Prognostic Risk Factor In Patients Research Articles

Prognostic risk factors in patients with bone metastasis from colorectal cancer.

The morbidity of bone metastasis (BM) from colorectal cancer (CRC) is increasing more than ever; however, insufficient research on BM from CRC leads to reduced awareness of the issue. Therefore, the aim of this study was to evaluate the clinical features and prognostic risk factors of CRC patients with BM. Clinical data were retrospectively analyzed for a total of 242 CRC patients with BM. Of the 242 CRC patients with BM, 52 (21.5%) had bone metastasis alone (BMA) and 190 (78.5%) had both bone and visceral metastasis (BM&VM). The median survival time (MST) after the diagnosis of BM in all 242 patients was 15.6months (95% confidence interval [CI] 12.74-18.46months). The MST of the BMA group was significantly longer than that of the BM&VM group (29.1 vs. 12.8months, p=0.003). Using a Cox proportional hazard model, we identified a high carcinoembryonic antigen (CEA) level and BMA as independent prognostic factors for CRC patients with BM. For the BMA group, the independent prognostic factors were elevated alkaline phosphatase (ALP) and perineural invasion of the primary cancer, which were distinct from the factors for the entire group of BM patients. Furthermore, we found that the BMA patients with multiple sites of BM had similar prognosis to the BM&VM patients. These findings together provide us with a further understanding of BM from CRC and reveal that BMA may be a distinct subset of BM from CRC that has unique independent prognostic factors and a good prognosis.

Percutaneous coronary intervention for nonagenarian patients with ST-segment elevation myocardial infarction: Experience of a single Japanese center

BackgroundOld age is a prognostic risk factor for patients with ST elevation acute myocardial infarction (STEMI); however, few data exist describing STEMI patients aged over 90 years. MethodsWe retrospectively evaluated the clinical indices and outcomes of 282 consecutive STEMI patients who underwent primary percutaneous coronary intervention (PCI) in our hospital between January 2008 and December 2012. Patients with acute myocardial infarction complicated by out-of-hospital cardiopulmonary arrest, patients with a left main trunk culprit lesion, and patients diagnosed more than 24h after symptom onset were excluded. ResultsOf the patients treated during the study period, 11 (3.8%) were >90 years old. The mean door-to-balloon time was significantly longer for nonagenarians than younger patients (66.2 vs. 44.0minutes; p<0.001). This was mainly attributed to delays in decision-making regarding invasive treatment by both the doctors and families. Nonagenarians had multiple coronary artery stenoses more frequently (36.4% vs. 15.0%; p<0.05) and required intra-aortic balloon pumping more often (36.4% vs. 18.9%; p=0.15) compared with patients aged ≤89 years. However, the peak creatinine kinase levels and the left ventricular ejection fractions were similar between the groups. Moreover, the in-hospital and 30-day mortality rates were similar (9.1% vs. 4.6%, p=0.50; 9.1% vs. 3.6%, p=0.34, respectively) between the groups. The two-year survival rate was 81.8% in nonagenarians. ConclusionsDespite the longer door-to-balloon time, higher use of intra-aortic balloon pumping, and larger number of diseased vessels, the 30-day and 2-year survival rates of nonagenarians with STEMI were comparable to those of younger patients.

The Indications for Hepatectomy for Multinodular Hepatocellular Carcinoma: Experience from a Single Institution

