Prevalence Of Comorbidities Research Articles

Predictors of new-onset in-hospital atrial fibrillation in 122 089 patients admitted with COVID-19: an Australian statewide population study

Abstract Background New-onset atrial fibrillation (AF) when encountered in COVID-19 patients may be associated with increased mortality and thromboembolic events. Few studies have investigated predictors of new-onset AF in the context of COVID-19 and no study has assessed the utility of CHA2DS2VASc score in predicting new-onset AF in COVID-19 patients. Purpose This study aims to identify independent predictors of new-onset in-hospital AF in patients admitted with COVID-19. Methods Patients admitted with COVID-19 (1-Jan-2020 to 30-Sept-2021) were identified from the Admitted-Patient-Data-Collection database in an Australian state, stratified by AF status (no-AF vs new-AF during index COVID-19 admission) and followed-up until 31-Mar-2022. Patients with prior-AF were excluded from analysis. New-AF was defined as new-onset AF during the hospital admission for COVID-19. Independent predictors of new-AF were identified using multivariable logistic regression. Receiver Operating Characteristic (ROC) derived Area Under Curve (AUC) score was performed to determine the predictive power of independent predictors of new-AF. Results The cohort comprised 122089 COVID-19 patients (median age 62.7 yrs; 48.5% males) of whom 5140 developed new-AF (4.2%). Compared to patients with no-AF, patients with new-AF had a higher prevalence of comorbidities and cardiac risk factors (hypertension, diabetes and smoking) as well as a higher CHA2DS2VASc score (p < 0.001) (Table 1). Independent predictors of new-AF included referral from Emergency Department (adjusted odds ratio [aOR] =1.63, 95% confidence interval [CI]=1.49-1.78, intensive-care-unit admission (aOR=3.46, 95%CI=3.22-3.71), current/ex-smoker (aOR=1.20, 95%CI=1.12-1.27), prior coronary revascularization (percutaneous coronary intervention or coronary artery bypass graft surgery) (aOR=1.33, 95%CI=1.01-1.75), valvular heart disease (aOR=3.20, 95%CI=2.73-3.75), malignancy (aOR=1.15, 95%CI=1.02-1.29), chronic pulmonary disease (aOR=1.30, 95%CI=1.19-1.42) and higher CHA2DS2VASc score (per-1-score increase: aOR=1.62, 95%CI=1.59-1.65) (all P<0.05). CHA2DS2VASc score alone had an AUC score of 0.729 (95%CI=0.72-0.74) (Figure 1). Adding the above additional independent variables to CHA2DS2VASc score improved the predictive model to an overall AUC score of 0.773 (95%CI=0.77-0.78), p < 0.001. Conclusions This study identified patients at risk of developing new-AF in the setting of COVID-19 infection. Our multivariable logistic regression analysis that included CHA2DS2VASc score has a relatively good predictive value and if confirmed in other COVID-19 cohorts, may be used to identify patients in whom antiarrhythmic and more aggressive thromboprophylactic strategies can be considered.

Prognostic significance of coexistent coronary artery disease in patients undergoing transcatheter aortic valve implantation for aortic stenosis

Abstract Background The optimal management of coronary artery disease (CAD) in patients undergoing transcatheter aortic valve implantation (TAVI) for aortic stenosis (AS) is uncertain. As TAVI expands into lower risk cohorts with longer life expectancies there is increasing need to determine the prognostic significance of coexistent CAD and identify which lesions may benefit from revascularisation. Purpose To evaluate the prognostic significance of coexistent CAD in patients with AS undergoing TAVI stratified according to myocardial territories at risk. Methods Using a retrospective, single-centre, observational registry, patients undergoing TAVI for severe AS between 2015 and 2020 were included. CAD was angiographically determined using computed tomography or invasive coronary angiography. CAD was stratified into 1) low-risk: <70% stenosis in all major epicardial coronary arteries or <50% in the left main (LM); 2) intermediate-risk: ≥70% stenosis in one or two arteries, except the proximal left anterior descending (LAD) and LM; 3) high-risk: ≥70% stenosis in the proximal LAD, ≥70% stenosis in 3 arteries or LM stenosis ≥50%. Patients with previous CABG were categorised as high-risk if: ≥70% stenosis of 3 coronary grafts or graft supplying a proximally stenosed LAD; and intermediate-risk if: ≥70% stenosis of 1 or 2 non-LAD grafts. Baseline characteristics and procedural outcomes were compared between the 3 cohorts, with the impact of CAD on outcomes evaluated after adjustment for demographics and comorbidities. Results 1805 patients were included; median age 84 (79-88), 51% male sex, median logistic Euroscore 13 (8-21). 1281 (71%), 384 (21%) and 140 (8%) patients were characterised as low-, intermediate- and high-risk coronary anatomy respectively. High risk patients were older than the other groups, however, did not have the highest prevalence of comorbidities (Table 1). Other than pacemaker implantation (9% vs 12% vs 6%, p=0.04), there were no differences in procedural complications or in-hospital mortality between groups (Table 1). At a median follow-up of 3.5 (2.3-4.8) years, 920 patients (51%) died, 292 (16%) had hospitalisation for heart failure (HHF) and 565 patients (31%) had a major adverse coronary event (MACE); defined as either myocardial infarction, HHF or cardiovascular death. Coronary anatomical stratification was associated with MACE (Log rank p<0.001) (Figure 1). After multivariate adjustment, high-risk anatomy was associated with all-cause mortality (hazard ratio (HR): 1.34, 95% confidence interval (CI): 1.06-1.68, p=0.013), HHF (HR: 1.49, 95% CI: 1.01-2.21, p=0.046) and MACE (HR: 1.68, 95% CI: 1.27-2.21, p<0.001). Conclusions Whilst the presence of CAD does not impact TAVI procedural safety, untreated high-risk coronary anatomy is associated with future adverse events and may warrant intensive medical therapy and/or revascularisation.

