Risk Factor For All-cause Death Research Articles

High SBP trajectories are associated with risk of all-cause death in general Chinese population.

This study aimed to investigate whether long-term trajectories of high SBP can further predict risk of all-cause death in Chinese adults. We used a community-based cohort of 84 363 participants without myocardial infarction, stroke, or cancer, in 2010. SBP trajectories used latent mixture modeling with data from 2006, 2008, and 2010. Cox proportional hazards models were used to examine the association between SBP trajectories and risk of all-cause death in 2010-2015. We identified five distinct SBP trajectory patterns based on the 2006 status and the pattern of change during 2006-2010. Each pattern was labeled according to the SBP levels and pattern over time: low-stable (n = 21 249), moderate-stable (n = 39 390), moderate-increasing (n = 9634), elevated-decreasing (n = 9094) and elevated-stable (n = 4996). During 5.24 ± 1.04 years of follow-up, we documented 4131 deaths. After adjusting for potential confounding factors and using the low-stable group as a reference, hazard ratios [95% confidence interval (CI)] of all-cause death for the moderate-stable, moderate-increasing, elevated-decreasing, and elevated-stable groups were 1.32 (1.12-1.56), 1.60 (1.26-2.04), 1.69 (1.38-2.07), and 1.75 (1.33-2.32), respectively. Although the moderate-stable trajectory exhibited SBP ranges within the 'normal' range (126.90-130.09 mmHg) in 2006-2010, this group had higher all-cause death risk relative to the low-stable trajectory group (109.86-112.46 mmHg) (adjusted hazard ratio = 1.32, 95% CI 1.12-1.56). High SBP trajectories are independent risk factors for all-cause death. Our findings suggest increasing SBP trajectories within the currently designated 'normal' range may still increase risk of all-cause death.

Influence of obesity and metabolic syndrome on clinical outcomes of ST-segment elevation myocardial infarction in men undergoing primary percutaneous coronary intervention

BackgroundThe correlation between obesity and metabolic syndrome (MetS) and its impact on cardiovascular disease remains unclear. This study aims to investigate the impact of metabolic status and obesity on clinical outcomes of male patients with ST-segment elevation myocardial infarction (STEMI). MethodsData from the Korea Acute Myocardial Infarction Registry-National Institutes of Health registry were used to evaluate the impact of obesity and MetS on patients undergoing primary percutaneous coronary intervention (PPCI) from November 2005 to November 2015. Patients were grouped according to the presence or absence of obesity and MetS (‘obese−/MetS−’, ‘obese−/MetS+’, ‘obese+/MetS−’, or ‘obese+/MetS+’, respectively). All-cause death and major adverse cardiac events (MACE) were recorded during 12 months of follow-up. ResultsA total of 14,357 patients were included. Multivariate analysis showed that the presence of MetS was an independent risk factor for all-cause death (HR 2.08, 95% CI 1.30–3.31, p=0.002) and cardiovascular death (HR 2.44, 95% CI 1.33–4.46, p=0.004) at 12 months among normal weight patients. The protective effect of obesity was observed, compared with the obese−/MetS+ group, in terms of all-cause death (HR 0.50, 95% CI 0.31–0.81, p=0.005) and cardiovascular death (HR 0.52, 95% CI 0.28–0.96, p=0.038; vs. total obese individuals), but it might have disappeared compared with the obese−/MetS− group. The rate of MACE did not differ significantly according to category by obesity and MetS. ConclusionsThe obesity paradox has not been observed between obese and normal weight patients without MetS. Risk stratification on the basis of the presence or absence of MetS is not a clinically useful indicator of outcome in obese male patients with STEMI after PPCI.

