Risk Stratification In Adults Research Articles

Machine Learning for Prediction of Adverse Cardiovascular Events in Adults With Repaired Tetralogy of Fallot Using Clinical and Cardiovascular Magnetic Resonance Imaging Variables

Background: Existing models for prediction of major adverse cardiovascular events (MACE) after repair of tetralogy of Fallot have been limited by modest predictive capacity and limited applicability to routine clinical practice. We hypothesized that an artificial intelligence model using an array of parameters would enhance 5-year MACE prediction in adults with repaired tetralogy of Fallot. Methods: A machine learning algorithm was applied to 2 nonoverlapping, institutional databases of adults with repaired tetralogy of Fallot: (1) for model development, a prospectively constructed clinical and cardiovascular magnetic resonance registry; (2) for model validation, a retrospective database comprised of variables extracted from the electronic health record. The MACE composite outcome included mortality, resuscitated sudden death, sustained ventricular tachycardia and heart failure. Analysis was restricted to individuals with MACE or followed ≥5 years. A random forest model was trained using machine learning (n=57 variables). Repeated random sub-sampling validation was sequentially applied to the development dataset followed by application to the validation dataset. Results: We identified 804 individuals (n=312 for development and n=492 for validation). Model prediction (area under the curve [95% CI]) for MACE in the validation dataset was strong (0.82 [0.74–0.89]) with superior performance to a conventional Cox multivariable model (0.63 [0.51–0.75]; P =0.003). Model performance did not change significantly with input restricted to the 10 strongest features (decreasing order of strength: right ventricular end-systolic volume indexed, right ventricular ejection fraction, age at cardiovascular magnetic resonance imaging, age at repair, absolute ventilatory anaerobic threshold, right ventricular end-diastolic volume indexed, ventilatory anaerobic threshold % predicted, peak aerobic capacity, left ventricular ejection fraction, and pulmonary regurgitation fraction; 0.81 [0.72–0.89]; P =0.232). Removing exercise parameters resulted in inferior model performance (0.75 [0.65–0.84]; P =0.002). Conclusions: In this single-center study, a machine learning-based prediction model comprised of readily available clinical and cardiovascular magnetic resonance imaging variables performed well in an independent validation cohort. Further study will determine the value of this model for risk stratification in adults with repared tetralogy of Fallot.

Utility of HS-CRP as an add on to Lipid Profile for Cardiovascular Risk Stratification in Adults with Type II Diabetes Mellitus

Background: Diabetes mellitus (DM), which has a significant mortality and morbidity percentage, has emerged as a major health hazard. The aim of this study to evaluate the effects of hs-CRP with lipid profile effects on CVS risk in type II diabetic patients. Study design: It was a cross-sectional study conducted in the People’s University of Medical and Health Sciences for Women, Nawabshah, for six month duration from March 2022 to August 2022. Methodology: The total participants were 250 which included 180 diabetic participants and other remaining 70 were non-diabetic participants. These participants were divided into two groups, one group was non-diabetic participants serve as control group and other was diabetic group. The data analyses were done by SPSS 21 version. Results: The mean age of the male and female participant was 50.5±9.9 and 49.48±10.5. There was no significance change in the demographic variables like BMI, weight, systolic pressure and diastolic pressure p>0.005 in diabetic and control group. The participants were 31% and 72% raised CVS risk due to increase of LDL and hsCRP levels. The LDL, TC and TG were statistically significant in the participants having >4 mg/dl of hs-CRP. The HDL and ratio of HDL/LDL level were reduced significantly having >4 hs-CRP mg/dl. Conclusion: According to our observations, patients who are diabetic participants commonly have raised hs-CRP levels along with dyslipidemia. Continuous monitoring of these indicators can sometimes support in reducing the CVS risk among patients. Keywords: lipid profile, dyslipidemia, significant mortality and morbidity.