The clinical characteristics and prognosis of patients with acute ST-segment elevation myocardial infarction complicated with impaired activity daily living

Abstract Background Previous studies have indicated that activities of daily living (ADL) can influence the prognosis of patients with acute myocardial infarction. The purpose of this study is to delineate the clinical characteristics, treatment regimens, and prognosis of patients with acute ST-segment elevation myocardial infarction (STEMI) who have impaired ADL. Methods The data for this study were derived from a Health and Medical Big Data Superplatform, comprising a retrospective cohort of patients admitted to and discharged from 72 secondary and tertiary hospitals from 2010 to 2023. The inclusion criteria encompassed patients with a discharge diagnosis of STEMI.ADL prior to STEMI was evaluated using the Barthel index(BI),a widely used assessment tool for evaluating ADL.The patients' BI were obtained from their resident health records.Patients were categorized into two groups: ADL normal group and ADL impaired group. A comparative analysis was conducted between the two groups regarding clinical characteristics, treatment regimens, and prognosis. Results This study included 24,906 STEMI patients with normal ADL and 1,002 STEMI patients with impaired ADL. Baseline data revealed that patients in the ADL impaired group had a higher proportion of females (43.0% vs. 37.8%, p=0.001), were older (74.0[64.0,81.0] vs. 69.0[65.0,75.0], p<0.001), and had a higher proportion of Killip III and above (24.30% vs. 14.10%, p<0.001). Additionally, the ADL impaired group had a higher prevalence of comorbidities. In terms of treatment, the ADL impaired group had lower proportions of patients undergoing percutaneous coronary intervention (PCI) (43.8% vs. 65.3%, p<0.001) and primary PCI (PPCI) (36.4% vs. 55.1%, p<0.001). Additionally, the ADL impaired group exhibited lower utilization rates of antiplatelet drugs, ACEI/ARB, beta-blockers, ARNI, and statins, but higher rates of diuretics and cardiac glycosides. Regarding prognosis, the ADL impaired group had a higher in-hospital mortality rate (5.69% vs. 2.89%, p<0.001). The median follow-up time was 1,220 days. In the ADL impaired group, the rates of all-cause mortality (52.0% vs. 24.7%, p<0.001), cardiovascular mortality (37.3% vs. 17.3%, p<0.001), recurrent non-fatal myocardial infarction (11.1% vs. 8.30%, p=0.002), and recurrent stroke (11.9% vs. 8.66%, p=0.001) were higher. However, the rate of revascularization was lower in the ADL impaired group (6.69% vs. 9.20%, p=0.008), and the risk of cerebral hemorrhage showed no significant difference (1.00% vs. 0.81%, p=0.631). In a multivariate Cox regression analysis adjusting for age, gender, Killip, medical history, and treatment strategies, impaired ADL remained an independent risk factor for increased all-cause mortality (aHR 1.309, 95% CI: 1.195-1.434, p<0.001). Conclusions Impairment of ADL is associated with adverse clinical outcomes in patients with STEMI.Baseline characteristics of patientsMedications of patients

Overdiagnosis for screen-detected prostate cancer incorporating patient comorbidities

Abstract Background Evidence regarding the likelihood of overdiagnosis in prostate cancer (CaP) screening with PSA are mainly based on clinical trials, which include younger population with fewer comorbidities than those receiving the test in clinical practice. We aimed to assess the likelihood of overdiagnosis and associated variables using real-world data. Methods Retrospective cohort of men >40 years with PCa, who had been diagnosed being asymptomatic and after a positive PSA test in the previous 12 months in two hospitals (2004-2022). The probability of overdiagnosis was estimated considering the life expectancy of the Spanish male in the year 2022 and the Charlson Comorbidity Index (lead time 10 years). PSA values and Gleason score were included as independent variables. Results Of the 2,331 patients in the cohort, 1,070 (46%) met the inclusion criteria for this analysis. The median follow-up time was 5.7 years (IQR 3.2-8.6). The median age was 71 years (IQR 65-78) and 37% had more than one comorbidity. At diagnosis, the median life expectancy was 12 years (IQR 4-18) and the probability of overdiagnosis was 30.8% (IQR 17.6-52.4). Patients with PSA levels >10 mg/dl tended to be older and with more comorbidities than those with PSA levels 4-10 mg/dl, and thus, with shorter life expectancy. The median probability of overdiagnosis was higher in patients with PSA levels >10 mg/dl (41.4%, IQR 21.5-73.9) than in those with PSA levels 4-10 mg/dl (20.1%, IQR 12.8-30.4), p < 0.001. Correspondingly, patients with Gleason score ≥8 were more likely to be overdiagnosed (median 42.6%, IQR 23.6-68.6) than those with Gleason score ≤6 (median 20.1%, IQR 12.8-30.4) (p < 0.001). Conclusions In clinical practice, older patients with comorbidities showed high PSA levels and Gleason score ≥8, presenting low life expectancy at diagnosis and, therefore, high probability of overdiagnosis. This highlights the importance of considering the patient’s comorbidities when ordering a new PSA test. Key messages • A detailed assessment of the prevalence of comorbidities among CaP patients in real-life settings has significant implications for patient management. • The decision to make an early diagnosis should be based on individual life expectancy, where comorbidity is at least as important as age.

Prediction model for survival of younger patients with breast cancer using the breast cancer public staging database

Breast cancer (BC) is a major contributor to female mortality worldwide, particularly in young women with aggressive tumors. Despite the need for accurate prognosis in this demographic, existing studies primarily focus on broader age groups, often using the SEER database, which has limitations in variable selection. This study aimed to develop an ML-based model to predict survival outcomes in young BC patients using the BC public staging database. A total of 3,401 patients with BC were included in the study. Patients were categorized as younger (n = 1574) and older (n = 1827). We applied several survival models—Random Survival Forest, Gradient Boosting Survival, Extra Survival Trees (EST), and penalized Cox models (Lasso and ElasticNet)—to compare mortality characteristics. The EST model outperformed others in predicting mortality for both age groups. Older patients exhibited a higher prevalence of comorbidities compared to younger patients. Tumor stage was the primary variable used to train the model for mortality prediction in both groups. COPD was a significant variable only in younger patients with BC. Other variables exhibited varying degrees of consistency in each group. These findings can help identify high-risk young female patients with BC who require aggressive treatment by predicting the risk of mortality.