Aims: This study was conducted in order to investigate the indications for hepatecomy for multinodular hepatocellular carcinoma (MNHCC) in single institution. Methods: We retrospectively analyzed the medical records from 55 MNHCC patients, mainly with Child-Pugh A liver function, who underwent hepatectomy from January 2006 to December 2008. Both short- and long-term outcomes were analyzed. In addition, the prognostic significance of clinicopathological factors on overall survival (OS) was investigated by univariate analysis using the log-rank test. A Cox proportional hazards model was used in a subsequent multivariate analysis. Results: The perioperative morbidity rate (grade II or higher) was 18.2% (n = 10), and the in-hospital mortality rate was 3.6%. The median OS was 23.9 months (range, 2.5-84 months), whereas the median disease-free survival was 8.75 months (range, 1-65 months). Independent prognostic risk factors of 5-year OS included the number of tumors >2 (p = 0.032) and gross morphology indicating multiple tumor nodules scattered throughout the liver (p = 0.009). Conclusions: The postoperative morbidity and mortality rates were acceptable. The number of tumors >2 and gross morphology indicating multiple tumor nodules scattered throughout the liver were independent prognostic risk factors for patients with MNHCC after hepatectomy. Patients with both of these features had a very poor prognosis and were not considered suitable for surgery.

GW25-e3409 The prognostic risk factors of patients with dilated cardiomyopathy: a single-center cohort study

Clinical parameters are associated with poor outcomes in patients with known cardiac diseases. The prognostic implications of many parameters in dilated cardiomyopathy (DCM) patients, however, need to be evaluated. The purpose of this study was to determine all-cause mortality in DCM with some

Autoimmune hepatitis-related hepatocellular carcinoma: its clinical characteristics and impact on prognosis

Objective To study the clinical features and prognostic risk factors of patients with autoimmune hepatitis-related hepatocellular carcinoma (AIH-HCC).Methods We reviewed the clinical data of 40 patients with AIH-HCC who were treated at the 302 Hospital between May 1,2008 and April 30,2013,and analyzed the clinical characteristics and prognostic risk factors of these patients.Results These patients were diagnosed to have HCC at a mean ± SD of 55.1 ± 13.5 years (range 28-76 years).The median duration from the time of confirmed cirrhosis to a diagnosis of HCC was 49.2 ± 44.5 months (range 3-194 months).The median survival of the AIH-HCC patients was 16.0 ±4.0 months (range 1-44 months),and the 1-year survival rate was 54.0％.Univariate analysis showed AFP,tumor size,tumor number were related to prognosis (P ＜ 0.05) ; while gender,age,IAIHG score,category,history of blood transfusion,alcohol-drinking and smoking did not significantly affect the patients' survival (P ＞ 0.05).Multivariate regression analysis showed AFP and tumor number were independent prognostic factors.Most of these patients received transcatheter arterial chemoembolization(TACE),however the survival rate of those patients who received hepatectomy was significantly higher than those who received TACE or accepted conservative treatment.Conclusion Liver cirrhosis in AIH is the sine qua non for HCC development,which subsequently occurs at a rate of 1.65％ per year.Patients who had AFP-negativity or a single tumor had a better prognosis.Surgical treatment prolonged survival. Key words: Autoimmune hepatitis; Liver cirrhosis; Hepatocellular carcinoma

Prognostic Risk Factors of Early Esophageal Adenocarcinomas

To define prognostic risk factors in patients with early adenocarcinomas of the esophagus (eACEs) who were treated by esophagectomy. Although endoscopic resection (ER) is more accepted for eACEs limited to the mucosa, the reported prevalence of lymph node metastases once the tumor infiltrates the submucosa seems to necessitate surgery in these cases. We analyzed the results of 168 patients who had an esophageal resection because of an eACE. On the basis of specimen histologies and clinical follow-up (median, 64 months), we investigated the influence of lymph node metastases (N+), tumor infiltration depth, tumor differentiation (G1-3), and lymphatic or venous infiltration (L+ or V+) on overall and tumor-specific survival and recurrence rates. The 5-year survival rate was 79%. Lymph node infiltration was the only prognostic factor for the overall survival [hazard ratio (HR), 2.856; 1.314-6.207; P = 0.008], tumor-specific survival (HR, 8.336; 2.734-25.418; P < 0.001), and tumor recurrence (HR, 8.031; 3.041-21.206; P < 0.001) that was consistently present in all multivariate hazard Cox regression analyses. A total of 47% of the patients who had an N+ status developed tumor recurrences compared with 5.2% of those who had no lymph node involvement (P = <0.001). We found a significant correlation between N+ status and increasing depth of tumor infiltration (P = 0.004), lymphatic vessel infiltration (P = 0.002), tumor differentiation (G1 + G2 vs G3; P = 0.014) and vascular infiltration (P = 0.01). Lymph node status is the only independent risk factor for survival and recurrence rates. Tumor infiltration depth correlates with the rate of the lymph node metastases, but a clear watershed between deep mucosal and submucosal infiltration does not exist. As a consequence, careful staging procedures, including diagnostic ER, are mandatory to determine which patients can be treated by ER and which require an esophagectomy.