Assessment of Cystatin C Level for Risk Stratification in Adults With Chronic Kidney Disease

Kidney function is usually estimated from serum creatinine level, whereas an alternative glomerular filtration marker (cystatin C level) associates more closely with future risk of cardiovascular disease (CVD) and mortality. To evaluate whether testing concordance between estimated glomerular filtration rates based on cystatin C (eGFRcys) and creatinine (eGFRcr) levels would improve risk stratification for future outcomes and whether estimations differ by age. A prospective population-based cohort study (UK Biobank), with participants recruited between 2006-2010 with median follow-up of 11.5 (IQR, 10.8-12.2) years; data were collected until August 31, 2020. Participants had eGFRcr greater than or equal to 45 mL/min/1.73 m2, albuminuria (albumin <30 mg/g), and no preexisting CVD or kidney failure. Chronic kidney disease status was categorized by concordance between eGFRcr and eGFRcys across the threshold for hronic kidney disease (CKD) diagnosis (60 mL/min/1.73 m2). Ten-year probabilities of CVD, mortality, and kidney failure were assessed according to CKD status. Multivariable-adjusted Cox proportional hazards models tested associations between CVD and mortality. Area under the receiving operating curve tested discrimination of eGFRcr and eGFRcys for CVD and mortality. The Net Reclassification Index assessed the usefulness of eGFRcr and eGFRcys for CVD risk stratification. Analyses were stratified by older (age 65-73 years) and younger (age <65 years) age. There were 428 402 participants: median age was 57 (IQR, 50-63) years and 237 173 (55.4%) were women. Among 76 629 older participants, there were 9335 deaths and 5205 CVD events. Among 351 773 younger participants, there were 14 776 deaths and 9328 CVD events. The 10-year probability of kidney failure was less than 0.1%. Regardless of the eGFRcr, the 10-year probabilities of CVD and mortality were low when eGFRcys was greater than or equal to 60 mL/min/1.73 m2; conversely, with eGFRcys less than 60 mL/min/1.73 m2, 10-year risks were nearly doubled in older adults and more than doubled in younger adults. Use of eGFRcys better discriminated CVD and mortality risk than eGFRcr. Across a 7.5% 10-year risk threshold for CVD, eGFRcys improved case Net Reclassification Index by 0.7% (95% CI, 0.6%-0.8%) in older people and 0.7% (95% CI, 0.7%-0.8%) in younger people; eGFRcr did not add to CVD risk estimation. The findings of this study suggest that eGFRcr 45 to 59 mL/min/1.73 m2 includes a proportion of individuals at low risk and fails to capture a substantial proportion of individuals at high-risk for CVD and mortality. The eGFRcys appears to be more sensitive and specific for CVD and mortality risks in mild CKD.

Prognostic Implications of Exercise-Induced Hypertension in Adults With Repaired Coarctation of Aorta.

The purpose of this study was to assess the relationship between exercise-induced hypertension (EIH) and cardiovascular events, and to determine whether exercise blood pressure (BP) improved risk stratification in adults with repaired coarctation of aorta. Retrospective study of patients with repaired coarctation of aorta on antihypertensive therapy that underwent exercise testing and exercise test (2003-2019). BP was measured at rest in 3 different clinical settings and averaged to determine the resting BP. Indices of left ventricular function and afterload were obtained from the echocardiogram. EIH was defined as systolic BP >210 (males) or >190 (females) at peak exercise. Cardiovascular event was defined as atrial fibrillation, ventricular tachycardia, heart failure hospitalization, heart transplant, and cardiovascular death. Of 327 patients (age 35±13 years), 116 (35%) had EIH. Although the resting BP was similar between patients with versus without EIH, the EIH group had higher pulsatile arterial load, more advanced left ventricular remodeling, and were less likely to be on angiotensin converting enzyme inhibitor/angiotensin receptor blocker. EIH was associated with cardiovascular events (hazard ratio, 1.06 [95% CI, 1.02-1.08]) independent of resting systolic BP, and improved prognostic accuracy above resting systolic BP (C statistic, 0.671 [95% CI, 0.645-0.694] to 0.727 [95% CI, 0.709-0.750]; P=0.01). Angiotensin-converting enzyme inhibitor/angiotensin receptor blocker was associated with a lower risk of cardiovascular events. EIH was associated with cardiovascular events independent of resting BP, and patients receiving angiotensin-converting enzyme inhibitor/angiotensin receptor blocker had lower risk of cardiovascular events. These data suggest that exercise BP could be used to assess adequacy of antihypertensive therapy, and to guide titration of antihypertensive therapy.