Integrating international lifestyle management of acute coronary syndrome and type 2 diabetes mellitus: a rapid review of guidelines

Abstract Background The rising prevalence of comorbidity has been described as an international health priority. There has been a dramatic increase in the levels of Type 2 Diabetes Mellitus (T2DM) among those with Acute Coronary Syndrome (ACS), with approximately 25-40% of patients admitted to hospital for ACS, also having diabetes. Comorbid ACS-T2DM provides a more complex set of symptoms for patients and clinicians to manage, and health policy makers to plan for. Those living with comorbid ACS-T2DM are at increased risk of death, another heart attack, re-hospitalisation, heart failure, reduced physical and psychological health, increased health service use and poorer quality of life. Due to shared disease determinants such as obesity, low physical activity levels and poorer dietary habits; individuals with ACS are more likely to have a comorbid T2DM. Care for patients with comorbidities is fragmented, siloed and poorly organised as it reflects a tradition of single disease management meaning comorbidity is rarely considered. Robust evidence is required to shape provision and guidance for those with comorbid ACS-T2DM and the clinicians involved in their care; with an emphasis on redesigning service provision and practice to address the needs of this growing population. Purpose To identify opportunities in existing clinical guidance to improve integrated care strategies and streamline management for those with comorbid ACS-T2DM. Methods Following Cochrane rapid review recommendations, a Population, Concept, and Context (PCC) framework guided eligibility. Guidelines for adults with ACS, T2DM, or both conditions in high-income countries were considered. Nineteen guidelines from the UK, Australia, Canada, Europe, Ireland, New Zealand, and the USA were compared, covering ACS (n = 10), T2DM (n = 6), and comorbid ACS-T2DM (n = 3). Lifestyle factors examined included diet/nutrition, physical activity, weight management, clinical and psychological aspects. Results The review identified consistent lifestyle recommendations for both ACS and T2DM, with overlaps in guidance for diet, physical activity, weight management, clinical, and psychological factors. The findings offer opportunity for integrated care strategies, potentially reducing duplicated lifestyle management efforts. The results lay the groundwork for more cohesive management of comorbid ACS-T2DM. Conclusions This research is relevant for healthcare providers, policymakers, and patients living with comorbid ACS-T2DM. Understanding the shared lifestyle factors provides valuable insights into the potential for integrated care. Recognising the overlap in existing clinical guidelines points to opportunity for a more streamlined and effective approach to managing comorbid ACS-T2DM. This knowledge can contribute to improved patient outcomes and seek to optimise healthcare resources.

Unveiling the prognostic journey: renal function trajectories in 'de novo' heart failure with reduced ejection fraction - insights from a cohort study and their impact on patient outcomes

Abstract Background HFrEF poses significant clinical challenges globally. Renal dysfunction frequently coexists with HF, exacerbating prognosis. However, the dynamic trajectory of renal function in 'de novo' HFrEF patients and its prognostic implications remain understudied. Methods We conducted a prospective cohort study involving 370 'de novo' HFrEF patients. Renal function was initially assessed upon admission and re-evaluated at the end of the titration period. The CKD-EPI formula was used for renal function assessment. Patients were followed up for a median of 15 months. Statistical analyses were performed to evaluate predictors of adverse outcomes. Results Baseline renal function significantly influenced outcomes, with eGFR < 45 ml/min associated with higher mortality and heart failure readmissions. Among patients with available renal function data at discharge (n=354), 87 (24.6%) had eGFR < 45 ml/min, while 267 (72.2%) ≥ 45 ml/min. Patients with eGFR < 45 ml/min exhibited older age, higher prevalence of comorbidities, lower haemoglobin levels, and higher creatinine and NT-proBNP levels, both at admission and discharge. Furthermore, they were less likely to receive certain heart failure medications at discharge. During follow-up, 46 deaths (13.0%) and 105 events of combined all-cause death and readmission due to heart failure (29.6%) occurred. Patients with eGFR ≥ 45 ml/min exhibited a lower overall mortality (HR: 0.29, p < 0.001) and all-cause death and heart failure readmissions (HR: 0.32, p < 0.001) both in univariate and multivariate analysis (HR: 0.63, p = 0.028 for mortality; HR: 0.53, p = 0.038 for combined endpoint). See Figure 1. Among patients with available renal function data at follow-up (n=304), 240 (78.9%) had eGFR ≥ 45 ml/min (stabilization or improvement), and 64 (21.1%) had eGFR < 45 ml/min (deterioration or previously < 45 ml/min). Patients with eGFR < 45 ml/min at follow-up exhibited older age, lower BMI, higher prevalence of comorbidities, lower haemoglobin levels, and higher NTproBNP levels at admission and discharge. They were also less likely to receive certain crucial heart failure medications at discharge and follow-up (Table 1). During follow-up, 31 deaths (10.1%) and 87 events of combined death and readmission due to heart failure (38.6%) occurred. In univariate analysis, patients with eGFR ≥ 45 ml/min exhibited a lower overall mortality (HR: 0.27, p < 0.001) and admissions (HR: 0.30, p < 0.001), which remained significant in multivariate analysis (HR: 0.43, p = 0.048 for mortality; HR: 46, p = 0.014 for admissions). See Figure 1. Conclusion Our findings underscore the importance of integrated heart-kidney care in 'de novo' HFrEF patients. Continuous monitoring of renal function and interventions to prevent deterioration are crucial for optimizing outcomes. Further research is needed to validate these findings and explore targeted therapeutic strategies for renal protection in HFrEF.

