cohort consisting of 6,082 patients with ICM and left ventricular ejection fraction (LVEF)<50% referred for viability assessment using CMR between 2008 and 2022. The primary outcome was all-cause mortality using the National French Registry of Death. Cox regression analysis was used to assess the incremental prognostic value of the LGE granularity model after adjustment for traditional prognosticators. Using a Cox model including all these LGE granularity parameters we built a new risk prediction score entitled "CMR-LGE score". Results Among the 6,082 patients (average age 65±12 years; 73% men), 3,591 (59%) exhibited ischaemic-LGE. Over a median follow-up period of 9 [7-12] years, 652 (11%) patients died. After adjustment, the presence of ischaemic-LGE was significantly associated with all-cause mortality (hazard ratio, HR=3.5, 99.5% CI: 2.6-4.7, p<0.001). In patients with ischaemic-LGE (N=3,591), the LGE extent (HR=1.4, 99.5% CI: 1.3-1.5), LGE transmurality (subendocardial ≤50%, subendocardial >50% HR=2.2, 99.5% CI: 1.5-3.2, and transmural HR=2.9, 99.5% CI: 1.9-4.4), and ischaemic LGE location (septal location HR=7.1, 99.5% CI: 4.9-10.4), and the presence of associated midwall-LGE were all independently associated with mortality (adjusted HR=1.9, 99.5% CI: 1.4-2.5, all p<0.001). The LGE granularity model, which included all these LGE features, showed the greatest improvement in model discrimination over traditional prognostic factors and ischaemic-LGE extent alone (ROC-AUC: 0.90 vs 0.84, p<0.001). The "CMR-LGE score" was highly effective ischaemic to predict mortality (ROC-AUC: 0.87, precision-recall-AUC: 0.61, Figure 2). Conclusions In a large cohort of ICM patients with reduced LVEF, a model incorporating the granularity of ischaemic-LGE—covering extent, transmurality, location, and associated midwall-LGE—provided additional prognostic value beyond traditional prognostic factors for predicting all-cause mortality. The “Ischaemic-LGE granularity" The “CMR-LGE Score”

Low myocardial work assessed by echocardiography is associated with prolonged ICU-Stay in CABG patients

Abstract Objectives The aim of this study was to investigate whether echocardiographic assessment of myocardial work is a predictor of outcome in patients undergoing operative revascularization. Background Global work index (GWI) is calculated by means of speckle tracking, blood pressure measurement at the moment of strain analysis, and a normalized reference curve. The prognostic value of GWI in patients who are scheduled for bypass surgery is unknown. Methods In this retrospective analysis, 193 patients scheduled for a bypass operation were tracked using echocardiographic strain measurement and calculation of the Global Longitudinal Strain (GLS), the GWI and ejection fraction concerning outcome parameters. The primary endpoint was the occurrence of intrahospital major cardiac events (MACE). As secondary endpoints, prolonged ICU stay (more than 24 hours), requirement for catecholamines (more than 12 hours) and duration of mechanical ventilation (mora than 12 hours) were defined as well as all-cause mortality within a year. Both GWI, EF, and Strain were examined for their validity with respect to the primary and secondary endpoints. Results The mean patient age was 63.41 years (SD 8.67). The median left ventricular ejection fraction was 53.78 % [IQR 48.30, 57.46] and the median global longitudinal strain -14.73 % [IQR-17.20, -11.87]. The median GWI was 1428.00mmHg% [IQR 1074.00, 1725.00]. Regarding the primary endpoint, no statistically significant differences were found between patients with a GWI of over 1000 mmHg% and those with a GWI of under 1000 mmHg% (p=0.281), which can be attributed to the low number of MACE events (n=13). For the secondary endpoints, there was no significant difference in terms of the duration of mechanical ventilation between patients with a GWI of under or over 1000 mmHg% (p= 0.879). However, there was a significantly higher risk for a longer stay in the ICU (OR 3.44, 95%CI [1.54, 8.33], p=0.004) among patients with a GWI of under 1000 mmHg%, and furthermore, a higher requirement for catecholamines was observed (p= 0.007). Conclusion GWI is associated with prolonged ICU Stay above 24 hours and requirement for catecholamines, but not for mace or ventilation time.