CA125: a novel cardiac biomarker for infants with congenital diaphragmatic hernia

BackgroundThe carbohydrate antigen 125 (CA125) was proven as a robust biomarker for risk stratification in adults with heart failure. This is the first study analyzing CA125 in a cohort of infants with congenital diaphragmatic hernia (CDH).MethodsSixty-eight infants with CDH, treated at the University Children’s Hospital Bonn (Germany), between January 2018 and February 2021, were prospectively enrolled for analysis. CA125 values were measured at the following timepoints: 6,12, 24, 48 h, and during ECMO daily from day 1 to day 7.ResultsIn infants not surviving to discharge, CA125 values were significantly higher at day 1 (6, 12, and 24 h). Infants with subsequent need for ECMO presented significantly higher CA125 values at 12 h of life. During ECMO, CA125 values measured at day 1 were significantly higher in infants not surviving to discharge. In the ROC analysis, a CA125 value of ≥10 U/ml was calculated as optimal cut-off for the prediction of ECMO and in-hospital mortality. CA125 values correlated significantly with the severity of PH and ventricular dysfunction.ConclusionsCA125 values correlate significantly with echocardiographic markers of PH and ventricular dysfunction and correlate significantly with parameters of disease severity (need for ECMO, mortality).ImpactCA125 was proven as robust cardiac biomarker in adult cohorts.Information about the utility as a biomarker in neonatal cohorts is lacking.This is the first study analyzing CA125 as a cardiac biomarker in a cohort of infants with congenital diaphragmatic hernia (CDH).CA125 correlates significantly with markers of echocardiographic assessment (PH and ventricular dysfunction) in infants with CDH and helps to identify infants at high risk for ECMO and in-hospital mortality.The results underline the need for the inclusion of cardiac biomarkers in the clinical routine in neonates at risk for cardiopulmonary failure.

Utility of hsCRP as an add onn to Lipid Profile for Cardiovascular Risk Stratification in Adults with Type 2 Diabetes Mellitus

Introduction: Dyslipidemia is common in Diabetes and is predictive of cardiovascular events. But, myocardial infarction in the setting of normal lipids levels is not uncommon. hsCRP has been studied elaborately and is found to be a stronger predictor of heart attack and stroke than LDL cholesterol. We conducted this study to observe the level of hsCRP in adults with Type 2 Diabetes and its association with lipid parameters. Methods: It is a cross sectional study including 168 Type 2 Diabetes patients conducted in department of biochemistry and internal medicine at B.P. Koirala Institute of Health Sciences, Dharan, Nepal for duration of one year. The ethical clearance was taken from the institutional ethical review board and patients were enrolled after taking informed consent. Venous blood was collected and serum lipid profile and hsCRP were measured. Results: The means±SD for age, TC, HDL-C, LDL-C and HDL/LDL ratio of patients were 52.2±11.9 years, 182.9±41.9 mg/dl, 41.6±8 mg/dl, 94.9±20 mg/dl, and 0.47±0.18 respectively. The medians of TG and hsCRP were 152.5 (109, 195) mg/dl and 1.9 (0.9, 2.8) mg/dl respectively. hs-CRP was found to have significant positive correlation with TC (r=0.286), LDL (r=0.652) and TG (r=0.299) and significant negative correlation with HDL (r= -0.614) and HDL/LDL ratio (r= -0.646). Only 33% of patients were categorised as having increased CVS risk according to high LDL levels but altogether 75% of patients had increased CVS risk according to hsCRP levels. Conclusion: hsCRP can be considered as an add on to lipid profile while predicting CVS complications in patients with Type 2 Diabetes Mellitus in our population.

Risk stratification of adults with congenital heart disease during the COVID-19 pandemic: insights from a multinational survey among European experts

ObjectiveAdults with congenital heart disease (ACHD) may be at a higher risk of a fatal outcome in case of COVID-19. Current risk stratification among these patients relies on personal experience...

Minimal residual disease level determined by flow cytometry provides reliable risk stratification in adults with T-cell acute lymphoblastic leukaemia.