Gender-specific differences in severe tricuspid regurgitation. Finding from a TR multicentre CMR registry

Abstract Background Observational studies have suggested that severe tricuspid regurgitation (TR) is more prevalent in women than in men, although the pathophysiological causes that justify this difference are unknown. Purpose 1) to assess clinical and imaging differences by Cardiac Magnetic Resonance (CMR) between men and women and 2) to examine the relationship between gender and all-cause mortality in a multicentre cohort of patients with at least severe TR. Methods The study-enrolled patients with at least severe TR assessed by 2D echocardiography who underwent a contemporary cardiac magnetic resonance (CMR) study. The primary outcome was all-cause mortality. Results 318 patients with severe TR recruited from 5 tertiary care hospitals were included in this study (70 ± 11 years, 67% female, 73% NYHA I or II). Regarding the etiology, 10% were primary TR, 1% CIED-related TR, 46 % atrial secondary TR and 43% ventricular secondary TR. Women showed a non-significant tend to lower prevalence of comorbidities, lower BNP and significantly lower creatinine values (table). Regarding CMR variables, women showed smaller indexed right ventricle (RV) volumes higher RVEF and lower TR regurgitant volume (table, p<0.05 for all). Left ventricle (LV) volumes were smaller and LVEF higher in women compared to men (p<0.001). During a median follow-up of 28 months (IQR: 10-54 months), there were 61 deaths (19%) with an estimated 5-year survival of 74%. Cumulative all-cause mortality was significantly worse in men compared to women (27% vs. 15%, p<0.001, figure). Male gender was significantly associated with all-cause mortality independently of age, RV volumes, RVEF and LVEF (HR 2,2 [1.34-3,68], p =0.002). Different cut-off values of index RV volumes and EF were predictive of mortality in men and women. In men a RV-EDV >110 ml/m2 and RVEF<57%; in women a RV-EDV >90 ml/m2 and RVEF< 60% were predictive of all-cause mortality (p<0.01). Conclusion Severe TR is more prevalent in women; however, it shows lower RV remodeling, better RV function and lower rate of events compared to men. Different prognostic RV cut-off values are provided based on CMR data.Gender differencesKaplan Meier Curves

Machine learning to predict incident atrial fibrillation in patients with acute stroke: FIND-AF STROKE

Abstract Background Atrial fibrillation (AF)-related strokes have a high rate of recurrence, and are associated with substantial morbidity, disability, healthcare expenditure, and mortality.(1-3) Detection of AF promises opportunity to prevent recurrent stroke through conversion of antiplatelet to anticoagulant therapy,(4,5) but use of extended monitoring has cost implications.(6) Thus accurately identifying patients with stroke at high risk for AF is important but previous previous models have been developed in small, unrepresentative cohorts.(7) Purpose To develop and validate a simple novel decision support tool for prediction of incident AF after hospitalisation with stroke through machine learning. Methods We developed the model (FIND-AF STROKE) in UK secondary care and death certificate-linked primary care health record data from individuals aged ≥30 years without known AF hospitalized with a stroke or transient ischaemic attack (Jan 2, 1998 to Feb 28, 2022), randomly divided into training (80%) and testing (20%) datasets. We evaluated logistic regression and random forest models for prediction of 2-year AF risk in the testing dataset with internal bootstrap validation, and compared against the CHA2DS2VASC score. Youden index was used to set a threshold for higher and lower risk. Results Of 35 530 UK individuals (mean age 72.1 (SD 12.7) years, 50.9% women), 1742 (4.8%) had developed incident AF at 2 years. Using feature importance a parsimonious version of the model was created requiring only age, sex, ethnicity (white versus other) and five comorbidities. In the testing dataset prediction performance for the random forest algorithm (area under the receiver operating characteristic (AUROC) 0.710, 95% CI 0.685 – 0.736) was superior to the CHA2DS2VASC score (0.645, 95% CI 0.617-0.672) (Figure 1). The threshold for higher risk using the Youden index was 4.81% which resulted in a negative predictive value of 97.6%, sensitivity 0.712, specificity 0.583. Of the post-stroke patients 44% were labelled at higher risk of AF, who were older, had a higher prevalence of comorbidities, and a 3.3-fold higher incidence of AF post-stroke, than those identified as lower risk (Table 1). Conclusions The machine learning FIND-AF STROKE decision support tool can accurately identify individuals at risk of incident AF after stroke to enable a targeted and cost-effective approach to extended monitoring. Validation within cohorts that have undergone extended monitoring post-stroke will give a more accurate estimation of yield at different risk thresholds.Figure 1

Screening for stage B heart failure in Type 2 diabetes: natriuretic peptide screening alone misses echocardiographic abnormalities