Impact of chronic kidney disease on the long-term prognosis of patients with atrial fibrillation undergoing coronary stenting

Background: The effect of Chronic Kidney Disease (CKD) on the long-term prognosis of patients with Atrial Fibrillation (AF) undergoing coronary stenting was less studied. Methods: We enrolled 2,511 patients with non-valvular AF undergoing coronary stenting between January 2010 and June 2015 from 12 hospitals in Beijing, China. Results: 22.9% had CKD (creatinine clearance<60 ml/min). Compared to those with preserved renal function, patients with CKD were older, and had the higher prevalence of women, hypertension, previous ischemic stroke, cardiac dysfunction, and anemia. All patients were treated with drug-eluting stents. Dual antiplatelet therapy was the dominant antithrombotic strategy in both groups (96.0% vs. 93.9%, P=0.054). The follow-up duration was 39.5 ± 18.6 months. Complete follow-up data was obtained for 95.3% of this cohort. CKD group had higher incidences of death (19.0% vs. 6.9%, P<0.001), ischemic stroke (5.5% vs. 3.3%, P=0.020), MACCE (a composite of all-cause death, non-fatal myocardial infarction, target vessel revascularization, ischemic stroke and arterial thromboembolism, 28.2% vs. 14.7%, P<0.001) and Bleeding Academic Research Consortium (BARC) ≥ grade 3 (2.4% vs. 0.8%, P=0.003). No significant difference was noted with regard to myocardial infarction and target vessel revascularization. Cox multivariate regression identified CKD as an independent risk factor for allcause death (Hazard ratio (HR): 1.85, 95% CI: 1.37-2.50), MACCE (HR: 1.56, 95% CI: 1.25-1.96) and BARC ≥ 3 bleeding (HR: 3.14, 95% CI: 1.49-6.61), but not for ischemic stroke (HR: 1.10, 95% CI: 0.67-1.79). Conclusion: CKD was independently associated with poor long-term prognosis except for ischemic stroke in patients with AF and coronary stenting.

Mortality of patients with previous stroke undergoing drug-eluting stent implantation.

Patients with previous stroke are increasing among patients receiving percutaneous coronary intervention (PCI) with drug-eluting stents (DES); however, data about the influence of previous stroke on patient outcomes are limited. We evaluated whether previous stroke is associated with increased risk for mortality in coronary artery disease. A total of 18 650 patients with coronary artery disease undergoing PCI with DES were enrolled. Databases from three real-world PCI registries were merged for a patient-level meta-analysis. The primary outcome was death from any cause. The secondary outcomes were death from a cardiac cause, myocardial infarction, stent thrombosis, stroke, or repeat revascularization. Patients with previous stroke (n=1361), compared with those without previous stroke (n=17 289), were older and had a higher prevalence of risk factors or comorbidities. At a median follow-up of 47.0 months, patients with previous stroke had a higher risk for death from any cause [adjusted hazard ratio (HR)=1.623; 95% confidence interval (CI): 1.342-1.962; P<0.001], death from a cardiac cause (adjusted HR=1.686; 95% CI: 1.339-2.124; P<0.001), and stroke (adjusted HR=2.456; 95% CI: 1.853-3.255; P<0.001). There were no significant differences in the risks for myocardial infarction, stent thrombosis, or repeat revascularization. Patients with previous stroke showed higher risks for all-cause death and stroke after PCI with DES than those without stroke. Previous stroke should be considered a risk factor for all-cause death and stroke in this patient population.

Impact of platelet distribution width on the extent and long-term outcome of patients with stable coronary artery disease post percutaneous coronary intervention