Minimal residual disease (MRD) is an important independent prognostic factor for relapse and survival in acute lymphoblastic leukaemia (ALL). Compared with adult B-cell ALL, reports of adult T-cell ALL (T-ALL) MRD have been scarce and mostly based on molecular methods. We evaluated the prognostic value of multiparameter flow cytometry (FCM)-based MRD at the end of induction (EOI-MRD). The present retrospective study included 94 adult patients with T-ALL. MRD was detected by six- to eight-colour FCM. Patients who were EOI-MRD positive had a higher cumulative incidence of relapse (CIR) (87·6% vs. 38·8%, P=0·0020), and a lower relapse-free survival (RFS) (5·4% vs. 61·0%, P=0·0005) and overall survival (OS) (32·7% vs. 69·7%, P<0·0001) than those who were EOI-MRD negative. Moreover, for patients who received allogeneic haematopoietic stem cell transplantation (allo-HSCT) at their first remission, EOI-MRD positivity was predictive of post-transplant relapse (2-year CIR: 68·2% vs. 4·0%, P=0·0003). Multivariate analysis showed that EOI-MRD was an independent prognostic factor for CIR [hazard ratio (HR) 2·139, P=0·046], RFS (HR 2·125, P=0·048) and OS (HR 2·987, P=0·017). In conclusion, EOI-MRD based on FCM was an independent prognostic factor for relapse and survival in adult T-ALL. For patients who underwent HSCT, EOI-MRD could be used to identify patients with a high risk of relapse after allo-HSCT.

Early detection of ventricular arrhythmias in adults with congenital heart disease using an insertable cardiac monitor (EDVA-CHD study)

BackgroundSudden cardiac death (SCD) due to ventricular arrhythmias (VA) is an important mode of death in adults with congenital heart disease (CHD). Risk stratification is difficult in this heterogeneous population. Insertable cardiac monitors (ICM) may be useful for risk stratification. The purpose of the present study was to evaluate the use of ICM for the detection of VA in adults with CHD. MethodsIn this prospective single-center observational study we included consecutive adults with CHD deemed at risk of VA who received an ICM between March 2013 and February 2019. The decision to implant an ICM was made in a Heart Team consisting of a cardiac electrophysiologist and a cardiologist specialized in CHD. ResultsA total of 30 patients (mean age, 38 ± 15 years; 50% male) received an ICM. During a median follow-up of 16 months, 8 patients (27%) had documented nonsustained VA. Of these 8 patients, 3 (10%) received a prophylactic ICD. Furthermore, ICM-detected arrhythmias were present in 22 patients (73%) leading to a change in clinical management in 16 patients (53%). Besides the patients receiving an ICD, 10 patients (33%) had a change in their antiarrhythmic drugs, 6 patients (20%) underwent an electrophysiology study, and 1 patient (3%) received a pacemaker. ConclusionsThe detection of VA by the ICM contributed to the clinical decision to implant a prophylactic ICD. Furthermore, ICM-detected arrhythmias led to important changes in the clinical management. Therefore, long-term arrhythmia monitoring by an ICM seems valuable for risk stratification in adults with CHD.

Exploring the Prognostic Value of Novel Markers in Adults With a Systemic Right Ventricle.

BackgroundAdults with a systemic right ventricle (sRV) have a high risk of cardiac complications. This study aimed to identify prognostic markers in adults with sRV based on clinical evaluation, echocardiography, and blood biomarkers.Methods and ResultsIn this prospective cohort study, consecutive clinically stable adults with sRV caused by Mustard‐ or congenitally corrected transposition of the great arteries were included (2011–2013). Eighty‐six patients were included (age 37±9 years, 65% male, 83% New York Heart Association functional class I, 76% Mustard transposition of the great arteries, 24% congenitally corrected transposition of the great arteries). Venous blood sampling was performed including N‐terminal pro B‐type natriuretic peptide, high‐sensitive‐troponin‐T, high‐sensitivity C‐reactive protein, growth differentiation factor‐15, galectin‐3, red cell distribution width, estimated glomerular filtration rate, and hemoglobin. Besides conventional echocardiographic measurements, longitudinal, circumferential, and radial strain were assessed using strain analysis. During a median follow‐up of 5.9 (interquartile range 5.3–6.3) years, 19 (22%) patients died or had heart failure (primary end point) and 29 (34%) patients died or had arrhythmia (secondary end point). Univariable Cox regression analysis was performed using dichotomous or standardized continuous variables. New York Heart Association functional class >I, systolic blood pressure, and most blood biomarkers were associated with the primary and secondary end point (galectin‐3 not for primary, N‐terminal pro B‐type natriuretic peptide and high‐sensitivity C‐reactive protein not for secondary end point). Growth differentiation factor‐15 showed the strongest association with both end points (hazard ratios; 2.44 [95% CI 1.67–3.57, P<0.001], 2.00 [95% CI 1.46–2.73, P<0.001], respectively). End‐diastolic basal dimension of the subpulmonary ventricle was associated with both end points (hazard ratio: 1.95 [95% CI 1.34–2.85], P<0.001, 1.70 [95% CI 1.21–2.38, P=0.002], respectively). Concerning strain analysis, only sRV septal strain was associated with the secondary end point (hazard ratio 0.58 [95% CI 0.39–0.86], P=0.006).ConclusionsClinical, conventional echocardiographic, and blood measurements are important markers for risk stratification in adults with a sRV. The value of novel echocardiographic strain analysis seems limited.