Prognostic impact of non-ischaemic late gadolinium enhancement in patients with ischaemic cardiomyopathy

Abstract Background Although the presence and extent of ischaemic late gadolinium enhancement (LGE) as assessed by cardiovascular magnetic resonance (CMR) have emerged as robust predictors of outcomes in patients with ischaemic cardiomyopathy (ICM), the prognostic significance of non-ischaemic LGE is not well established. Objective To assess the prognostic impact of the presence of non-ischaemic LGE in a large cohort of patients with ICM with reduced left ventricular ejection fraction (LVEF) undergoing CMR for myocardial viability. Methods Between 2008 and 2022, all consecutive patients referred for myocardial viability assessment using CMR with a history of ICM (≥70% stenosis in ≥1 epicardial coronary vessel on angiography and/or history of myocardial infarction and/or coronary revascularisation) and LVEF <50% were included. Non-ischaemic was defined as midwall-LGE corresponding to non-specific myocardial fibrosis. Patients with a history of acute myocarditis and/or sub-epicardial LGE were excluded. The primary outcome was all-cause mortality using the National Registry of Death. Nested Cox proportional hazard models were used to assess the additional prognostic value of the presence of non-ischaemic LGE, including its location (lateral and/or septal and other locations) and its extent (1 or ≥2 segments), beyond the presence of ischaemic-LGE and traditional prognostic factors. The incremental prognostic value of non-ischaemic LGE extent and location was assessed by the C-statistic increment. Results Among the 6,082 patients (average age 65±12 years, 73% male), 702 (12%) had additional midwall-LGE. Over a median follow-up of 9 years (IQR 7-12), 652 (11%) patients died. Non-ischaemic LGE alone was associated with a higher risk of mortality (HR: 2.9; 95% CI: 2.4-3.4, p<0.001). Figure 1 shows an increased all-cause mortality rate, regardless of ischaemic-LGE extent and transmurality. In patients with non-ischaemic LGE (N=702), survival curves indicated higher risk for lateral and/or septal locations, larger extent, and the presence of ischaemic-LGE (all p<0.001, Figure 2). After adjustment for traditional prognosticators and ischaemic-LGE extent, non-ischaemic LGE in septal and/or lateral locations (adjusted HR: 2.6; 95% CI: 1.8-3.6) and extent ≥2 segments (adjusted HR: 2.6; 95% CI: 1.8-3.7, both p<0.001) were independently associated with mortality. A comprehensive LGE model including all non-ischaemic LGE characteristics improved reclassification compared to traditional factors with and without ischaemic-LGE (C-statistic improvement: 0.13 and 0.05, all p<0.001). Conclusion In a large cohort of ICM patients, the presence of non-ischaemic LGE is an independent predictor of all-cause death, particularly for larger extent or in the septal and/or lateral segments. All-cause mortality rates Prognostic impact of non-ischaemic LGE

Genetic Risk Profiling Reveals Altered Glycosyltransferase Expression as a Predictor for Patient Outcome in Neuroblastoma.

Background/Objectives: Neuroblastoma is a highly aggressive pediatric cancer that arises from immature nerve cells and exhibits a broad spectrum of clinical presentations. While low- and intermediate-risk neuroblastomas often have favorable outcomes, high-risk neuroblastomas are associated with poor prognosis and significant treatment challenges. The complex genetic networks driving these high-risk cases remain poorly understood. This study aims to investigate differences in gene expression patterns that may contribute to disease outcomes. Methods: We employed an in silico approach to analyze a cohort of 493 neuroblastoma tumor samples that underwent mRNA sequencing (GSE49711). This dataset was reanalyzed in depth with a non-hypothesis-driven approach to identify the expression patterns and regulatory mechanisms associated with a poor prognosis. Results: By exploring global gene expression and the integration of clinical parameters, we stratified the samples into two groups with highly distinct gene expression profiles. MYCN amplification emerged as a major driver not only of poor prognosis but also of specific gene regulatory patterns. Notably, tumors with MYCN amplification exhibited the strong regulation of immune response genes and less immune infiltration, suggesting potential immune evasion. However, while we observed only minor changes in immune checkpoint expression, there was a strong modulation of glycosyltransferase genes in MYCN-amplified tumors. Using this information, we were able to construct a risk profile based on 12 glycosylation-related genes, which correlates with the survival outcomes of neuroblastoma patients. Conclusions: This study highlights the role of MYCN amplification in driving a poor prognosis in neuroblastoma through the regulation of immune response and glycosylation-related genes. Based on this finding, we developed a genetic risk profile that correlates with survival outcomes in neuroblastoma patients.