Erratum to: Changes in Postoperative Recurrence and Prognostic Risk Factors for Patients with Gastric Cancer who Underwent Curative Gastric Resection during Different Time Periods

Erratum to: Changes in Postoperative Recurrence and Prognostic Risk Factors for Patients with Gastric Cancer who Underwent Curative Gastric Resection during Different Time Periods

Prognostic Marker for Patients With Malignant Ureter Obstruction

PurposeTo investigate the relationship between overall survival (OS) and prognostic risk factors for patients with malignant ureteral obstruction. Patients and MethodsWe retrospectively evaluated 214 patients who had received a nephrostomy for ureteral obstruction because of malignancy. Univariate and multivariate Cox regression models addressed OS. ResultsThe median OS was 6.4 months. The OS at 1, 3, 6, and 12 months were 89.5%, 72.4%, 53.0%, and 26.5%, respectively. Using univariate Cox regression analysis, serum levels of creatinine (P = .0131), albumin (P < .0001), sodium (P < .0001), potassium (P = .0141), corrected calcium (P = .0167), C-reactive protein (P < .0001), white blood cell count (P = .0246), and the number of events related to malignant dissemination (P < .0001) were associated with OS. Using multivariate Cox regression analysis, serum levels of albumin (P = .0147), sodium (P = .0046), C-reactive protein (P < .0001), and the number of events related to malignant dissemination (P = .0002) were independent predictors of OS. ConclusionLow serum levels of albumin and sodium and the number of events related to malignant dissemination before PCN were independent factors associated with a poor prognosis. High serum C-reactive protein level was also associated with a poor prognosis using multivariate analysis.

Changes in Postoperative Recurrence and Prognostic Risk Factors for Patients with Gastric Cancer who Underwent Curative Gastric Resection during Different Time Periods

Current rates of survival for gastric cancer patients are much improved compared with those of the past. The purpose of our study was to analyze the survival of gastric cancer patients according to time period and to examine how different prognostic factors are related to changing survival rates. We analyzed data from 7,757 patients who underwent curative gastrectomy after diagnoses of gastric cancer at Samsung Medical Center from 1994 to 2006. Clinicopathologic characteristics and prognostic factors were analyzed retrospectively, with patients divided into period I, from 1994 to 2001, and period II, from 2002 to 2006. The 5-year, disease-free survival rate of patients with gastric cancer increased significantly from 76.7 % during period I to 85.9 % during period II (p < 0.001). The prognosis of the patient who underwent surgery during period I was worse than that of the patient in period II. When multivariate analyses were performed for each time period, independent prognostic factors for period I included patient age >60 years, tumor located in the whole stomach, tumor size, stage, vascular invasion, perineural invasion, and adjuvant chemotherapy. For period II, tumor size, vascular, and adjuvant chemotherapy were no longer independent prognostic risk factors. The disease-free survival of gastric cancer improved and prognostic factors changed over time. Active, concurrent chemoradiotherapy together with radical gastric resection performed by an expert surgeon seemed to contribute to the improvement in the survival rates of gastric cancer.