Long-term outcomes in adults with repaired tetralogy of Fallot and pulmonary atresia.

There are limited outcome data in adults with tetralogy of Fallot and pulmonary atresia. The purpose of this study was to describe re-operations and all-cause mortality in adults with tetralogy of Fallot and pulmonary atresia. Retrospective review of adults with repaired tetralogy of Fallot and pulmonary atresia who received care at the Mayo Adult Congenital Heart Disease Clinic, 1990-2016. All-cause mortality was calculated as events per 100 patient-years from the time of first presentation to the Adult Congenital Heart Disease Clinic. Of the 221 patients, the age at initial tetralogy of Fallot repair was 6 (5-13) years, and the age at first presentation to the clinic was 27 - 8 years. All patients had at least one right ventricular to pulmonary artery conduit re-operation. There were 31 deaths (14%) at mean age of 41 - 14years. The causes of death were end-stage heart failure (n = 17), sudden cardiac death (n=9), post-operative death after cardiac surgery (n = 2), sepsis with multi-system organ failure (n = 2), and unknown (n = 1). All-cause mortality rate was 1.7 per 100 patient-years. The risk factors for all-cause mortality were older age (>12 years) at the time of repair (hazard ratio 1.41, 95 confidence interval 1.06-2.02, p = 0.033), non-sustained ventricular tachycardia (hazard ratio 1.36, 95 confidence interval 1.17-2.47, p = 0.015), and left ventricular ejection fraction <50% (hazard ratio 1.39, 95 confidence interval 1.08-2.31, p = 0.031). Based on a review of 221 adults with repaired tetralogy of Fallot and pulmonary atresia, all patients had re-operations and all-cause mortality rate was 1.7 events per 100 patient-years. The current study provides important outcomes data for risk stratification in adults with tetralogy of Fallot and pulmonary atresia.

Which patients with acute myeloid leukemia in CR1 can be spared an allogeneic transplant?

Disease relapse remains the major cause of treatment failure in adults with acute myeloid leukemia (AML) in first complete remission (CR1) treated with intensive chemotherapy alone. Allogeneic stem cell transplantation (allo-SCT) reduces the risk of disease recurrence, and thus the advent of reduced intensity-conditioning regimens coupled with increased donor availability has increased the deliverability of potentially curative transplant therapy in AML. However, allo-SCT remains associated with significant additional morbidity and mortality, and it is therefore important to identify patients whose outcome if treated with chemotherapy alone is good enough to spare them the risks associated with allo-SCT. Characterization of cytogenetic and molecular abnormalities present at diagnosis coupled with dynamic assessments of measurable residual disease now permit greater accuracy in defining the relapse risk in patients treated with chemotherapy alone. At the same time, the risk of transplant-related mortality can be predicted by a number of scoring systems which assess patient comorbidity. Taken together, such assessments permit a dynamic assessment of the risks and benefits of transplantation aiding the identification of patients who are unlikely to benefit from transplantation in CR1. Increasingly accurate risk stratification in adults with AML CR1 aids the rational utilization of allo-SCT. Future research integrating the results of serial MRD analysis in molecularly defined subtypes of AML will further improve rational selection of patients for transplant.

Role of QRS Fragmentation for Risk Stratification in Adults With Tetralogy of Fallot.