Predictors of outcome in patients with cerebral palsy following selective dorsal rhizotomy

BackgroundTo identify outcome predictors of selective dorsal rhizotomy (SDR) in children with spastic cerebral palsy (CP) using logistic regression models. MethodsA retrospective single-center study was conducted on children with spastic CP who had undergone SDR. Two outcomes were defined, one representing children not improving in motor function and spasticity and one representing children improving in motor function two years after surgery. Baseline variables were chosen based on established regressors and clinical considerations and tested for being predictors using multivariate logistic regression. ResultsWe included 96 patients (mean age [SD] 6y 9 m [2y 5 m], range 2y to 17y) in the study. Significant predictors of non-improvement in motor function and spasticity two years after SDR were higher age at surgery and higher preoperative Gross Motor Function Measure-88 (GMFM-88) score. Significant predictors of motor function improvement after SDR were lower preoperative Modified Ashworth Scale (MAS) scores, higher preoperative passive range of motion (pROM) and lower age at surgery. ConclusionsFor the first time, pROM and preoperative spasticity were identified as predictors of SDR outcome. We confirmed motor function and age as predictors. These variables will be useful for future patient selection. Adjusting for the GMFM-88's ceiling effect, children with higher motor function can still profit significantly from SDR.

Natural History and Predictors of Clinical Outcomes in Autoimmune Liver Diseases: A Multicenter Study.

Prognosis in autoimmune hepatitis (AIH), primary biliary cholangitis (PBC), and primary sclerosing cholangitis (PSC) has historically been poor. This multicenter retrospective cohort study investigated the natural history and assessed the predictors of outcomes in patients with AIH, PBC, and PSC. AIH, PBC, and PSC patients were identified from the state-wide Hepascore and Clinical Outcome cohort. Overall death or transplant, liver-related mortality (liver-related death or transplant), and liver-related decompensation were determined using a population-based data linkage system. Baseline Liver Outcome Score (LOS), Hepascore, and MELD were examined for predicting outcomes. Two-hundred thirty-seven AIH patients (24% male, median age 56.6 years [range, 14.3-94.0]), 157 PBC patients (8.3% male, median age 60.5 years [range, 25.6-87.1]), and 167 PSC patients (52.7% male, median age 55.6 years [range, 18.4-88.6]) were enrolled. Five-year transplant-free survival was 88% (95%CI: 81-92%) in AIH, 92% (95%CI: 85-96%) in PBC, and 61% (95%CI: 51-69%) in PSC. PSC had a significantly worse overall death or transplant, liver-related mortality, and liver-related decompensation when compared to AIH and PBC (p < 0.0001). LOS was a significant independent predictor of overall death or transplant, liver-related mortality, and liver-related decompensation among patients with AIH and PBC. LOS was a significant independent predictor of overall death or transplant in patients with PSC, and Hepascore was a significant independent predictor of liver-related mortality and liver-related decompensation. Outcomes for AIH and PBC are excellent but remain poor in PSC. LOS is a predictor of outcomes in autoimmune liver disease.

Outcome predictors in patients with temporal lobe epilepsy after temporal resective surgery

BackgroundTemporal lobe epilepsy is one of the most common types of partial epilepsy. Although surgical treatment has led to significant improvements in seizure-free rates, nearly one-third of patients still have poor seizure control after surgery. Moreover, the long-term outcome is less favorable compared to short-term outcome, with 48–58% of patients experiencing seizures five years after surgery. The aim of this study was to investigate the surgical outcomes and the predictive value of prognostic factors associated with poor surgical outcomes in temporal lobe epilepsy patients receiving surgery.MethodsWe retrospectively reviewed 94 patients undergoing temporal resective surgery in the Epilepsy Center of Guangdong Provincial Hospital of Traditional Chinese Medicine between July 2016 and July 2020. Patient information including age, gender, personal and family history, as well as preoperative and postoperative clinical data (clinical type and duration of disease) was collected.ResultsThe differences of postoperative clinical efficacy in both seizure free group and non-seizure free group patients were observed. A log-rank test was used for univariate analysis, and a Cox proportional hazard model was used for multivariate analysis. Ninety-four patients were followed up for at least 1 years. At 12 months of follow-up, 71 (75.5%) patients achieved Engel class I, 5 (5.3%) patients were classified as Engel class II, 5 (5.3%) patients were classified as Engel class III, and 13 (13.8%) patients were classified as Engel class IV. Univariate analysis and multivariate Cox regression analysis indicated that the postoperative EEG abnormalities were significantly correlated with seizure recurrence and were significant independent predictive factors, with a hazard ratio of 12.940.ConclusionsThe relapse rate in our study was similar to commonly reported overall rates in temporal lobe epilepsy patients receiving surgery. Anterior temporal lobectomy is a reliable treatment option for temporal lobe epilepsy patients. Postoperative electroencephalograph abnormalities are independent risk factors for poor surgical prognosis.