Predicting Outcomes of Patients with Ventricular Assist Devices Who Suffer Neurological Injuries

Purpose Neurological injuries (Nis), both ischemic neurological injuries (INIs) and hemorrhagic neurological injuries (HNIs), are a significant source of morbidity and mortality in patients with a ventricular assist device (VAD). There is no published data that identifies prognostic risk factors in patients with VADs who suffer a NI. This study attempts to identify risk factors for increased mortality after a NI. Methods and Materials A single-institution, retrospective review of 159 consecutive patients treated with VADs from January 2007 to December 2011 was undertaken. Premorbid patient data and demographics were considered. Patients who suffered Nis and predictors of increased mortality were identified. Results Fifty-three patients (33%) suffered at least one NI (30 INIs and 18 HNIs). The 12-month mortality rates for INIs and HNIs were 63.3 and 72.2%, respectively. In INIs, male sex, longer time with a VAD, a Glasgow Coma Scale (GCS) of ≤11, and prior stroke were associated with increased 12-month mortality. A presenting GCS of ≤9, higher prothrombin time, longer time with a VAD, and prior stroke were associated with increased 12-month mortality in HNIs. The most devastating NI noted was intracerebral hemorrhage (ICH) with 70 and 90% of patients dying within 30-day and 12-month follow-up periods, respectively. Only patients with supratentorial ICHs who presented with a GCS of ≥14 and an ICH volume 3 survived longer than 30 days. When neurosurgical consults were obtained for a NI, 12-month mortality was 78.9%. Patients who underwent a neurosurgical procedure had an 87.5% 30-day mortality. Conclusions Despite improvements in both morbidity with VAD implantation and survival after implant, Nis remain a significant source of morbidity and mortality. This retrospective analysis has identified several predictors of increased mortality in patients who suffer a NI including male sex, longer time with a VAD, a presenting GCS of ≤11, and prior stroke. This information may be useful to guide prognosis.

O-0015 Survival According to Prognostic Risk Factors in Patients Receiving First-Line Chemotherapy Plus Cetuximab in the Crystal and Opus Studies

ABSTRACT Introduction Analysis of randomized trials has shown that patients with metastatic colorectal cancer (mCRC) can be divided into prognostic risk groups according to baseline clinical parameters including Eastern Cooperative Oncology Group (ECOG) performance status, white blood cell count (WBC), alkaline phosphatase (ALP) and number of metastatic sites. The effect of adding cetuximab to first-line chemotherapy on overall survival (OS) in these groups of KRAS wild-type mCRC patients was investigated in the CRYSTAL and OPUS studies. Methods Patient risk groups were: low-risk (LRG= ECOG 0/1, 1 metastatic site), intermediate-risk (IRG= ECOG 1 metastatic site, ALP 1, low WBC, 1 metastatic site) and high-risk (HRG= ECOG 1 metastatic site, ALP >300 U/L or ECOG >1, high WBC, or ECOG >1, low WBC and >2 metastatic sites). Exploratory analyses comprised estimates of effects using the Cox proportional hazards regression model for OS on individual patient data, and comparison of treatment arms using the log-rank test. Results In the pooled analyses, in both treatment arms OS was longest in LRG patients (median 27.0 months, 95% CI 24.8-29.5 with chemotherapy + cetuximab [n = 173] and 25.7 months, 95% CI 21.9–28.7 with chemotherapy [n = 164]), and shortest in HRG patients (median 17.7 months, 95% CI 13.1–19.3 with chemotherapy + cetuximab [n = 46]; 12.6 months, 95% CI 9.2–14.4 with chemotherapy [n = 59]). In IRG patients, median OS was 16.4 (95% CI 14.9–20.0) and 22.2 months (95% CI 19.5–25.7) with chemotherapy (n = 213) and chemotherapy + cetuximab (n = 166), respectively. Adding cetuximab to chemotherapy led to marked improvements in OS in the HRG (hazard ratio [HR] 0.765, 95% CI 0.506–1.157, p = 0.203) and IRG (HR 0.781, 95% CI 0.622–0.981, p = 0.033), while improvements in LRG patients (HR 0.869, 95% CI 0.672–1.124, p = 0.287) were observed only after prolonged follow up. In CRYSTAL, median OS in LRG patients was 28.2 months (95% CI 24.9-31.5) with chemotherapy + cetuximab (n = 132) and 26.1 months (95% CI 21.2–29.9) with chemotherapy (n = 127). Median OS in HRG patients was 16.7 months (95% CI 8.3–19.0) with chemotherapy + cetuximab (n = 31) and 12.8 months (95% CI 9.2–14.6) with chemotherapy (n = 43). In IRG patients, median OS was 16.6 (95% CI 14.8–20.4) and 23.5 months (95% CI 20.0–29.6) with chemotherapy (n = 172) and chemotherapy + cetuximab (n = 141), respectively. In OPUS, median OS in LRG patients was 26.0 months (95% CI 22.9-not estimable [NE]) with chemotherapy + cetuximab (n = 41) and 23.9 months (95% CI 19.5–NE) with chemotherapy [n = 37]). For HRG patients, median OS was 19.9 months (95% CI 13.1–30.4) with chemotherapy + cetuximab (n = 15) and 11.8 months (95% CI 4.8–18.5) with chemotherapy (n = 16). In IRG patients, median OS was 16.2 (95% CI 12.0–21.6) and 18.4 months (95% CI 11.0–19.8) with chemotherapy (n = 41) and chemotherapy + cetuximab (n = 25), respectively. Conclusion These analyses confirm the concept of prognostic risk groups for OS according to baseline clinical parameters in patients with KRAS wild-type mCRC. Benefit from the addition of cetuximab to first-line chemotherapy in terms of OS appears to be more pronounced in the IRG and HRG.