BackgroundPatients with tetralogy of Fallot (TOF) remain at risk for cardiovascular events despite successful repair. Some of the current risk stratification tools require advanced imaging and invasive studies, and hence are difficult to apply to routine patient care. A recent study showed that QRS fragmentation (QRS‐f) is predictive of mortality in patients with TOF. The current study aims to validate this result by assessing whether severity of QRS‐f could predict all‐cause mortality in a different TOF population.Methods and ResultsThe authors reviewed the Mayo Adult Congenital Heart Disease database for patients with TOF who had ECG from 1990–2017. QRS‐f was defined as notches in QRS complex in ≥2 contiguous leads on ECG, not related to bundle branch block, and classified as none, mild (≤3 leads), moderate (4 leads), or severe (≥5 leads). Of 465 patients (age 37±14 years) in the study, QRS‐f was present in 161 (35%): mild (n=43, 9%), moderate (n=77, 17%), and severe (n=41, 9%). There were 55 deaths (12%) during 13.6±8.2 years of follow‐up. Severity of QRS‐f remained an independent predictor of all‐cause mortality after adjustment for other ECG parameters, patient demographics, and atrial and ventricular arrhythmia (hazard ratio, 1.74 per class; 95% confidence interval, 1.08–2.93 [P=0.041]).ConclusionsThe presence of severe QRS‐f may be used as complementary data to the usual clinical indices to determine whether interventions such as invasive electrophysiology study should be performed in patients with nonsustained ventricular tachycardia or to proceed with pulmonary valve replacement in patients with severe pulmonary regurgitation with ventricular volumes below the guideline‐directed threshold for intervention.

Hypertrophic cardiomyopathy: Sudden cardiac death risk stratification in adults.

[first paragraph of article]Sudden cardiac death (SCD) is a devastating and often unpredictable complication of hypertrophic cardiomyopathy (HCM) that may occur as the initial disease presentation, frequently in asymptomatic or mildly symptomatic young people. Until 2000, only small series of patients examining predictors of SCD had been published, with a selection bias towards severe disease. Subsequently, larger series that are more representative of the HCM spectrum have shown that the annual SCD rate is less than 1%, and that there are subgroups of patients with a clearly higher risk.

High-Sensitive Cardiac Troponin T and Systemic Right Ventricular Area Predict Outcomes in Adults With Congenitally Corrected Transposition

BackgroundCongenitally corrected transposition of the great arteries (ccTGA) is a rare clinical condition in which the morphologically right ventricle sustains systemic circulation. This congenital heart anomaly exposes patients with ccTGA to adverse events over time. Strategies to identify persons who are at high risk of clinical events will be crucial for improving patient outcomes. Thus the aim of this study was to identify screening tools that enable morbidity and mortality risk stratification in adults with ccTGA. MethodsThis was a prospective observational study. Electrocardiography, laboratory testing, echocardiography, and cardiopulmonary exercise testing were performed at baseline. A Cox proportional hazards regression analysis was conducted to establish determinants of composite clinical endpoints, including death, heart transplantation, systemic ventricular device assist implantation, worsening of heart failure, vascular events, tricuspid valve regurgitation requiring intervention, and clinically relevant arrhythmias. ResultsFifty-one patients—30 male and 21 female—with a mean age of 36 years were studied. During a median follow-up period of 3.15 years, 19 patients experienced 39 clinical events. Detectable high-sensitivity troponin T (hsTnT) combined with echocardiography-derived systemic right ventricular end-diastolic (sRVED) area were the best predictors of adverse outcomes (hazard ratio [HR] = 6.25, P = 0.02 and HR = 1.05, P = 0.02, respectively). ConclusionsA combination of detectable hsTnT and an increased sRVED area are the best predictors of adverse clinical events in adults with ccTGA. This observation may be useful to guide follow-up, as both risk determinants are widely available and simple to obtain in everyday practice.

Cardiopulmonary Exercise Testing for Surgical Risk Stratification in Adults with Congenital Heart Disease.