Abstract Background Heart failure (HF) often manifests as the first cardiac event in individuals with type 2 diabetes mellitus (T2DM). International guidelines recommend natriuretic peptide (NP) screening for stage B/ pre-HF in asymptomatic individuals with T2DM, with echocardiography reserved for those with elevated NPs ("NP-gated" echo approach). Whether this strategy misses individuals with echocardiographic abnormalities despite normal NPs is not fully understood. Purpose To assess the proportion of individuals with T2DM who will be classified as Stage B HF based on biomarker and echocardiography, using independent and combined screening approaches. Methods We utilised the Performance of NT-proBNP In risk Stratification for Cardiovascular Events and mortality in patients with diabetes [PISCES] study (n=765, mean age 62±9 years, 62% men), which enrolled patients with T2DM with no HF. All patients underwent laboratory-based N-terminal pro-B-type NP (NT-proBNP) testing and a point-of-care artificial intelligence echocardiography (Us2.ai). Abnormal echocardiography was defined as left ventricular ejection fraction <50%, left ventricular mass index ≥115(male) or ≥95g/m2(female), left atrial volume index>34 in sinus rhythm or >40mL/m2 in atrial fibrillation, relative wall thickness (RWT) >0.42, E/e' >9, peak tricuspid regurgitation velocity >2.8m/s, pulmonary arterial systolic pressure >35mmHg. Patients with T2DM were classified into either (1) Stage B(biomarker) with elevated NT-proBNP (≥125pg/mL) and normal echocardiography, or (2) Stage B(echo) with abnormal echocardiography and normal NT-proBNP, or (3) Stage B(biomarker+echo) with elevated NT-proBNP and abnormal echocardiography or (4) no abnormalities. Results Among asymptomatic patients with T2DM, the highest proportion of individuals were in Stage B(echo) (43%), followed by those with no abnormalities (37%), Stage B(biomarker+echo) (15%) and Stage B(biomarker) (5%). Patients with Stage B(echo) (vs. no abnormalities) were older (62.5 vs 59.8 years), had a higher prevalence of hypertension (78.4 vs. 72.4%), higher systolic blood pressure (135 vs. 128 mmHg), higher RWT and higher E/e’ (p<0.001 for all). Individuals in Stage B(biomarker+echo) (versus no abnormalities) were older, had a longer duration of T2DM, higher prevalence of hypertension, atrial fibrillation, prior CVD, highest NT-proBNP levels, lowest eGFR levels, and more echocardiography abnormalities (higher RWT and E/e’). Patients identified as Stage B(biomarker) (versus no abnormalities) had a longer duration of T2DM, higher NT-proBNP levels, higher prevalence of comorbidities and comparable echocardiographic measures. Conclusion Among asymptomatic patients with T2DM, a significant proportion have subclinical cardiac abnormalities despite a lack of diagnostic NP elevation. Instead of NP-gated echocardiography, an integrated approach using both NT-proBNP and AI echocardiography may improve the early detection of Stage B HF.

Long-term outcomes of aortic stenosis patients with different flow/gradient patterns undergoing transcatheter aortic valve implantation

Abstract Background Few data exist on the comparative long-term outcomes of severe aortic stenosis (AS) patients with different flow-gradient patterns undergoing transcatheter aortic valve implantation (TAVI). This study sought to evaluate the impact of the pre-TAVI flow-gradient pattern on long-term clinical outcomes after TAVI. Methods Consecutive patients with severe AS undergoing TAVI in our institution were screened and prospectively enrolled. Patients were divided into four subgroups according to pre-TAVI flow/gradient pattern: (i) low flow—low gradient (LF-LG): stroke volume indexed (SVi) ≤ 35 mL/m2 and mean gradient (MG) < 40 mmHg); (ii) normal flow—low gradient (NF-LG): SVi > 35 mL/m2 and MG < 40 mmHg; (iii) low flow—high gradient (LF-HG): Svi 35 mL/m2 and MG ≥ 40 mmHg and (iv) normal flow—high gradient (NF-HG): SVi > 35 mL/m2 and MG ≥ 40 mmHg. Clinical follow-up was obtained at 12 months, and yearly thereafter until 5-year follow-up was complete for all patients. Results A total of 272 patients with complete echocardiographic and clinical follow-up were included in our analysis. Their mean age was 80 ± 7 years and the majority of patients (N = 138, 50.8%) were women. 62 patients (22.8% of the study population) were distributed in the LF-LG group, 98 patients (36%) were LF-HG patients, 95 patients (34.9%) were NF-HG, and 17 patients (6.3%) were NF-LG. There was a greater prevalence of comorbidities among LF-LG AS patients. One-year all-cause mortality differed significantly between the four subgroups of AS patients (log-rank p: 0.022) and was more prevalent among LF-LG patients (25.8%) compared to LF-HG (11.3%), NF-HG (6.3%) and NF-LG patients (18.8%). At 5-year follow-up, global mortality remained persistently higher among LF-LG patients (64.5%) compared to LF-HG (47.9%), NF-HG (42.9%), and NF-LG patients (58.8%) (log-rank p: 0.029) (Figure 1). At multivariable Cox hazard regression analysis, baseline SVi (HR: 0.951, 95% C.I.; 0.918–0.984), the presence of at least moderate tricuspid regurgitation at baseline (HR: 3.091, 95% C.I: 1.645–5.809) and at least moderate paravalvular leak (PVL) post-TAVI (HR: 1.456, 95% C.I.: 1.106–1.792) were significant independent predictors of late global mortality. Conclusions Patients with LF-LG AS have acceptable 1-year outcomes, but exhibit exceedingly high 5-year mortality following TAVI. The presence of low transvalvular flow and at least moderate tricuspid regurgitation at baseline and significant paravalvular leak post-TAVI were associated with poorer long-term outcomes in the entire cohort of AS patients.

Electrocardiographic criteria for the diagnosis of left ventricular hypertrophy in patients with severe aortic stenosis

