Tool For Risk Stratification Of Patients Research Articles

The abdominal waist circumference and 4-year outcomes following peripheral bypass grafting.

Current literature evaluating the relationship between obesity, utilizing measures other than the Body Mass Index (BMI), and postoperative outcomes following vascular surgery are sparse. This study aimed to investigate any association between abdominal waist circumference (AWC) and waist-hip ratio (WHR) in relation to postoperative morbidity and mortality following peripheral artery bypass graft (PABG) surgery. AWC and hip circumference (HC) were measured from pre-intervention magnetic resonance (MR) and computed tomography (CT) scans of patients undergoing elective and nonelective PABG. The AWC and WHR were assessed in relation to: the need for higher level care (i.e. level 2/3), the duration of higher level care, postoperative limb ischemia, postoperative hospital stay, graft patency on discharge and 30 day readmission, using logistic and linear regression analysis. Mortality was assessed using cox-regression analysis with calculation of hazard ratios at 30 days and 4 years. In total, 177 patient images performed between January 2014 to January 2017 were analyzed. There were no significant intra-observer and interobserver differences in measurements of AWC and HC. Pre-intervention AWC was predictive of the need for higher level care following non-elective PABG (adjusted OR 1.1 [95% CI: 1.0-1.1, P=0.026]). An inverse relationship between AWC and mortality at 4 years was also observed (adjusted HR=0.9, 95% CI: 0.9-1.0, P=0.028). However, pre-intervention WHR failed to predict mortality and morbidity. AWC may potentially be a suitable risk stratification tool in patients undergoing non-elective PABG. The association of AWC with long-term mortality outcomes require further investigation so that suitable cut-off values may be determined.

MELD and MELD XI Scores as Predictors of Mortality After Pericardiectomy for Constrictive Pericarditis

ObjectiveTo assess the association between the preoperative model for end-stage liver disease (MELD) and MELD-XI (exclude international normalized ratio) score and outcomes in patients undergoing pericardiectomy for constrictive pericarditis. Patients and MethodsPatients >18 years of age undergoing pericardiectomy for constrictive pericarditis between January 1, 2007, and October 12, 2017, were analyzed with data for MELD and MELD-XI score calculation within 30 days preoperatively. The association between the MELD and MELD-XI scoring systems and risk of postoperative outcomes was assessed in regression models adjusting for relevant covariates. The primary outcome was operative mortality (death within 90 days or in hospital). Secondary outcomes included various measures of postoperative morbidity. ResultsA total of 175 and 226 patients had data for MELD/MELD-XI, respectively. Ninety-day mortality was 8.7%. When stratified into tertiles of MELD-XI, the unadjusted risk of 90-day mortality was 2.7%, 8.2%, and 16.0%, respectively. In Cox regression models fitted for MELD-XI and MELD, higher scores associated with increased risk of mortality (P<.001 for both). In secondary multivariable analyses, both MELD-XI and MELD were associated with increased incidence of renal failure and greater levels of chest-tube output and transfusion, whereas MELD-XI was additionally associated with prolonged intubation and extended intensive care unit and hospital stays. ConclusionAmong patients undergoing pericardiectomy for constrictive pericarditis, MELD-XI and MELD were associated with increased postoperative morbidity and mortality. Although the simpler MELD-XI score generally performed as well or better than MELD as a correlate of various outcomes, both scores can serve as a simple yet robust risk stratification tool for patients undergoing pericardiectomy for constrictive pericarditis.

CT texture-based radiomics analysis of carotid arteries identifies vulnerable patients: a preliminary outcome study.

To assess the potential role of computed tomography (CT) texture analysis (CTTA) in identifying vulnerable patients with carotid artery atherosclerosis. In this case-control pilot study, 12 patients with carotid atherosclerosis and a subsequent history of transient ischemic attack or stroke were age and sex matched with 12 control cases with asymptomatic carotid atherosclerosis (follow-up time 103.58 ± 9.2 months). CTTA was performed using a commercially available research software package (TexRAD) by an operator blinded to clinical data. CTTA comprised a filtration-histogram technique to extract features at different scales corresponding to spatial scale filter (fine = 2 mm, medium = 3 mm, coarse = 4 mm), followed by quantification using histogram-based statistical parameters: mean, kurtosis, skewness, entropy, standard deviation, and mean value of positive pixels. A single axial slice was selected to best represent the largest cross-section of the carotid bifurcation or the greatest degree of stenosis, in presence of an atherosclerotic plaque, on each side. CTTA revealed a statistically significant difference in skewness between symptomatic and asymptomatic patients at the medium (0.22 ± 0.35 vs - 0.18 ± 0.39, p < 0.001) and coarse (0.23 ± 0.22 vs 0.03 ± 0.29, p = 0.003) texture scales. At the fine-texture scale, skewness (0.20 ± 0.59 vs - 0.18 ± 0.58, p = 0.009) and standard deviation (366.11 ± 117.19 vs 300.37 ± 82.51, p = 0.03) were significant before correction. Our pilot study highlights the potential of CTTA to identify vulnerable patients in stroke and TIA. CT texture may have the potential to act as a novel risk stratification tool in patients with carotid atherosclerosis.