Adult congenital heart disease (ACHD) patients often require repeat cardiothoracic surgery, which may result in significant morbidity and mortality. Currently, there are few pre-operative risk assessment tools available. In the general adult population, pre-operative cardiopulmonary exercise testing (CPET) has a predictive value for post-operative morbidity and mortality following major non-cardiac surgery. The utility of CPET for risk assessment in ACHD patients requiring cardiothoracic surgery has not been evaluated. Retrospective chart review was conducted on 75 ACHD patients who underwent CPET less than 12months prior to major cardiothoracic surgery at Children's Hospital of Wisconsin. Minimally invasive procedures, cardiomyopathy, acquired heart disease, single ventricle physiology, and heart transplant patients were excluded. Demographic information, CPET results, and peri-operative surgical data were collected. The study population was 56% male with a median age of 25years (17-58). Prolonged post-operative length of stay correlated with increased ventilatory efficiency slope (VE/[Formula: see text] slope) (P = 0.007). Prolonged intubation time correlated with decreased peak HR (P = 0.008), decreased exercise time (P = 0.002), decreased heart rate response (P = 0.008) and decreased relative peak oxygen consumption (P = 0.034). Post-operative complications were documented in 59% of patients. While trends were noted between post-operative complications and some measurements of exercise capacity, none met statistical significance. Future studies may further define the relationship between exercise capacity and post-operative morbidity in ACHD patients.

Abstract P255: Long-term Associations Between Non-High Density Lipoprotein and Apolipoprotein B in Young Adulthood and Coronary Artery Calcification in Adults With Nonalcoholic Fatty Liver Disease in Middle Age: The CARDIA Study

Background: Cardiovascular disease (CVD) is the leading cause of death in nonalcoholic fatty liver disease (NAFLD). Apolipoprotein B (apoB) and non-high density lipoprotein-C (NHDL-C) are positively associated with NAFLD in small studies. High apoB predicts atherosclerotic CVD even when NHDL-C is low, suggesting that apoB may be the strongest predictor of atherosclerotic risk in adults. Objective: To quantify associations between apoB, NHDL-C and the discordance between apoB and NHDL-C levels in young adulthood with prevalent NAFLD, and coronary artery calcium (CAC) in adults with NAFLD in midlife. Methods: CARDIA recruited young adults ages 18 to 30 years in 1985-86. Participants with complete baseline CVD risk factor data and year 25 (Y25) NAFLD assessment and CAC score were included. NAFLD was defined as noncontrast computed tomography (CT) liver attenuation ≤40 Hounsfield Units after exclusions for other causes of liver fat. Presence of CAC was defined as Agatston score &gt;0 on CT. Baseline NHDL-C or apoB values were divided into tertiles and 4 mutually exclusive concordant/discordant groups, stratified based on being above or below median NHDL-C or apoB levels. Results: Analysis included 2,508 participants (baseline age: 27 ± 4 years; body mass index: 25 ± 4 kg/m 2 ; 58% women; 53% white). Y25 NAFLD prevalence was 10%. Compared with the lowest tertile, higher odds of NAFLD were seen in the middle and high tertiles of both apoB and NHDL-C in separate adjusted models. High NHDL-C and low apoB, but not high apoB and low NHDL-C, discordance was associated with Y25 NAFLD in adjusted models. Among NAFLD participants (n=261), NHDL-C/apoB discordance was not associated with Y25 CAC. Highest odds of CAC were observed in NAFLD participants with high NHDL-C ( TABLE ). Conclusion: High NHDL-C is a strong early risk marker for both NAFLD and atherosclerosis among adults with NAFLD in midlife. Based on our study findings, the additional benefit of measuring apoB levels for risk stratification in adults with NAFLD is not apparent.

Abstract O.69: Coronary Vessel Wall Imaging By Using Multi-detector Computed Tomography And Outcomes In Patients Long After Kawasaki Disease: Potential For Risk Stratification