Objective: To evaluate the relationship between platelet distribution width(PDW) and the extent of coronary artery disease and 2-year outcome in patients received percutaneous coronary artery intervention(PCI) because of stable coronary artery disease(SCAD). Methods: We consecutively enrolled 4 293 patients who received PCI because of SCAD in Fuwai Hospital from Jan 2013 to Dec 2013, patients were followed up for 2 years. Patients were divided into three groups according to tertiles values of PDW as follows: PDW≤11.4%(1 402 patients), 11.4%<PDW≤12.9%(1 441 patients) and PDW>12.9% (1 450 patients). Major adverse cardiovascular and cerebrovascular events (MACCE) were defined as the occurrence of death, myocardial infarction, target vessel revascularization, intra stent thrombosis and stroke during follow-up. Multivariable logistic regression was used to evaluate the relationship between PDW and the extent of CAD. Multivariable Cox regression was used to evaluate the relationship between PDW and prognosis of SCAD patients. Results: PDW was associated with diabetes mellitus, body mass index, red cell distribution width, mean platelet volume (MPV), platelet counts and glycosylated haemoglobin (P<0.05), but not associated with age, sex, estimated glomerular filtration rate (P>0.05). PDW was not correlated with the extent of CAD(P=0.990), SYNTAX score(P=0.721), no-reflow phenomenon after PCI(P=0.978). Multivariable logistic regression also showed no relationship between PDW and extent of CAD (OR=0.994, 95%CI 0.961-1.029, P=0.73). PDW was found to be an independent risk factor of 2-year cardiac death (HR=1.242, 95%CI 1.031-1.497, P=0.022), but was not an independent risk factor of all-cause death and MACCE. Conclusions: PDW is not related with the extent of coronary artery disease. PDW is an independent risk factor of 2-year cardiac death, but is not an independent risk factor of all-cause death and MACCE in this patient cohort.

Usefulness of the d-ROMs test for prediction of cardiovascular events

Backgroundd-ROMs test developed to determine the degree of individual oxidative stress may predict cardiovascular events. Methods and results265 patients (204 men, 61 women; age, 65±13years) who had been treated for cardiovascular disease were divided evenly by quartile of baseline d-ROMs levels, and were followed up. During the observation periods of 2.66±1.47years, there were 14 (5%) deaths, 8 (3%) cardiovascular deaths, 13 (5%) major adverse cardiovascular events (MACEs), and 51 (19%) all cardiovascular events including heart failure, cardiovascular surgery, and revascularization. Log-rank tests demonstrated that the patients in the 4th quartile (d-ROMs≧395.00U.CARR) had a higher incidence rate of cardiovascular death than those in the 2nd quartile (d-ROMs 286.00–335.00, p=0.022). In multivariate Cox regression analysis, even after adjustment for age, sex, coronary risk factors, C-reactive protein, and renal function, high d-ROMs was a risk factor for all-cause death [adjusted HR of 4th vs. 1st quartile, 10.791 (95% confidence interval 1.032–112.805), p=0.047], and all cardiovascular events [HR of 4th vs. 1st quartile, 2.651 (95% confidence interval 1.138–6.177), p=0.024]. ConclusionsOur results suggest that d-ROMs is a useful oxidative stress marker to assess prognosis and risk of further cardiovascular events.

Mammalian Target of Rapamycin Inhibitors and Clinical Outcomes in Adult Kidney Transplant Recipients.

Emerging evidence from recently published observational studies and an individual patient data meta-analysis shows that mammalian target of rapamycin inhibitor use in kidney transplantation is associated with increased mortality. Therefore, all-cause mortality and allograft loss were compared between use and nonuse of mammalian target of rapamycin inhibitors in patients from Australia and New Zealand, where mammalian target of rapamycin inhibitor use has been greater because of heightened skin cancer risk. Our longitudinal cohort study included 9353 adult patients who underwent 9558 kidney transplants between January 1, 1996 and December 31, 2012 and had allograft survival ≥1 year. Risk factors for all-cause death and all-cause and death-censored allograft loss were analyzed by multivariable Cox regression using mammalian target of rapamycin inhibitor as a time-varying covariate. Additional analyses evaluated mammalian target of rapamycin inhibitor use at fixed time points of baseline and 1 year. Patients using mammalian target of rapamycin inhibitors were more likely to be white and have a history of pretransplant cancer. Over a median follow-up of 7 years, 1416 (15%) patients died, and 2268 (24%) allografts were lost. There was a higher risk of all-cause mortality with time-varying mammalian target of rapamycin inhibitor use (hazard ratio, 1.47; 95% confidence interval, 1.23 to 1.76) as well as in the fixed time model analyses comparing mammalian target of rapamycin inhibitor use at baseline (hazard ratio, 1.54; 95% confidence interval, 1.22 to 1.93) and 1 year (hazard ratio, 1.63; 95% confidence interval, 1.32 to 2.01). Time-varying mammalian target of rapamycin inhibitor use was associated with higher risk of death because of malignancy (hazard ratio, 1.37; 95% confidence interval, 1.09 to 1.71). There were no statistically significant differences in the risk of all-cause (hazard ratio, 0.98; 95% confidence interval, 0.85 to 1.12) and death-censored (hazard ratio, 0.85; 95% confidence interval, 0.69 to 1.03) allograft loss between the mammalian target of rapamycin inhibitor use and nonuse groups in the time-varying model as well as the fixed time models. Mammalian target of rapamycin inhibitor use was associated with a higher risk of all-cause mortality but not allograft loss.