Risk of Venous and Arterial Thromboembolism in Patients With Giant Cell Arteritis and/or Polymyalgia Rheumatica: A Veterans Health Administration Population-Based Study in the United States

Background: Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are two chronic systemic inflammatory diseases that primarily affect elderly women. Both GCA and PMR can be complicated by thromboinflammation. We evaluated the risk of thromboembolic events as well as retinal vascular occlusive events in patients with giant cell arteritis (GCA), polymyalgia rheumatica (PMR), and overlap of GCA with PMR compared to patients with a non-inflammatory condition such as osteoarthritis (OA) in a Veteran based population. Methods: 1,535 patients with GCA, 10, 265 with PMR, and 1,203 with overlap of GCA with PMR as well as 39,009 age- and sex-matched patients with OA were identified in this retrospective study. Incidence rate ratios (IRR) of pulmonary embolism (PE), deep venous thrombosis (DVT), arterial thromboembolism (ATE), central retinal artery occlusion (CRAO) and central retinal vein occlusion (CRVO) were calculated among all three-study groups and trended over time after diagnosis. We also plotted cumulative incidence and calculated hazard ratios (HRs) of thromboembolic events in the study groups, adjusting for independent risk factors of thromboembolism. Findings: Patients with GCA, PMR and overlap of GCA with PMR had higher IRR of all thromboembolic events compared to patients with OA. IRRs of all thromboembolic events were highest within the first year of diagnosis for GCA and gradually decreased over time, whereas for the overlap and PMR groups the time trend of IRRs varied for each of the thromboembolic events. Patients with GCA had a higher risk of developing DVT and retinal vascular occlusive events compared to patients with overlap disease (2.01, 95%CI: 1.35-2.99, p<0.001, and 2.37, 95%CI: 1.23-4.53, p=0.009 respectively) and PMR (1.89, 95%CI: 1.50-2.41, p<0.001, and 95%CI: 4.68, 95%CI: 3.10-7.07, p<0.001 respectively). Patients with GCA had a higher risk of developing PE compared to patients with PMR (1.55, 95%CI: 1.1-2.18, p=0.01). Patients with overlap disease were at higher risk of developing retinal vascular occlusions compared to patients with PMR (1.97, 95%CI: 1.05-3.69, p=0.03). Interpretation: The risk of thromboembolic events differs in patients with GCA, PMR and overlap disease. Our findings may help physicians predict risk of thromboembolic events determined by disease phenotype and duration, and assist with the development of venous thromboembolism risk stratification tools in patients with GCA and/or PMR that would allow identification of high risk patients. Funding Information: D.M. is supported by the T32 NIH grant from Nutrition, Obesity and Atherosclerosis (#5T32HL007028-44) and Pfizer US Pharmaceuticals Group grant, award number 53857367 Declaration of Interests: DM received Advisory Board fee from Chemocentryx. All other authors report no competing interests. Ethics Approval Statement: MIRB#01854.

Frailty as a Predictor of Postoperative Morbidity and Mortality Following Liver Resection.