Abstract Introduction There is a lack of data regarding the performance of current electrocardiographic (EKG) criteria for left ventricular hypertrophy (LVH) in patients with severe aortic stenosis (AS). Purpose To test the performance of the current EKG scores to diagnosis LVH in AS patients, and also to compare the performance of a new proposed score. Methods The present study evaluated 80 patients with severe AS that underwent cardiac magnetic resonance to diagnose LVH, defined as left ventricular indexed mass of 95 g/m² for female and 115 g/m² for male patients. The EKG criteria used for left ventricular hypertrophy were Sokolow-Lyon criteria, Romhilt-Estes point score system, Cornell voltage criteria and Peguero-Lo Presti criteria. Results Among the 80 patients included in analysis, 58.7% were male and the mean age was 64±8 years. There was a high prevalence of comorbidities, highlighting diabetes (32.5%), hypertension (67.5%), atrial fibrillation (5.0%) and coronary artery disease (11.3%). Regarding echocardiogram, the median left ventricle ejection fraction was 64 (56-68)% and the median indexed aortic valve area was 0.43 (0.35-0.49) cm²/m². Cardiac magnetic resonance analysis demonstrated a mean left ventricle mass of 168±55g, and the LVH incidence was 26.3%. Regarding EKG, Strain pattern was found in 49.1% of the patients, Cornell voltage criteria was positive in 51.3%, Sokolow-Lyon criteria in 51.3%, Romhilt-Estes point score system in 42.5% and Peguero-Lo Presti criteria in 61.3%. Discriminative capacity of electrocardiographic criteria for LVH is shown in Figure 1. Peguero-Lo Presti score had the best diagnostic accuracy in the overall population and in male sex (AUC 0.776), while Cornell voltage criteria had the best diagnostic accuracy in female patients (AUC 0.776). Based on linear regression model, the proposed score was created to predict LVH at cardiac magnetic resonance: 48 + (1.3 x Deepest S wave) + (0.5 x S wave in V1 or V2 plus R wave in V5). The proposed score cutoff value of 90.5 mm had a sensitivity of 0.765 and specificity of 0.707 (for male sex: 0.769 and 0.655, respectively; for female sex: 0.750 and 0.759, respectively). Compared to the scores described in the literature, the proposed score had the best area AUC for the overall population (Figure 1), for female and male patients (AUC 0.796, 0.819 and 0.780, respectively). Conclusion In patients with severe AS, the proposed score had the best diagnostic accuracy compared to the scores described in the literature for LVH identification, followed by Peguero-Lo Presti score, even when analyzed based on gender. Besides, the proposed score had also acceptable sensitivity and specificity for LVH detection.AUC of electrocardiographic scores.

Insulin-like growth factor binding protein 2 predicts course of concomitant right-ventricular dilation and tricuspid regurgitation after transcatheter edge-to-edge mitral valve repair

Abstract Aims Right ventricular (RV) dilation and secondary tricuspid regurgitation (TR) are highly prevalent comorbidities in patients with mitral regurgitation and are associated with a worse prognosis. TR improvement after successful transcatheter edge-to-edge mitral valve repair (M-TEER) is reported regularly, however specific factors contributing to the recovery of RV function and TR after M-TEER are poorly understood. Particularly the role of serum biomarkers in this context is unclear. We aimed to identify specific biomarkers associated with the course of concomitant RV dilation and TR after M-TEER. Methods and Results We prospectively included 242 patients undergoing M-TEER at our center and obtained pre-procedural blood samples for biomarker analysis. A commercial multiplex protein assay (Cardiovascular III, Olink, Uppsala, Sweden) was used to quantify expression levels of 92 defined biomarkers. We then analyzed differences in biomarker expression between patients with and without right ventricular reverse remodeling (RVRR) as defined by improvement of concomitant TR by at least one grade and/or downsizing of the basal RV diameter of at least 10%. 242 patients were included in this analysis, 94 had no/mild concomitant TR at baseline, 148 had moderate/severe TR. RV diameters correlated with TR severity and were significantly larger in patients with moderate/severe TR. At baseline, expression of numerous cardiometabolic biomarkers was significantly higher in patients with moderate/severe TR. These included NT-proBNP (1.9-fold, p < 0.001), matrix metalloproteinase 2 (1.4-fold, p < 0.001) as well as insulin-like growth factor binding proteins 1 (1.7-fold, p < 0.001), -2 (1.3-fold, p = 0.001) and -7 (1.4-fold, p < 0.001). Follow-up analysis was performed in patients with initial moderate/severe TR. The course of TR and RV dimensions three months after M-TEER could be assessed in 99 patients (56 with moderate TR, 43 with severe TR). RVRR had occurred in 50 patients (50.5%). Patients without RVRR had a higher prevalence of chronic pulmonary disease (24.5 vs. 2.2%, p < 0.001). No further differences in clinical characteristics were found. Specifically, RV diameter, systolic pulmonary artery pressure (sPAP) and right-ventricular systolic function did not differ substantially between both groups. Strikingly however, the expression of insulin-like growth factor binding protein 2 (IGFBP-2) was significantly higher in patients, who did not develop RVRR (fold change 1.3 compared to patients with RVRR, p = 0.022). After adjustment for covariates IGFBP-2 was independently associated with absence of RVRR (Odds Ratio 2.078, 95% Confidence interval 1.108 – 3.897, p = 0.023). Conclusions In patients undergoing M-TEER with concomitant moderate or severe TR, numerous cardiometabolic biomarkers including IGFBP-2 are upregulated. Higher levels of IGFBP-2 at baseline are independently associated with persistent TR and/or RV dilation after M-TEER.

Exploring heart failure prevalence and overlooked dimensions: a comprehensive NT Pro-BNP study in high-risk primary care patients

Abstract Background Heart failure (HF) is a prevalent syndrome linked to significant morbidity and mortality, especially in those with comorbid conditions like diabetes, hypertension, and atherosclerotic cardiovascular disease. Early detection and intervention are crucial. Natriuretic peptides, particularly NT-proBNP, are promising biomarkers for identifying at-risk individuals, but their use in primary care settings is not fully understood. Methods This prospective cohort study enrolled 874 participants aged 40 and above with documented risk factors for HF, such as diabetes mellitus, hypertension, metabolic syndrome, obesity, atherosclerotic cardiovascular disease, genetic variants for cardiomyopathy, or exposure to cardiotoxic agents. NT-proBNP levels were measured in blood samples collected at primary care clinics, and participants underwent comprehensive cardiac evaluations at a referral hospital. Clinical characteristics, laboratory findings, electrocardiography, and echocardiography results were recorded. Results The study included 874 patients with at least one risk factor for HF, with a mean age of 62.5 ± 9.1 years and 51.9% female. According to the 2022 AHA/ACC/HFSA HF Guideline, 69.1% were Stage A HF, 21.9% Stage B HF, and 9% Stage C HF. Clinical characteristics, laboratory and echocardiographic findings are shown in Picture 1. The majority had hypertension (71.1%), while other prevalent comorbidities included diabetes mellitus (43.4%), dyslipidemia (35.2%), obesity (27.1%), and atherosclerotic cardiovascular disease (26.2%). Laboratory findings showed a significant decrease in HbA1C, eGFR, LDL, triglycerides, and hemoglobin from Stage A to C HF. Median NT-proBNP levels rose from Stage A to C HF (46.4 pg/mL in Stage A, 219 pg/mL in Stage B, and 268.5 pg/mL in stage C), with 84.8% of Stage B HF patients exhibiting elevated levels. NT-proBNP levels were correlated positively with left atrial volume index, left ventricular mass index, age, E/e’, and estimated systolic pulmonary artery pressure levels. Conversely, NT-proBNP levels showed a negative correlation with estimated glomerular filtration rate and left ventricular ejection fraction. Among Stage C patients, 92.4% had HFpEF. The Picture 2 depicted the study's design and outcomes, providing a comprehensive visual representation. Conclusion NT-proBNP screening in primary care settings identified a substantial proportion of individuals with undiagnosed HF, particularly those in Stage B and Stage C. The high prevalence of HFpEF underscores the need for comprehensive evaluation and management strategies targeting this population. Early detection facilitated by NT-proBNP screening may lead to timely interventions and improved outcomes in individuals at risk for HF.