Effects of body mass index on risks for ischemic stroke, thromboembolism, and mortality in Chinese atrial fibrillation patients: a single-center experience.

BackgroundObesity is considered to be related to recurrence of atrial fibrillation (AF), left atrial thrombus formation, and atrial remodeling. However, whether obesity is an independent risk factor for stroke and other thromboembolic events is still controversial.ObjectiveThis study aimed to investigate the effects of body mass index (BMI) on the risks of stroke, thromboembolism, and mortality in AF patients.MethodsPatients who were diagnosed with nonvalvular AF were included in this observational, retrospective study. The study population was stratified by BMI at baseline. The Cox proportional hazard model was adopted to calculate adjusted hazard ratios of risk factors for adverse clinical events (stroke, thromboembolism, and mortality).ResultsA total of 1286 AF patients (males, 78.30%; mean age, 74.50 years; 94.48% paroxysmal AF) were followed up for a median of 2.1 years (IQR: 1.5–2.9 years). Overall, 159 patients died. A total of 84 strokes and 35 thromboembolic events occurred. Multivariate analysis showed that overweight (25.0≤BMI<30.0 kg/m2) and age ≥75 years were independent risk factors for ischemic stroke (both P<0.01). Obesity (BMI ≥30.0 kg/m2), age ≥75 years, persistent/permanent AF, and prior thromboembolism were independent risk factors for thromboembolism (all P<0.05). Underweight (BMI <18.5 kg/m2), age ≥75 years, prior ischemic stroke/transient ischemic attack, renal dysfunction, and heart failure were independent risk factors for all-cause deaths (all P<0.05).ConclusionsOverweight or obesity may be a risk factor of ischemic stroke and thromboembolism in AF patients. Excessive low weight is significantly associated with increased all-cause mortality.

Increased interventricular septum wall thickness predicts all-cause death in patients with coronary artery disease.

There is debate regarding the predictive value of interventricular septum (IVS) wall thickness for adverse events. The study investigated the association between the severity of thickened IVS and all-cause death in Chinese patients with coronary artery disease (CAD). A total of 2297 CAD patients verified by angiography was consecutively included. Patients were grouped according to the severity of thickened IVS. Cox regression analysis was conducted to determine the independent prognostic value of thickened IVS for all-cause death. During a median follow up of 25 months, 149 patients died. A gradient increase in the risk of death was observed across thickened IVS groups. Compared to patients with normal IVS thickness, the adjusted hazard ratio (HR) was 1.49 (95% confidence interval (CI) 1.00-2.23, P = 0.05) and 2.13 (95% CI 1.29-3.54, P = 0.003) for all-cause death in those with mildly and moderately/severely thickened IVS respectively. For one unit increase in IVS thickness, the risk of all-cause death was elevated by 14% (adjusted HR 1.14, 95% CI 1.05-1.24, P = 0.003). In patients with normal indexed left ventricular mass, thickened IVS was also demonstrated as an independent risk factor for all-cause death. Thickened IVS can be served as a reliable marker for predicting all-cause death in Chinese patients with CAD, even in those with normal left ventricular mass.

Spotlight on the February 3 Issue

#### Notable in Neurology This issue features articles on risk factors for all-cause death after diagnosis of unruptured intracranial aneurysms and on lipid and lipoprotein measurements and the risk of ischemic vascular events. Other featured articles focus on whether the diagnosis of dementia with Lewy bodies is affected by β-amyloid load, predicting progression in mild cognitive impairment with suspected nonamyloid pathology, and dopamine transmission in patients with comorbid REM sleep behavior disorder and major depressive disorder. ### Arterial stiffness and progression of structural brain changes: The SMART-MR study Distension measurements of the common carotid arteries and a brain MRI were performed in 526 patients, followed by a …

New-onset atrial fibrillation at discharge in patients after coronary artery bypass surgery: short- and long-term morbidity and mortality.