Antibiotic resistance genotype, phenotype, and clinical outcomes in patients with Gram-negative infections at Rabin Medical Center in Israel.

While there have been several studies that attempt to find clinical predictors of outcomes in patients hospitalized with bacterial infections, less has been done to combine clinical data with genomic mechanisms of antibiotic resistance. This study focused on a hospitalized patient population in Israel with infections due to medically important bacterial pathogens as a way to build a framework that would unite clinical data with both bacterial antibiotic susceptibility and genomic data. Merging both clinical and genomic data allowed us to find both bacterial and clinical factors that impact certain clinical outcomes. As genome sequencing of bacteria becomes both rapid and commonplace, near real-time monitoring of resistance determinants could help to optimize clinical care and potentially improve outcomes in these patients.

Neutrophil-albumin ratio serves as a superior prognostic biomarker for traumatic brain injury

Traumatic brain injury (TBI) represents a common and severe medical condition necessitating prompt risk stratification to enhance patient outcomes. Although substantial research has been conducted on the prognostic utility of various biomarkers for TBI, no single biomarker has been definitively recognized as the most precise predictor of disease outcomes. In comparison to other markers, the neutrophil-albumin ratio (NAR) has emerged as a cost-effective and reproducible inflammatory biomarker, demonstrating potential in evaluating the severity of inflammation and prognosticating outcomes in infections and cerebrovascular diseases. This study evaluated the prognostic significance of the NAR in comparison to two other readily accessible and cost-effective composite indices: the Neutrophil-Lymphocyte Ratio (NLR) and the Platelet-Lymphocyte Ratio (PLR) in individuals with TBI. We conducted a retrospective cohort analysis involving 297 hospitalized TBI patients, gathering comprehensive demographic, anthropometric, medical, clinical, laboratory, and imaging data to assess the expression changes of these biomarkers. Our findings suggest that both the NAR and the NLR possess predictive value regarding prognosis following TBI. However, receiver operating characteristic (ROC) curve analysis revealed that NAR outperformed NLR as a prognostic predictor. In conclusion, our examination of blood biochemistry composite indicators indicates that, while both NAR and NLR serve as significant prognostic markers, NAR is a more effective predictor of outcomes in patients with TBI.

Trends in Clinico-radiological and Laboratory Characteristics of All-Cause Meningoencephalitis in Western Rajasthan.

Meningoencephalitis encompasses the coexistence of meningitis and encephalitis in different proportions. This study aimed to delineate the clinical profile, laboratory parameters, radiological features, and outcome predictors of patients with meningoencephalitis. This prospective, observational, and descriptive study was conducted from July 2021 to March 2023. Patients satisfying the case definition of "meningitis" and "encephalitis" were enrolled. Mortality and morbidity (by modified Rankin Score [mRS]) were noted at discharge and at 1 and 3 months post-discharge. Of 102 patients recruited, among infectious meningoencephalitis cases, 28 (27.5%) were viral, 11 (10.8%) were pyogenic, 32 (31.4%) were tubercular, four (3.9%) each were rickettsial, atypical bacterial, and fungal, and three (2.9%) were parasitic. Among noninfectious etiologies, 12 (11.8%) were antineuronal antibody mediated, three (2.9%) had systemic inflammatory etiology, and one (1%) had carcinomatous meningitis. Cerebrospinal fluid (CSF) analysis showed the highest protein content (336.82 ± 251.26 mg/dL) and cell count (476.73 ± 999.16/mm 3 ) in pyogenic followed by tubercular (200.29 ± 174.28/mm 3 ) meningoencephalitis. CSF glucose was lowest in tubercular group (38.30 ± 20.29 mg/dL). Imaging showed leptomeningeal enhancement predominantly in tubercular group (89.7%) and limbic involvement in viral etiology (38.5%). Overall mortality was highest in fungal and rickettsial groups (three out of four patients died at 1 month in each group). Pyogenic, atypical bacterial, and systemic inflammatory meningoencephalitis had maximum temporal improvement in mRS at 1 month, while tubercular, viral, and antineuronal antibody-mediated meningoencephalitis had decrease of at least 1 mRS at 3 months. Fever, altered sensorium, speech disturbances, neck stiffness, albumin, total leukocyte count, erythrocyte sedimentation rate, C-reactive protein, kidney and liver function tests showed significant association with mortality. Tubercular, followed by viral meningoencephalitis, was the most common cause in our center in western India. Pyogenic, atypical bacterial, and systemic inflammatory groups had the best recovery at discharge, while fungal and rickettsial meningoencephalitis groups had worst mRS at 3 months.