Impact of age on clinical characteristics and 1-year outcomes of non-disabling ischemic cerebrovascular events: A multicenter prospective cohort study

BackgroundThe exploration of age-related clinical features and adverse outcomes of non-disabling ischemic cerebrovascular disease (NICE) has been largely unaddressed in current research. This study aimed to analyze the differences in clinical characteristics and prognostic outcomes of NICE across various age groups, utilizing data from the Xi’an Stroke Registry Study in China.MethodsThe age distribution of NICE was categorized into four groups: age ≤ 54 years, age 55–64 years, age 65–74 years, and age ≥ 75 years. Multivariate Cox logistic regression analysis was employed to evaluate the 1-year risk of outcome events in each age group of patients with NICE. A subgroup analysis was conducted to explore interaction factors influencing age-dependent outcomes in patients with NICE.ResultsThis study included 1,121 patients with NICE aged between 23 and 96 years, with an average age of 63.7 ± 12.2 years. Patients aged ≥ 75 years had a higher proportion of women, lower education levels, and a greater likelihood of having urban employee medical insurance. Those aged < 55 years had a higher prevalence of smoking, while individuals aged > 65 years showed a higher prevalence of comorbidities. Furthermore, there was a significant decrease in body mass index among patients aged ≥ 75 years. Laboratory tests indicated well-controlled blood lipids, liver function, and inflammation across all age groups, but renal function was notably reduced in patients with NICE aged ≥ 75 years. Adjusting for potential confounding factors revealed a significant increase in the one-year risk of all-cause mortality and poor prognosis among patients aged ≥ 75 years compared to those aged < 55 years, with no significant gender difference observed. Subgroup analysis indicated that patients with NICE who consumed alcohol were more prone to experience all-cause mortality with advancing age.ConclusionsAge significantly influences the clinical characteristics and prognostic outcomes of NICE patients. Clinicians should consider age-specific characteristics when diagnosing, treating, and developing prevention strategies. Tailored prevention and treatment strategies for different age groups can enhance prognosis and reduce adverse outcomes in NICE patients.

Age Differences and Prevalence of Comorbidities for Death and Survival in Patients with COVID-19: A Single-Center Observational Study in a Region of Southern Italy

The SARS-CoV-2 outbreak has resulted in a considerable number of deaths worldwide. The virus damages the pulmonary artery endothelium, leading to a condition known as microvascular pulmonary inflammatory thrombotic syndrome (MPITS), which can be fatal and cause multiple organ failure. The presence of preexisting comorbidities has been shown to significantly impact the severity and prognosis of patients with SARS-CoV-2 infection. The objective of this study was to compare the age groups of patients with coronavirus disease 2019 (COVID-19) and to identify the prevalence of comorbidities associated with death and survival in an area of southern Italy. The data set consisted of 1985 patients with confirmed cases of SARS-CoV-2 infection who were admitted to the A.O.U. San Giovanni di Dio e Ruggi d’Aragona Hospital in Salerno between January 2021 and December 2022. The results were presented for the overall population and stratified by outcome and age group. All analyses were performed using the XLSTAT (Lumivero, 2024, Paris, France) and STATA software (release 16.1, StataCorp LLG, College Station, TX, USA, 2019) packages. In the study, population, 636 cases (32%) resulted in death, with a higher prevalence in the 60–79 age group, followed by the ≥80 and 30–59 age groups. The most prevalent diseases among deceased and surviving patients with confirmed cases of SARS-CoV-2 infection were those affecting the circulatory system (61.5% vs. 55.5%), the respiratory system (55.8% vs. 26.2%), and the metabolic system (25.9% vs. 25.4%). In patients aged 30–79, respiratory diseases were the primary cause of mortality, whereas in those aged ≥80, circulatory system diseases were more prevalent. Among survivors, cardiovascular diseases were the most common comorbidities across all age groups, followed by respiratory diseases and endocrine, metabolic, and immune disorders. Moreover, these comorbidities were associated with an elevated risk of mortality. The study emphasizes the substantial influence of age and comorbidities on the mortality associated with SARS-CoC-2 infection. These findings highlight the necessity for targeted interventions to manage comorbid conditions in patients with SARS-CoV-2 infection, particularly in older adults.