Atrial fibrillation (AF) after coronary artery bypass surgery is often considered a non-harmful and self-terminating condition. We studied the mortality and morbidity in patients with new-onset AF (NOAF) present at the time of hospital discharge. We conducted a retrospective follow-up study of 138 patients discharged in NOAF (NOAF group) and a propensity score-matched control group of 138 patients who were in sinus rhythm (SR) at the time of discharge (SR group). Follow-up data were obtained from the hospitals' records, from the national registry of hospital discharge diagnoses and death records from the Finnish Statistical Bureau. At 3 and 12 months after surgery, AF was present in 20.3 and 23.2% of patients in the NOAF group, respectively, but in none of the patients in the SR group (P < 0.001). At the end of follow-up (8.5 ± 2.8 years), 28.3 and 5.1% of the patients who survived in the NOAF and SR groups, respectively, were in chronic AF (P < 0.001). All-cause mortality (33.3 vs 18.8%, P = 0.002) and cardiac mortality (15.2 vs 4.3%, P = 0.001) were higher in the NOAF group when compared with the SR group. The incidence of cerebrovascular disorders in the NOAF and SR groups did not differ from each other (13.8 vs 10.9%, P = NS). Independent risk factors for all-cause death were NOAF [P = 0.024, hazard ratio (HR) 1.828, 95% CI 0.547-3.09], age (P = 0.0025, HR 1.074, 95% CI 1.026-1.13), diabetes (P = 0.015, HR 1.965, 95% CI 1.142-3.38) and prolonged respiratory support (P = 0.00024, HR 3.394, 95% CI 1.767-6.52). In addition, patients in the NOAF group had more hospitalizations due to heart failure (7.2 vs 0.7%, P < 0.001) and had a higher rate of implantation of permanent pacemakers (6.5 vs 0.4%, P < 0.001). A majority of NOAF patients revert to SR during the first months after surgery. On the other hand, 20-25% of NOAF patients develop chronic AF during long-term follow-up. Almost half of the NOAF patients were hospitalized during follow-up due to cardiovascular causes. Similarly, NOAF was associated with increased mortality due to cardiac causes, but not increased risk of stroke. This highlights the need for proper oral anticoagulation therapy in these patients.

Risk factors for all-cause death after diagnosis of unruptured intracranial aneurysms.

We investigated all-cause mortality and risk factors of death of patients with unruptured intracranial aneurysms (UIAs) in a long-term follow-up study. A total of 142 patients with 181 UIAs diagnosed between 1956 and 1978 when UIAs were not treated were included in this study. Patients were followed until death or until 2011 to 2012. Mortality rates and risk factors were studied with Kaplan-Meier survival analysis and the Cox proportional hazards regression models. During 3,530 person-years, 113 (80%) had died, giving an average annual mortality of 3.2%. Of them, 19 (17%) died of aneurysm rupture from the index UIA, 6 (5%) of other aneurysm-related causes, and 2 (2%) of unspecified subarachnoid hemorrhage. The remaining 86 died of causes unrelated to intracranial aneurysms. The cumulative death rate was 20% (95% confidence interval 14%-27%) at 10 years and 60% (52%-68%) at 30 years. Independent risk factors for subsequent death were patient age (adjusted hazard ratio 1.09 per year, 95% confidence interval 1.05-1.12, p < 0.001), male sex (2.81, 1.59-4.96, p < 0.001), heavy alcohol use (4.22, 2.22-8.02, p < 0.001), and cigarette smoking (1.72, 0.97-3.07, p = 0.064). History of hypertension, family history of subarachnoid hemorrhage, and diameter of UIA predicted death only in univariable analysis. In patients of working age with a UIA, alcohol consumption and cigarette smoking are modifiable risk factors for untimely death through several causes and should be taken into account when treatment is considered.