Validation of existing risk scores for worsening renal function in patients with newly diagnosed heart failure: a longitudinal population cohort study

Abstract Background Worsening renal function (WRF) is one of the strongest predictors of outcome in patients with heart failure (HF). The presence of WRF often influences the decision to start, up-titrate, or discontinue disease-modifying HF therapies and is one of the key determinants of suboptimal guideline-directed medical therapy. However, there are now potential cardiovascular pharmacotherapies that have favourable cardiorenal outcomes and reduce the risk of renal decline. It is therefore important to identify patients with HF early in their disease trajectory who are at risk of developing WRF. Purpose The aim of this study was to evaluate two existing WRF risk scores (the Forman risk score and the Basel risk score) in a population-based longitudinal cohort diagnosed with incident HF. Methods Data for individuals with incident HF between 2016 to 2021 were extracted and analysed from the NELSON study conducted in Tayside, Scotland. WRF was defined as a composite event of (i) having two consecutive eGFRs declined by 40% or greater; (ii) having an eGFR &amp;lt; 15mL/min/1.73m2; (iii) initiation of sustained dialysis; (iv) development of end-stage kidney disease; or (v) receiving kidney transplantation. The primary outcome was the occurrence of WRF within 180 days of diagnosis of HF. Among patients hospitalised with HF, in-hospital WRF was also assessed. The area under the curve (AUC) was used to assess the discrimination performance of the two risk scores in individuals with incident HF diagnosed as either in-patients or out-patients. Results 4076 individuals (mean age 72.8 ± 13.2; 58% male; 1081 HFrEF, 646 HFmrEF, 1348 HFpEF, and 1001 HF with unknown ejection fraction (EF)) who were WRF-free at incident HF diagnosis were identified. Of these, 2095 (51.4%) were diagnosed as in-patients, and 1981 (48.6%) were diagnosed as out-patients. 285 (7%) patients developed WRF within 180 days post HF diagnosis. Among the 2,095 HF in-patients, 75 (3.6%) developed WRF before discharge. The Forman risk score had an AUC of 0.618 (95% CI: 0.585 – 0.651) in predicting 180-day WRF, and an AUC of 0.650 (0.587 – 0.713) for in-hospital WRF. The Basel risk score showed similar discriminating performance with an AUC of 0.618 (0.585 – 0.651) for 180-day WRF, and 0.656 (0.593 – 0.719) for in hospital WRF. Conclusions In a contemporary population, conventional risk scores such as the Forman or Basel risk scores have limited discrimination in predicting WRF in incident HF. New models with better discrimination for WRF prediction are therefore needed.

The effect of Trimetazidine on the left ventricular global longitudinal strain assessed by cardiac magnetic resonance in stable angina patients with previous myocardial infarction and left ventricular

Abstract Introduction Trimetazidine (TMZ) is an anti-ischemic metabolic agent that is indicated in adults as add-on therapy for the symptomatic treatment of patients with stable angina pectoris (SA). Global left ventricular (LV) systolic function is an important predictor of outcomes in patients after myocardial infarction (MI). Cardiac magnetic resonance (CMR) imaging has now evolved into a major tool for the evaluation of patients with LV dysfunction, providing precise measurements of ejection fraction (EF) and viability assessment but also now allowing assessment of global longitudinal strain (GLS) from standard cine CMR images. We hypothesized that the use of TMZ 80 mg as an anti-ischemic agent in patients with SA, history of MI, reduced EF and in the presence of viable myocardium may produce an early modification of GLS. Methods TRIM-AZ - was a non-interventional, prospective Azerbaijan study to analyze the capacity of short-term therapy with TMZ 80 mg on LV GLS evaluated by CMR in patients with previous MI. Patients with a confirmed diagnosis of heart failure (HF) with impaired LV systolic function and SA in the presence of viable myocardium were included. The treatment of all patients was optimized according to the latest ESC guidelines before entry in the study. Patients were randomized into two groups, one received TMZ 80 mg on top of guidelines directed medical therapies, and the other was the control group. A CMR as well as a transthoracic echography were performed for all patients at the inclusion visit and 8 weeks later. Results 52 patients were included in the study, 30 patients in the TMZ group and 22 in the control group,. At baseline, the mean age was 62±7 years , 63% were smokers, 60% hypertensive, 60% diabetics, 48% had a family history of MI, 12% had typical symptoms of SA while 88% had atypical form (e.g. like shortness of breath). All patients received baseline therapy with ARNI/ACE-i, SGLT2 inhibitors, beta-blockers, MRA, ASA, and statin. 8 weeks after the initiation of TMZ, there were no significant changes in LVEF assessed both by Echo and CMR (29,8%±3,2% vs 30,1%±3,5% by echo in TMZ group; 31,3%±2,7% vs 31,6%±2,7% by echo in the control group; 25,9%±3,1% vs 26,9±4,1% by CMR in TMZ group; 26,9%±2,1% vs 30,1%±2,3% by CMR in the control group), however GLS was significantly improved in TMZ group (-9,9%±1,1% to -12,7%±1,2%, p=0,00), but not in control group (-9,3%±1,3% vs -10,3%±1,4% p=0,3). No adverse event related to TMZ use was reported during the study. Conclusion These findings suggest that the use of trimetazidine in patients with stable angina , previous MI and heart failure in the presence of viable myocardium could improve the left ventricular global longitudinal strain assessed by CMR.