Acute liver failure in children: 20-year experience

We aimed to determine the causes, demographic findings, clinical status, outcomes, and prognostic risk factors of patients with acute liver failure admitted to Hacettepe University Children's Hospital between October 1987-October 2006. This retrospective case study included 74 patients with acute liver failure according to the Pediatric Acute Liver Failure Study Group definition. The etiology of acute liver failure was metabolic in 26 (35.1%) and infectious in 21 (28.4%) patients. Sixteen (21.6%) patients had indeterminate causes. Wilson's disease (16/26 patients, 61.5%) was the most frequent metabolic disease, while hepatitis A (14/21 patients, 66.7%) was the most frequent infectious agent. Neurologic functions were normal in 21 (28.4%) patients. Forty-nine (66.2%) patients died and 24 (32.4%) recovered. Two patients underwent liver transplantation. The mortality rate was 82.9% for patients who were not transplanted but fulfilled King's College Hospital criteria and 45.4% for patients who were not suitable for transplantation. This difference was statistically significant (p=0.001). Total bilirubin >5.35 mg/dl, international normalized ratio (INR) >3.66 and prothrombin time >23.5 seconds were shown to be the risk factors to predict death. Metabolic and infectious etiologies were responsible for most of the acute liver failure cases. Clinical encephalopathy may not be present in children.

Neutrophils and clinical outcomes in patients with acute coronary syndromes and/or cardiac revascularisation

Some studies have suggested that high levels of total white blood cell (WBC) count and C-reactive protein (CRP) may be considered as independent prognostic factors in patients with acute coronary syndromes (ACS) and/or after cardiac revascularisation by percutaneous coronary intervention or coronary artery bypass grafting surgery. Evidence on the role of neutrophils in cardiovascular disease is less compelling. Therefore, we conducted a systematic review of the literature with the aim of identifying all the available evidence to clarify the role of neutrophils (absolute or relative count, neutrophil/lymphocyte ratio) as a prognostic risk factor in patients with ACS and/or cardiac revascularisation. All published studies evaluating the role of neutrophils as a risk factor for clinical outcomes were assessed using the MEDLINE and EMBASE databases. Study selection, data extraction and validity assessment was performed independently by two reviewers. Twenty-one studies (17 of which had positive results) for a total of more than 34,000 patients were included. Ten of 13 studies in ACS patients found that neutrophils measured on-admission are related to mortality rate and/or to major adverse clinical events. A predictive value of neutrophils after cardiac revascularisation procedures was reported in seven out of eight studies. Most of the studies showed that neutrophils were independent predictors of cardiovascular outcomes when analysed concomitantly with other markers of inflammation (WBC, CRP). The findings of our systematic review highlight the potential application of this inexpensive and readily available inflammatory marker for risk stratification in patients with ACS and/or cardiac revascularisation.