Background: In acute coronary syndrome (ACS) in adults after Kawasaki disease (KD), acute thrombosis occurs in culprit lesions with calcified intima even in the absence of giant aneurysms (AN) or severe stenosis. Recently, multi-detector computed tomography (MDCT), a non-invasive modality, was shown to have good diagnostic accuracy of detecting IVUS-defined intimal thickening and calcification. We investigated whether MDCT-derived vessel wall lesions are associated with coronary artery lesions (CAL) and outcomes in patients long after KD. Methods: MDCT was performed and analyzed (Vitrea fX, vs2.0, VITAL) in patients ≥10 years after KD, in which CAL were determined by ultrasound (US) during acute KD and serial CAG (if CAL was detected by US). Any discernible structure under the luminal surface with the CT density with or without areas ≥ 130 Hounsfield units, was defined as a calcified or noncalcified intima. Results: A total of 42 patients (median age 19.7 yo, male 64%, median interval after KD 17.5 y) were recruited and followed-up for 4.0 years (median) (range 0.1-5.5): 23 (55%) patients have any CAL in any segments, including regressed AN in 42 segments, persistent AN in 27 segments, localized stenosis (LS) in 7 segments; normal coronary artery from the onset was found in 225 segments in total patients. MDCT findings revealed no intimal lesions in 271 segments, 6 non-calcified intima, and 24 calcified intima; Mean (range) value of Agatston calcium score was 140 (0-2247) with zero value in 29 (69%). Normal segments from the onset exhibited no intimal lesions (225/225, 100%); regressed AN exhibited no intima (35/42, 83%), non-calcified intima (2/42, 5%), and calcified intima (5/42, 12%); persistent AN exhibited no intima (11/27, 41%), noncalcified intima (4/27, 15%), and calcified intima (12/27, 44%); all the LSs exhibited calcified intima (7/7, 100%). In the follow-up after MDCT, a 23 year-old patient (calcium score 17) had ACS at the culprit lesion with LS &lt;50% and calcified intima; another 16 year-old patient (calcium score 545) had asymptomatic myocardial infarction at the culprit lesion with persistent aneurysm and calcified intima. Conclusions: Coronary vessel wall imaging by using MDCT may have a potential role for risk stratification of adults after KD.

Risk Stratification in Very Old Adults: How to Best Gauge Risk as the Basis of Management Choices for Patients Aged Over 80

Cardiovascular disease (CVD) is the leading cause of mortality in older adults, however, in the elderly accurate stratification of CVD risk to guide management decisions is challenging due to the heterogeneity of the population. Conventional assessment of CVD and therapeutic risk is based on extrapolation of guidelines developed from evidence demonstrated in younger individuals and fails to weight the increased burden of complications and multimorbidity. Using a comprehensive geriatric based assessment of older adults with CVD that includes an estimation of complexity of multimorbidity as well as traditional risk assessment provides a patient centered approach that allows for management decisions congruent with patient preferences. This review examines the complexity of risk stratification in adults over 80, assessment methods to augment current tools and the basis of management decisions to optimize patient and family centered goals.

Circulation: Heart Failure Editors’ Picks

Summary : Lifelong exercise training maintains a youthful compliance of the left ventricle (LV), whereas a year of exercise training started later in life fails to reverse LV stiffening, possibly because of accumulation of irreversible advanced glycation end products. Alagebrium is a novel drug that breaks advanced glycation end product crosslinks and improves LV stiffness in aged animals. In this study, the authors prescribed alagebrium (200 mg daily) or placebo combined with aerobic exercise training or contact control in healthy, sedentary older individuals for 1 year. The authors evaluated overall cardiac function by the use of several modalities, including invasive pressure–volume measurements, exercise testing, and cardiac MRI before and after the training. To the authors’ knowledge, this is the first study to evaluate the effects of alagebrium and exercise training in healthy aged humans. After intervention, exercise training significantly increased exercise capacity, LV mass, and LV end-diastolic volume. Conversely, alagebrium had little effect on exercise capacity or LV geometry. However, alagebrium showed a modest improvement in LV stiffness compared with placebo. This favorable effect of alagebrium on LV stiffness was most prominent in individuals with combined alagebrium and exercise training. Conclusions : Alagebrium had no effect on hemodynamics, LV geometry, or exercise capacity in healthy, previously sedentary seniors. However, it did show a modestly favorable effect on age-associated LV stiffening.1 Summary : Maximum oxygen consumption (peak VO2) and efficiency of ventilation (VE) during exercise (VE/VCO2 slope) are known to stratify adults in heart failure for 1-year survival. On the basis of adult data, a recent American Heart Association scientific statement suggested that peak VO2<50% predicted for age and sex should be considered substantial impairment in exercise performance in children with heart disease and therefore a class I indication for heart transplant listing. This single-center study examined the association of …