Coronary microvascular dysfunction in patients with heart failure with reduced and mildly reduced ejection fraction: results from the PANACEA study

Abstract Aims Coronary microvascular dysfunction (CMD) is common and associated with impaired survival in patients with heart failure with preserved ejection fraction (HFpEF). In patients with heart failure with reduced ejection fraction (HFrEF) and mildly reduced ejection fraction (HFmrEF) the impact of CMD is not fully known. Purpose We aimed to investigate the prevalence of CMD and its association with phenotype, biomarkers, endothelial function and echocardiographic measurements in patients with HFrEF or HFmrEF. Method A prospective, exploratory bi-center study in patients with chronic stable heart failure, New York Heart Association (NYHA) Class II-IV, and ejection fraction (EF) &amp;lt;50% was performed. Study procedures included echocardiography, adenosine-based transthoracic Doppler echocardiography to assess coronary flow reserve (CFR), physical examination, fasting blood and urine sample, pulse wave velocity (PWV) and hemodynamic measurements. The cutoff of CFR&amp;lt;2.5 was used to diagnose CMD. A multivariable linear regression analysis with CFR as dependent variable, adjusted for age, sex, body mass index, smoking, atrial fibrillation and left ventricular mass, was performed to explore biomarkers, endothelial function, and echocardiographic measurements associated with CMD. Results Of 112 included patients, 87 (78%) were men, with a mean age of 73.3 (±7.5) years. Among patients with a successful CFR measurement (n=62), CMD was present in 40 (65%), mean age of 75.4 (±5.8) years (Table 1). Patients with CMD had higher N-terminal pro B-type natriuretic peptide (NTproBNP) and Troponin T (p&amp;lt;0.05), and more often HFrEF ( p=0.06). Patients with CMD had larger ventricles with greater left ventricular mass and larger end-diastolic volumes (p&amp;lt;0.05). In a linear regression analysis CMD was associated with higher NTproBNP, lower EF, PWV and global strain (table 2). Conclusion CMD was common and present in two thirds of patients with HFrEF or HFmrEF. Further CMD was associated with markers of more severe heart failure and systemic endothelial dysfunction indicating that CMD may be an important predictor of outcome in patients with HFrEF and HFmrEF.

Development and validation of a risk prediction model for worsening renal function in patients with incident heart failure

Abstract Background Worsening renal function (WRF) is one of the strongest predictors of outcome in patients with heart failure (HF). The presence of WRF often influences the decision to start, up-titrate, or discontinue disease modifying HF therapies and is one of the key determinants of suboptimal guideline-directed medical therapy. Existing WRF risk scores were developed in hospitalised HF patients to predict in-hospital WRF. Their performance among incident HF is far from ideal. It is therefore important to develop a new WRF risk prediction model in people with newly diagnosed HF. Purpose This study was to develop and validate a clinical risk prediction model for 180-day WRF post diagnosis of incident HF using data from a population-based longitudinal cohort. Methods We developed and validated a multivariable logistic regression model for WRF in the 180 days post diagnosis of incident HF. Data for individuals with incident HF between 2016 to 2021 were extracted from the NELSON study conducted in Tayside, Scotland. WRF was defined as a composite event of (i) having two consecutive eGFRs declined by 40% or greater; (ii) having an eGFR &amp;lt; 15mL/min/1.73m2; (iii) initiation of sustained dialysis; (iv) development of end-stage kidney disease; (v) receiving kidney transplantation; or (vi) kidney related death. Four candidate models included one model using literature knowledge; one multivariable fractional polynomial (MFP) model; and two stepwise selected models based on either Akaike or Bayesian information criterion (AIC or BIC). Calibration and discrimination were assessed, and performance stability were evaluated using optimism corrected performance via 1000 times bootstrapping. Results 4076 individuals (mean age 72.8 ± 13.2; 58% male; 1081 HF with reduced ejection fraction (HFrEF), 646 with HF with mildly reduced ejection fraction (HFmrEF), 1348 HF with preserved ejection fraction (HFpEF), and 1001 HF with unknown ejection fraction (EF)) who were WRF-free when diagnosed with HF were identified. Of these, 2095 (51.4%) were in-patients, and 1981 (48.6%) were out-patients. 285 (7%) patients developed WRF within 180 days post HF diagnosis. The selected MFP model (comprising 12 predictors, Table 1) showed good calibration (slope = 1.00 [0.86, 1.14]; intercept = 0.0 [-0.13, 0.13]) discrimination (C-statistic = 0.69 [95% CI: 0.65, 0.72]), and stability (optimism corrected: calibration slope = 0.94 [0.80, 1.07]; calibration intercept = -0.14 [-0.50, 0.20]; C-statistic = 0.67 [0.64, 0.71]). Discrimination of the developed model significantly outperformed two existing risk scores (Forman and Basel, both with a C-statistic = 0.62 [0.59 – 0.65]). Conclusions We have shown that the developed model performed better in predicting WRF in individuals with newly diagnosed HF. This could have utility in identifying at risk patients with HF early in the disease trajectory for therapies that can reduce renal decline.Calibration of predicted riskModel estimates for predicting 180d WRF