Predicting periprosthetic joint infection: external validation of preoperative prediction models

Abstract. Introduction: Prediction models for periprosthetic joint infections (PJIs) are gaining interest due to their potential to improve clinical decision-making. However, their external validity across various settings remains uncertain. This study aimed to externally validate promising preoperative PJI prediction models in a recent multinational European cohort. Methods: Three preoperative PJI prediction models – by Tan et al. (2018), Del Toro et al. (2019), and Bülow et al. (2022) – that have previously demonstrated high levels of accuracy were selected for validation. A retrospective observational analysis of patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA) at centers in the Netherlands, Portugal, and Spain between January 2020 and December 2021 was conducted. Patient characteristics were compared between our cohort and those used to develop the models. Performance was assessed through discrimination and calibration. Results: The study included 2684 patients, 60 of whom developed a PJI (2.2 %). Our cohort differed from the models' original cohorts with respect to demographic variables, procedural variables, and comorbidity prevalence. The overall accuracies of the models, measured with the c statistic, were 0.72, 0.69, and 0.72 for the Tan, Del Toro, and Bülow models, respectively. Calibration was reasonable, but the PJI risk estimates were most accurate for predicted infection risks below 3 %–4 %. The Tan model overestimated PJI risk above 4 %, whereas the Del Toro model underestimated PJI risk above 3 %. Conclusions: The Tan, Del Toro, and Bülow PJI prediction models were externally validated in this multinational cohort, demonstrating potential for clinical application in identifying high-risk patients and enhancing preoperative counseling and prevention strategies.

High prevalence of comorbidities in older adult patients with type 2 diabetes: a cross-sectional survey

BackgroundDiabetes is a global health problem, and its incidence and complications increase with the duration of the disease and over time. This increase in complications in older patients can lead to disability and a lower quality of life. This study aimed to investigate the rate of diabetes control and complications in older adults.MethodThis was a cross-section of an ongoing cohort of patients with type 2 diabetes mellitus (T2DM) aged 65 years and older. The clinical and laboratory characteristics of older adult patients with T2DM in good and intermediate health conditions were collected between 2010 and 2022.ResultsA total of 2,770 older adult patients with T2DM were enrolled, including 1,530(55.3%) female and 1,240 (44.7%) male participants. Metabolic syndrome, hypertension, and coronary artery disease were the most common comorbidities, affecting 1,889 (71.4%), 1,495 (54.4%), and 786 (29.2%) patients, respectively. Albuminuria was present in 626 (22.6%) patients, while retinopathy was detected in 408 (14.7%) patients, including 6% with proliferative retinopathy. Most patients were treated with oral antidiabetic agents (88.9%), with metformin being the most prescribed medication (85.6%). Statins were prescribed to 71.8% of the patients. The most prescribed antihypertensive medications were angiotensin receptor blockers and angiotensin-converting enzyme inhibitors, prescribed to 54% and 15% of patients, respectively. The hemoglobin A1c (HbA1c) goal (HbA1c < 7.5%) was achieved in 1,350 (56.4%) patients, and the low-density lipoprotein cholesterol (LDL-C) goal (LDL < 100) was achieved in 1,165 (45.6%) patients. Blood pressure control (BP < 140/90) was achieved in 1,755 (65.4%) patients. All three goals were achieved in 278 (10.3%) patients. There were no significant differences in clinical laboratory results and the patients’ characteristics based on gender.ConclusionThe rate of progression of complications in older adult patients is higher than the effectiveness of the treatment, indicating the need for increased social support for this age group.

Evolving epidemiology of NAFLD in South Korea: incidence, prevalence, progression, and healthcare implications from 2010 to 2022.

Non-alcoholic fatty liver disease (NAFLD), now the most common chronic liver worldwide, has become a significant public health concern. This study aims to analyze the evolving epidemiology of NAFLD in South Korea. We utilized claim data from the Korean National Health Insurance Service from 2010 to 2022 to analyze NAFLD's incidence, prevalence, and progression. From 2010 to 2022, the incidence and prevalence rates of NAFLD each increased from 1.87% to 4.47% and from 10.49% to 17.13%, respectively. The differences in prevalence rates between urban and rural areas were minimal in 2012 and 2022, yet both areas showed significant increases in the prevalence of NAFLD over the decade. The NAFLD group had a higher prevalence of comorbidities compared to the control group, and the most common comorbid condition was hypertension. Moreover, the ten-year incidence rates of malignancy, heart disease, and stroke in the NAFLD group were 13.42%, 15.72%, and 8.36%, respectively, which were significantly higher than those in the control group. The incidence rates of cirrhosis and hepatocellular carcinoma in NAFLD over 10 years were 2.22% and 0.77%, respectively. The total medical costs of NAFLD patients more than doubled over ten years and were all significantly higher than those of the control group. A significant increase in NAFLD prevalence and its impact on healthcare utilization was observed in South Korea. With NAFLD leading to serious liver diseases and increased healthcare costs, integrated care strategies that include both medical treatment and lifestyle modifications are essential.

Risk of physical health comorbidities in autistic adults: clinical nested cross-sectional study.

Physical health conditions are more common in individuals with autism. Some, like epilepsy, have considerable evidence supporting their increased prevalence, but many diseases lack literature to make strong conclusions. To investigate the prevalence of physical health comorbidities in autism. We undertook a nested cross-sectional study, using a sample from the National Centre for Mental Health database. It included participants from England and Wales who reported a clinician-made diagnosis of autism (n = 813), and a control sample without autism or mental illness (n = 2781). Participants had provided a medical history at enrolment. Analysis was carried out by binomial logistic regressions controlling for age, gender, smoking status, and antipsychotic and mood stabiliser use. A subanalysis of individuals with concurrent intellectual disability (n = 86) used binomial logistic regression with the same control variables. Many physical health conditions were significantly more common in autism. Sixteen out of 28 conditions showed increased odds, with the highest odds ratios observed for liver disease, chronic obstructive pulmonary disease, kidney disease, osteoporosis and rheumatoid arthritis. A subanalysis demonstrated a similar pattern of physical health in individuals with autism with and without concurrent intellectual disability. Some conditions, including osteoporosis, hyperthyroidism, head injury and liver disease, had larger odds ratios in individuals with concurrent intellectual disability. Physical health conditions occur more commonly in individuals with autism, and certain conditions are further increased in those with concurrent intellectual disability. Our findings contribute to prior evidence, including novel associations, and suggest that people with autism are at greater risk of physical health problems throughout adulthood.