Heart rate as an independent prognostic risk factor in patients with acute myocardial infarction undergoing primary percutaneous coronary intervention

BackgroundIt has been shown that elevated heart rate identified patients with coronary artery disease and left ventricular dysfunction at increased risk of cardiovascular outcomes. ObjectiveWe sought to assess the prognostic impact of heart rate at presentation in patients with ST-elevation acute myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). Methods and resultsWe collected 6-month follow-up data in 2477 consecutive patients with STEMI treated by primary PCI. Patients with atrio-ventricular block (n=64) and atrial fibrillation (n=34) were excluded from the analysis. The association of baseline heart rate with cardiovascular outcomes was analysed using Cox proportional hazard models for groups with a heart rate of 80 beats per min (bpm) or greater (n=799) versus those with a heart rate between 60 and 79bpm (n=1192) and those with a heart rate less than 60bpm (n=388). The variables related to mortality were: age (hazard ratio (HR) 1.072, 95% confidence interval (CI) 1.052–1.092, p<0.0001), cardiogenic shock (HR 4.622, 95% CI 2.892–7.387, p<0.0001), previous myocardial infarction (HR 1.724, 95% CI 1.036–2.869, p=0.036), peak creatine-kinase value (HR 1.227, 95% CI 1.142–1.318, p<0.0001), heart rate 80bpm or greater (HR 2.170, 95% CI 1.414–3.332, p=0.0001), and optimal PCI result (HR 0.126, 95% CI 0.065–0.244, p=0.0001). For every increase of 5bpm, there were increases in mortality (HR 1.321, 95% CI 1.232–1.415, p=0.0001), but not in reinfarction or in coronary revascularization rates. ConclusionIn patients with acute myocardial infarction undergoing primary PCI, elevated heart rate (80bpm or greater) identifies those at increased risk of death. It is unknown whether heart rate reduction will result in improved outcome in this setting of patients.

Prognostic significance of positive peritoneal cytology in adenocarcinoma of the uterine cervix

Objective A retrospective analysis was carried out to evaluate the prognostic significance of peritoneal cytology in cervical adenocarcinoma. Methods The records of 107 patients with FIGO stage IB to IIB cervical adenocarcinoma who underwent hysterectomy were reviewed. Results Sixteen patients (15%) had positive peritoneal cytology. The 5-year survival rate among patients with positive or negative cytology was 50% or 87%, respectively, showing a significant difference (log-rank, P < 0.001). The recurrence-free survival (RFS) rate at 36 months in the cytology-positive or –negative group was 53% or 87%, respectively, the difference being significant (log-rank, P = < 0.001). Cox model analysis revealed positive cytology [hazards ratio (HR) 6.27, 95% confidence interval (CI) 2.13–18.41], positive lymph node (HR 6.20, 95% CI 1.87–20.57), ovarian metastasis (HR 5.20, 95% CI 1.18-22.82), and histological grade (HR 5.97, 95% CI 2.00-17.78) to be independent adverse risk factors for survival among the factors analyzed (lymph node status, lymph-vascular space invasion, tumor size, depth in cervical wall, pathological parametrial involvement, infiltration to vagina, ovarian metastasis, and histological grade). Cox model analysis showed that positive cytology (HR 4.58, 95% CI 1.48–14.16), positive lymph node (HR 7.61, 95% CI 2.69–21.54), and histological grade (HR6.13, 95% CI 2.14–17.77) were independent adverse risk factors for RFS. The incidence of peritoneal spread at the first recurrence among the cytology-positive group (62.5%) was significantly higher than that among the cytology-negative group (12.5%) (Fisher's exact test, P = 0.021). Conclusion The presence of positive peritoneal cytology appears to be an independent prognostic risk factor in patients with cervical adenocarcinoma.