Three dimensional biatrial expansion index as an independent predictor of outcome in dilated cardiomyopathy

Abstract Background Left atrial expansion index (LAEI) is a marker of left ventricular (LV) diastolic dysfunction and an outcome predictor in heart failure (HF). However, the role of the right atrial expansion index (RAEI) in the setting of left-sided HF is incompletely understood. Purpose We sought to evaluate the left, right and combined bi-atrial expansion index (BAEI) with three-dimensional (3D) echocardiography in a cohort of patients with dilated cardiomyopathy (DCM) and to assess their prognostic role. Methods We enrolled 121 consecutive patients (mean age 59±14 years, 74% men) with DCM in sinus rhythm, who underwent 3D echocardiography and were prospectively followed for 19±11 months for an endpoint of death, nonfatal cardiac arrest and HF hospitalization. As previously described, for the left atrium (LA), LAEI was measured as (3D LA Vmax – 3D LA Vmin) x 100/3D LA Vmin, where Vmax was the maximal end-systolic atrial volume and Vmin was the minimal end-diastolic atrial volume. For the right atrium (RA), RAEI was calculated as (3D RA Vmax – 3D RA Vmin) x 100/3D RA Vmin. BAEI was defined as the sum of LAEI and RAEI. Results 55 patients (46%) reached the endpoint: there were 27 deaths, 5 nonfatal cardiac arrests and 23 readmissions for HF. Patients with adverse outcome had lower LAEI (52±25 vs. 63±36, p=0.047), lower RAEI (57±29 vs. 70±32, p=0.02), lower BAEI (108±46 vs. 133±55, p=0.008). In univariate Cox regression, all three expansion indices were predictors of adverse events: HR=3.23 [95% CI, 1.45-7.20], p=0.004 for LAEI, HR=2.12 [95% CI, 1.24-3.61], p=0.006 for RAEI, HR=3.99 [95% CI, 1.70-9.36], p=0.001 for BAEI. We constructed a multivariable model with well-established event predictors in DCM and one expansion index at a time. After adjustment for age, left ventricular ejection fraction, mitral regurgitation severity and pulmonary artery systolic pressure, all three expansion indices remained independent predictors of the composite endpoint: HR=2.75 [95% CI, 1.18-6.38], p=0.02 for LAEI, HR=1.86 [95% CI, 1.04-3.31], p=0.04 for RAEI, HR=3.53 [95% CI, 1.46-8.51], p=0.005 for BAEI. BAEI yielded the highest incremental prognostic power (likelihood ratio chi2 test=14, p=0.03) on top of the baseline model consisting of age, left ventricular ejection fraction, mitral regurgitation severity and pulmonary artery systolic pressure (likelihood ratio chi2 test=9). Conclusion In DCM, 3D atrial expansion indices are significantly lower in patients with major adverse events, reflecting a more impaired atrial reservoir dysfunction. Both LAEI, RAEI and BAEI were independent outcome predictors in patients with DCM. Combining the left and right atrial expansion indices might improve risk stratification, since BAEI had the highest predictive value after adjustment for confounders.