Association of borderline ankle-brachial index with mortality and the incidence of peripheral artery disease in diabetic patients

ObjectivePeripheral artery disease (PAD) and diabetes mellitus are significant risk factors for all-cause death or cardiovascular death. PAD occurs more frequently in diabetic than in non-diabetic patients. However, the association of ankle-brachial index (ABI), especially borderline ABI, with clinical outcomes has not been fully elucidated in diabetic patients. This study aimed to investigate the association of ABI with mortality and the incidence of PAD in Japanese diabetic patients. MethodsThis observational study included 3981 diabetic patients (61.0 ± 11.8 years of age, 59.4% men), registered in the Kyushu Prevention Study for Atherosclerosis. Patients were divided into 3 groups according to the value of ABI at baseline: ABI ≤0.90 (abnormal ABI:354 patients), 0.91 ≤ ABI ≤ 0.99 (borderline ABI:333 patients), and 1.00 ≤ ABI ≤ 1.40 (normal ABI:3294 patients). ResultsCumulative incidence of all-cause death was significantly higher in patients with abnormal and borderline ABI than in those with normal ABI (34.4% vs. 13.5%, P < 0.0001 and 26.1% vs. 13.5%, P < 0.0001, respectively). In multivariate analysis, the risks for all-cause death in patients with abnormal ABI (HR:2.16; 95%CI:1.46–3.14; P = 0.0002) and borderline ABI (HR:1.78; 95%CI:1.14–2.70; P = 0.01) were significantly higher than in those with normal ABI. The incidence of PAD was remarkably higher in patients with borderline ABI than in those with normal ABI (32.2% vs.9.6%, P < 0.0001). After adjustment, the risk for PAD was significantly higher in patients with borderline ABI than in those with normal ABI (HR:3.10; 95%CI:1.90–4.95; P < 0.0001). ConclusionsBorderline ABI in diabetic patients was associated with significantly higher risks for mortality and PAD compared with normal ABI.

Midlife and late-life handgrip strength and risk of cause-specific death in a general Japanese population: the Hisayama Study

BackgroundDecreased handgrip strength has been reported to be a risk factor for all-cause death among the elderly. However, it is unclear whether handgrip strength measured in midlife is associated with...

Heart failure with systolic dysfunction complicating acute myocardial infarction – differential outcomes but similar eplerenone efficacy by ST-segment or non-ST-segment elevation: A post hoc substudy of the EPHESUS trial

Differential outcomes in patients with acute systolic heart failure (HF) complicating acute myocardial infarction (AMI) and the efficacy of mineralocorticoid receptor antagonists according to non-ST-segment and ST-segment elevation myocardial infarction (NSTEMI, STEMI) status has not been specifically investigated. In the EPHESUS study, 6632 patients with acute HF and left ventricular ejection fraction<40% were randomized 3-14 days post-AMI (median 7.3 ± 3.0 days) to receive eplerenone (n=3319) or placebo (n=3313). Among them, 6392 patients with available data on baseline ST-segment status (4634 STEMI; 1758 NSTEMI) were compared using a Cox model analysis stratified according to quintiles of propensity score (PS), taking into account major baseline risk factors, including revascularization. STEMI and NSTEMI patients differed significantly across a large variety of baseline characteristics. During 30 months of follow-up, all-cause death occurred in 19% and 13% (P<0.0001), cardiovascular death in 16% and 12% (P<0.0001), cardiovascular death and hospitalization in 33% and 26% (P<0.0001) and death from progression of HF in 5% and 3% (P<0.0001) of unadjusted NSTEMI and STEMI patients, respectively. After Cox model PS adjustment without revascularization, NSTEMI status still proved to be a risk factor for all-cause death, cardiovascular death and death from progression of HF. After Cox model PS adjustment including revascularization, none of the outcomes differed between STEMI and NSTEMI patients. Eplerenone morbidity and mortality benefits were consistent in the STEMI and NSTEMI subgroups. In patients with acute systolic HF complicating AMI, eplerenone improves outcomes equally in STEMI and NSTEMI patients. Worse outcomes associated with NSTEMI could be explained by more co-morbidities, less aggressive therapies and, mainly, less frequent revascularization.