TCT-343: Heart Rate as an Independent Prognostic Risk Factor in Patients with Acute Myocardial Infarction Undergoing Primary PCI

TCT-343: Heart Rate as an Independent Prognostic Risk Factor in Patients with Acute Myocardial Infarction Undergoing Primary PCI

Slower Heart Rates for Healthy Hearts

The management of atrial fibrillation, even in the modern era, remains complex and challenging. Preventing atrial fibrillation occurrence by identifying and favorably improving modifiable risk factors thus assumes great importance. It is well known that hypertension and resultant structural heart disease contributes significantly to the incidence of atrial fibrillation.1,2 The Losartan Intervention For End point reduction in hypertension (LIFE) study thus far has shown us that angiotensin-receptor blockade and reduction in left ventricular hypertrophy, irrespective of blood pressure–lowering, reduces the incidence of new-onset atrial fibrillation.1,3 Article see p 337 In recent years, accumulating evidence has linked high resting sinus heart rates (HR) directly and indirectly to adverse cardiovascular outcomes.4,5 Epidemiological studies show resting HR to be an independent predictor of cardiovascular and all-cause mortality in general population as well as in hypertensive patients.6 The cardiovascular benefits offered by β-blockade in coronary artery disease and heart failure have, in part, been attributed to β-blocker–mediated HR reduction.7,8 Other studies have linked high baseline HR to the development of hypertension, to the progression of coronary artery disease, and to the triggering of myocardial infarction, ventricular dysfunction, and ventricular arrhythmias.6,9–11 In this issue of Circulation: Arrhythmia and Electrophysiology , Okin and colleagues12 examines the relationship of HR changes over time on risk of atrial fibrillation in hypertensive patients as part of the LIFE study. In this post hoc analysis of the prospective LIFE study, 8828 hypertensive patients with left ventricular hypertrophy by ECG but without a history of atrial fibrillation were followed for a mean of 4.7±1.1 years. New onset atrial fibrillation was determined by 12-lead ECG performed on an intermittent, infrequent basis (at baseline, 6 months, and yearly thereafter). Hypertension was treated with losartan or atenolol. Using a variety of analyses, higher in-treatment HR on serial …

Heart rate as a prognostic risk factor in patients with coronary artery disease and left-ventricular systolic dysfunction (BEAUTIFUL): a subgroup analysis of a randomised controlled trial

The BEAUTIFUL study assessed the morbidity and mortality benefits of the heart rate-lowering agent ivabradine. The placebo arm of the BEAUTIFUL trial was a large cohort of patients with stable coronary artery disease and left-ventricular dysfunction. We did a subanalysis of this placebo group to test the hypothesis that elevated resting heart rate at baseline is a marker for subsequent cardiovascular death and morbidity. The association of baseline resting heart rate with cardiovascular outcomes was analysed using Cox proportional hazard models for groups with a heart rate of 70 beats per min (bpm) or greater (2693 patients) versus less than 70 bpm (2745 patients). Additional analyses were done with finer categorisation of heart rate, and with heart rate as a continuous variable. After adjustment for baseline characteristics, patients with heart rates of 70 bpm or greater had increased risk for cardiovascular death (34%, p=0.0041), admission to hospital for heart failure (53%, p<0.0001), admission to hospital for myocardial infarction (46%, p=0.0066), and coronary revascularisation (38%, p=0.037). For every increase of 5 bpm, there were increases in cardiovascular death (8%, p=0.0005), admission to hospital for heart failure (16%, p<0.0001), admission to hospital for myocardial infarction (7%, p=0.052), and coronary revascularisation (8%, p=0.034). The analysis of fine-groupings of heart rate suggests that the increase in mortality and heart failure outcomes rises continuously above 70 bpm, whereas the relation is less pronounced for coronary outcomes. For heart failure outcomes, the predictive value of resting heart rate was stronger for earlier events than for later events. In patients with coronary artery disease and left-ventricular systolic dysfunction, elevated heart rate (70 bpm or greater) identifies those at increased risk of cardiovascular outcomes, with a differential effect on outcomes associated with heart failure and outcomes associated with coronary events.