The associations of post-stroke delirium with outcomes: a systematic review and meta-analysis

BackgroundPublished data on whether post-stroke delirium (PSD) is an independent predictor of outcomes in patients with acute stroke are inconsistent and have not yet been synthesized and quantified via meta-analyses.MethodsThis systematic review and meta-analysis followed the Meta-analysis of Observational Studies in Epidemiology (MOOSE) and Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The study protocol involved a search of the PubMed, Embase, PsycINFO, and Medline databases from 1946 to November 1, 2023, of which prospective observational and case–control studies were included. The quality of the included studies was rated using the Newcastle Ottawa Scale. Pooled effect estimates calculated using a random-effects model were expressed as the odds ratios (ORs), hazard ratios (HRs), and standardized mean differences (SMDs) with 95% confidence intervals (CIs). The protocol was registered in PROSPERO (CRD42023472551).ResultsThe search yielded 39 eligible articles comprising 3295 and 9643 patients with and without PSD, respectively. Thirty studies were high quality, while 9 had moderate quality. The primary analyses, adequately adjusting for predefined confounders, showed that PSD was significantly associated with mortality risk (average follow-up of 19.50 months; OR, 3.47; 95% CI, 2.35–5.12; I2, 26.0%) and poor neurological function (average follow-up of 21.75 months; OR, 3.62; 95% CI, 2.15–6.09; I2, 0). Secondary analyses, with or without inadequate adjustment, showed that PSD was significantly associated with prolonged hospital length of stay, increased risk of institutionalization, poor cognitive outcomes, and quality of life after discharge.ConclusionsThis systematic review and meta-analysis provides evidence that PSD was independently associated with mortality and poor neurological function after controlling for pre-specified confounders. The prevention of PSD remains a high clinical and research priority.

Letter Regarding: Validation of the C-DU(KE) Calculator as a Predictor of Outcomes in Patients Enrolled in Steroids for Corneal Ulcer and Mycotic Ulcer Treatment Trials.

Letter Regarding: Validation of the C-DU(KE) Calculator as a Predictor of Outcomes in Patients Enrolled in Steroids for Corneal Ulcer and Mycotic Ulcer Treatment Trials.

C-reactive protein/albumin ratio versus lactate/albumin ratio as an outcome predictor for patients with sepsis and septic shock in hospital stay

Background &amp; Objective: Pre-emptively identifying individuals at risk of developing sepsis and septic shock remains challenging. In septic patients, the Lactate/Albumin Ratio (LAR) and C-reactive protein (CRP)/Albumin ratio (CAR) have been suggested to be promising prognostic indicators for prediction of intensive care unit (ICU) mortality. We compared the prognostic values of CAR and LAR in patients with sepsis and septic shock. Methodology: Eighty adult patients diagnosed with sepsis and admitted to the ICUs of Ain Shams University Hospitals, were included in this observational prospective study. CRP levels, serum lactate, serum albumin, complete blood count (CBC), procalcitonin levels, and SOFA scores were assessed upon admission, with subsequently observing 28-day mortality among the selected patients. Results: CAR values were comparable between the mortality and survival groups (P = 0.807). However, LAR values were significantly elevated in the mortality group vs the survival group (P = 0.044). ROC analysis for mortality indicated that LAR had an AUC of 0.633 at a cutoff value &gt; 0.68, achieving sensitivity and specificity of 89.4% and 21.2%, respectively. In contrast, CAR had an AUC of 0.484 at a cutoff value ≥ 1.54, with sensitivity and specificity values of 63.8% and 57.6%, respectively. Length of ICU stay (P &lt; 0.001), duration of mechanical ventilation (P &lt; 0.001), cardiovascular support (P &lt; 0.001) and the need for renal replacement therapy (P &lt; 0. 039), were increased in the mortality group compared to the survival group. Conclusion: Lactate/albumin ratio is superior and more reliable bio-marker predictor compared to C-reactive protein (CRP)/albumin ratio for ICU mortality. Abbreviations: CAR - C-reactive protein/albumin ratio; CRP - C-reactive protein; ICU - intensive care unit; LAR - Lactate/Albumin Ratio; Keywords: Albumin; CRP To Albumin Ratio; Lactate; Lactate to Albumin Ratio; Mortality; Sepsis; Septic Shock; SOFA; Survival Citation: Abdou K, Mounir M, Abdelmohsen S, Salem S, Ali A. C-reactive protein/albumin ratio versus lactate/albumin ratio as an outcome predictor for patients with sepsis and septic shock in hospital stay. Anaesth. pain intensive care 2023;28(5):901−907; DOI: 10.35975/apic.v27i5.2571 Received: July 29, 2024; Reviewed: August 23, 2024; Accepted: August 28, 2024