Impact of atrial fibrillation on long-term clinical outcomes in outpatients with heart failure

BackgroundAtrial fibrillation (AF) is a common arrhythmia in patients with heart failure (HF); however, its impact on unselected outpatients with HF remains unclear. MethodsWe followed 2024 symptomatic outpatients with HF who visited the Cardiovascular Institute Hospital (The Shinken Database: 2004–2011, N=17,517). We examined the prevalence, clinical characteristics, and outcomes of AF in these outpatients with HF. ResultsAF was observed in 310 of the patients (15%). Patients with AF were older; more likely to be female; and had lower rates of hypertension, diabetes mellitus, and ischemic heart disease. However, they also had higher rates of New York Heart Association grades III/IV, lower left ventricular ejection fraction (EF), renal dysfunction, and dilated cardiomyopathy. The use of cardiovascular drugs including beta-blockers, renin-angiotensin-system inhibitors, diuretics, digitalis, and antiarrhythmic drugs was more common in patients with AF. Kaplan–Meier curves revealed that the incidences of all-cause death, cardiovascular disease death, and HF-related admission were significantly higher in patients with AF. Kaplan–Meier curves and an unadjusted Cox regression analysis showed that AF was associated with a significantly higher risk of all-cause death, cardiovascular death, and HF-related admission. However, the adjusted Cox regression model showed that AF was no longer an independent risk factor for all-cause death, cardiovascular death, and HF death but remained an independent risk factor of HF-related admission (hazard ratio, 1.781; 95% confidence interval, 1.172–2.704; p=0.007). ConclusionsAF was frequently observed in outpatients with HF. AF was not associated with long-term mortality but was independently associated with HF-related admission in this outpatient population.

Clinical impact of diastolic function after surgical ventricular restoration.

The impact of diastolic function on the clinical outcome of surgical ventricular restoration remains controversial. 71 patients undergoing surgical ventricular restoration between 1999 and 2012 were investigated. Perioperative echocardiographic parameters were compared, risk factors for deaths and cardiac events were analyzed, and actuarial freedom from death and cardiac events was computed. Preoperatively, the left ventricular end-systolic volume index was 77 ± 40 mL·m(-2) and left ventricular ejection fraction was 33% ± 11%. Postoperatively, left ventricular systolic function was significantly improved (end-systolic volume index 49 ± 31 mL·m(-2), ejection fraction 42.1% ± 11.7%) with a 33.8% ± 21.9% reduction in left ventricular end-systolic volume index. The transmitral filling deceleration time decreased from 198 ± 54 to 150 ± 46 ms, and the ratio of early peak filling velocities increased significantly postoperatively (from 16 ± 10 to 21 ± 17). Freedom from death and cardiac events at 5 years was 78% ± 5% and 64% ± 6%, respectively. Multivariate analyses revealed that age was a significant risk factor for all-cause death, postoperative transmitral inflow pattern for cardiac death, and preoperative mitral regurgitation and postoperative transmitral inflow pattern for cardiac events. Despite its positive impact on systolic function, surgical ventricular restoration negatively affects postoperative diastolic function. Postoperative severe diastolic dysfunction may correlate with late mortality and cardiac events.

Small proximal aortic diameter is associated with higher central pulse pressure and poor outcome in patients with congestive heart failure