Met expression is an independent prognostic risk factor in patients with oesophageal adenocarcinoma

Oesophageal adenocarcinoma is an aggressive malignancy with propensity for early lymphatic and haematogenous dissemination. Since conventional TNM staging does not provide accurate prognostic information, novel molecular prognostic markers and potential therapeutic targets are subject of intense research. The aim of the present study was to study the prognostic significance of Met, the hepatic growth factor (HGF) receptor and a possible target for therapy in comparison to cyclooxygenase-2 (COX-2). Tumour sections from 145 consecutive patients undergoing intentionally curative surgery for oesophageal adenocarcinoma were immunohistochemically analysed for Met and COX-2 expression. Clinicopathological data were prospectively collected for all patients. Patients with high Met expression had significantly reduced overall and disease-specific 5-year survival rates (P⩽0.001 and P⩽0.001, respectively) and were more likely to develop distant metastases (P=0.002) and local recurrences (P=0.004) compared to patients with low Met expression. High COX-2 expression tended to be correlated with poor long-term survival but this did not reach statistical significance. Expression of Met was recognised as a significant and independent prognostic factor by stage-specific analysis and multivariate analysis (relative risk=2.3; 95% CI=1.3–4.1). These findings support the importance of Met in oesophageal adenocarcinoma and support the concept of Met tyrosine kinase inhibition as (neo-) adjuvant treatment.

Prognosis of Patients Taking Selective Serotonin Reuptake Inhibitors Before Coronary Artery Bypass Grafting

Depression is increasingly recognized as an independent prognostic risk factor in patients with coronary artery disease and coronary artery bypass grafting (CABG). The use of selective serotonin reuptake inhibitors (SSRIs) for depression in patients with cardiac disease is becoming more prevalent. We examined the long-term outcomes of patients on SSRIs before CABG. We prospectively examined collected data in the Duke Databank for Cardiovascular Disease from January 1, 1999 to December 31, 2003. The median and maximum follow-up periods were 3 and 6 years, respectively. We screened patients who underwent CABG (n = 5,364) and excluded those who underwent simultaneous CABG and valvular surgery (n = 570). SSRI antidepressants included fluoxetine, fluvoxamine, paroxetine, sertraline, citalopram, escitalopram, venlafaxine, and clomipramine, and their use was determined from the inpatient pharmacy records during the index hospitalization. Outcomes included event-free survival from all-cause mortality, rehospitalization, and a composite end point of all-cause mortality or rehospitalization. Of 4,794 CABG-only patients, 246 (5.1%) took SSRIs before CABG. The SSRI group had a higher prevalence of diabetes, hypercholesterolemia, hypertension, cerebrovascular disease, peripheral vascular disease, and previous cardiovascular intervention. After adjustment for baseline differences, patients on SSRIs before CABG had increased risks of mortality, rehospitalization, and the composite end point (hazard ratio 1.61, 95% confidence interval 1.17 to 2.21, p = 0.003; hazard ratio 1.52, 95% confidence interval 1.30 to 1.77, p <0.0001; and hazard ratio 1.46, 95% confidence interval 1.26 to 1.70, p <0.0001, respectively). In conclusion, SSRI use before CABG was associated with a higher risk of long-term post-CABG mortality and rehospitalization. The explanation behind these findings requires further research.