A small proximal aortic diameter (AoD) is thought to be associated with a higher characteristic impedance of the proximal aorta. However, there has been no evidence of a relationship between directly evaluated AoD and directly measured central aortic pressure or the outcome of patients with cardiovascular diseases. (a) In 135 patients without heart failure (HF), who underwent coronary catheterization, we retrospectively examined the relationship between the AoD and the central aortic pressure or aortic elastance. The AoD adjusted with covariates was inversely correlated with the central pulse pressure (cPP; coefficient=-0.75; P=0.04; model R(2)=0.575) and the effective arterial elastance index (coefficient=-0.12; P=0.001; model R(2)=0.366). (b) In 197 patients who were hospitalized due to HF, we examined the relationship between the AoD (evaluated using echocardiography) and the outcome using a Cox proportional hazard model. Fifty-three patients died from various causes during the follow-up period (2.2±1.1 years). Multivariable analysis revealed that the AoD remained an independent risk factor for all-cause death (hazard ratio for 1 s.d. increase of the AoD: 0.68, 95% confidence interval: 0.50-0.92, P=0.013) and cardiovascular death (hazard ratio for 1 s.d. increase of the AoD: 0.63, 95% confidence interval: 0.43-0.93, P=0.019). A small AoD was associated with a higher cPP and aortic stiffening in the patients without HF, as well as with a poor outcome for HF patients. Although it is easy to evaluate the AoD, it may offer important information regarding the pulsatile load and may be useful for risk stratification of HF patients.

Elevated resting heart rate is an independent predictor of all-cause death and cardiovascular events in Japanese ambulatory hemodialysis patients

Elevated heart rate (HR) is an independent risk factor for all-cause death or cardiovascular events in non-hemodialysis subjects; however, the clinical significance of elevated HR in hemodialysis patients is not well studied. We prospectively evaluated the relationship between HR and adverse outcome in a total of 229 ambulatory hemodialysis patients (57% men; mean age 62.2years) recruited from two dialysis clinics in 2009. Mean (SD) HR of this cohort was 74.1 (11.0) beats per minute (bpm). Receiver operating characteristic curves identified an HR cut-off level of ≥80bpm for increased adverse outcome. After a mean follow-up of 525days (range 7-760days) a total of 30 primary endpoints (21 all-cause deaths, 4 acute coronary syndromes and 8 strokes) and 38 secondary endpoints (30 primary endpoints, 8 congestive heart failures, and 5 other cardiovascular events) were detected. Cox regression analysis revealed that HR >80bpm was not an independent predictor of primary endpoints [hazard ratio 1.81, 95% confidence interval (CI) 0.79-4.11, p=NS], but of secondary endpoints (hazard ratio 2.01, 95% CI 1.01-4.22, p<0.05) after adjusting for age, sex, hemodialysis duration, and cardiovascular risks. Elevated HR is an independent predictor of all-cause death and cardiovascular events in Japanese ambulatory hemodialysis patients.

Clinical Outcomes of Japanese MPO-ANCA-related Nephritis: Significance of Initial Renal Death for Survival

Anti-myeloperoxidase anti-neutrophil cytoplasmic antibody (MPO-ANCA)- related nephritis constitutes 60% of rapidly progressive glomerulonephritis (RPGN) in Japan. The reported 1-year survival rate is over 80%, however, the long-term prognosis remains unknown. We therefore investigated the prognosis and factors affecting the clinical course of patients. We retrospectively investigated 74 patients (female, n=42; median age, 73.0 years) with MPO-ANCA-related nephritis. The patients were admitted to Fukushima Medical University and two affiliated hospitals between 2000 and 2010. Median estimated GFR (eGFR) was 12.1 mL/min/1.73 m2 at admission. The Birmingham Vasculitis Activity Score (BVAS version 3: max 63 points) at diagnosis and at 4 weeks after start of treatment were 15.0 and 5.0, respectively. Twenty-three patients (31%) died during a median observation period of 30.5 months. Sixteen patients (22%) presented with end-stage renal disease (ESRD) at the initial phase, and needed regular dialysis therapy. Multivariate Cox proportional hazards model analysis revealed that renal death at the initial phase was a significant risk factor for all-cause death (Hazard ratio, 5.72; 95% confidence interval, 2.49-13.09; p<0.001). Furthermore, BVAS>6, evaluated 4 weeks after start of treatment, is an independent risk factor for ESRD and patient survival. This is the first investigation to demonstrate clinical features focusing on MPO-ANCA-related nephritis. Renal death at the initial phase of treatment is a powerful risk factor for all-cause death in patients with MPO-ANCA-related nephritis. Patients at high risk of death and ESRD could be stratified according to BVAS.