Liver resection is commonly performed among patients at risk of being frail. Frailty can be used to assess perioperative risk. Thus, we evaluated frailty as a predictor of postoperative complications following liver resection using a validated modified frailty index (mFI). A retrospective cohort of consecutive patients undergoing liver resection (2011-2018) were stratified according to the mFI and classified as the following: high (≥.27) and low mFI (<.27). The effect of mFI on postoperative complications (Clavien-Dindo) was evaluated using multiple logistic regression, expressed as odds ratios (OR) and 95% CI. Of 409 patients, 58 (14%) had high mFI. There were no differences in type of liver resection (laparoscopic: 57% vs 55%, P = .766), number of segments resected (3 vs 4, P = .417), or operative time (257 vs 293 minutes, P = .097) between the high and low mFI groups, respectively. High mFI patients had a longer median length of hospital stay (9.5 vs 5 days, P < .001) and higher proportion of postoperative complications (79% vs 46%, P < .001), including minor complications (69% vs 42%, P < .001), major complications (50% vs 13%, P < .001), and 90-day postoperative mortality (12% vs 3.4%, P = .04). On multivariable analysis, longer operating time (OR 1.15, 95% CI, 1.03 to 1.27), higher number of segments resected (OR 1.43, 95% CI, 1.12 to 1.82), and high mFI (OR 6.74, 95% CI, 2.76 to 16.51) were independent predictors of major postoperative complications. mFI predicts postoperative outcomes following liver resection and can be used as a risk stratification tool for patients being considered for surgery.

Comparison of Deep Whole Exome Versus Targeted Gene Sequencing for Assessment of Persistent Molecular Disease in Acute Myeloid Leukemia Samples

Background There is growing evidence that genomics-based assessment of persistent molecular disease (PMD) may be a useful risk stratification tool for patients with acute myeloid leukemia (AML). However, there is no consensus about the optimal approach for detection and monitoring of leukemia-associated mutations (LAMs) for PMD testing. One approach is whole exome sequencing (WES), which provides a comprehensive assessment of the clonal architecture by identifying LAMs across the exome at diagnosis, which can then be measured in follow-up samples. Another approach is to use highly sensitive targeted gene sequencing (TGS) to detect persistent LAMs even at very low levels, although detection is limited to genes interrogated by the panel. Although both of approaches have been shown to predict outcome in retrospective studies, there are substantial differences in the number of LAMs identified and the limit of detection, and a head-to-head comparison has not yet been reported. Here, we use a defined cohort enrolled in a prospective clinical trial to compare PMD results from deep WES to error-corrected TGS. Methods Cohort: Patients were age 18-60 with de novo AML classified as intermediate risk by European Leukemia Net criteria, who achieved a morphologic remission after undergoing standard induction therapy. All patients were enrolled in a prospective clinical trial (NCT02756962). Sequencing: Deep WES was performed using DNA from normal tissue (buccal swab or skin) and pre- and post-induction (~day 30) bone marrow (BM) samples to achieve an average coverage depth of ~600x. LAMs identified via paired tumor/normal analysis of the pre-induction sample were queried in the post-induction sample for assessment of PMD. PMD testing by TGS was performed using error-corrected sequencing of 40 genes recurrently mutated AML genes to an average error-corrected coverage depth of ~4500x. Definitions: Based on previously published work, we used two separate variant allele frequency (VAF) cutoffs to define PMD. For WES, PMD+ was defined as ≥1 LAM with a VAF &amp;gt;2.5% (Klco JAMA 2015). For TGS, PMD+ was defined as having ≥1 LAM with a VAF &amp;gt;0.5% (Duncavage NEJM 2018). LAMs were sub-classified per Table 1. TGS mutations not identified as LAMs by WES at diagnosis were excluded from the primary analysis. Results 31 patients were studied. LAMs are summarized in Table 1. 20 patients (65%) were PMD+ by WES after induction, and 22 patients (71%) were PMD+ by TGS. The concordance between WES and TGS was 81% (25/31) (Table 2). Two patients were PMD+ by WES only, due to the persistence of LAMs in the exome space, but not in the targeted panel. Four patients were PMD+ by TGS only, due to the presence of recurrent mutations at VAFs below the detection limit of WES (range: 0.59 - 1.90%). Two patients were PMD+ by both assays, but due to different mutations. All other patients who were PMD+ by both assays had at least one overlapping mutation. Analysis of the mutations that persisted after therapy in both assays showed that 26% of patients (8/31) were PMD+ by TGS because of mutations in DNMT3A, TET2, or ASXL1 (i.e., "DTA" mutations). All of these patients were also PMD+ by WES, with 7 of the 8 patients having ≥1 additional non-DTA mutation (median: 3, range: 1 - 7). In an exploratory analysis, 22 additional mutations in 13 patients were identified by TGS that were not detected by WES on the diagnostic sample. This included two patients who were PMD-, but who had new mutations in TET2 and DNMT3A, respectively, likely representing selection for ancestral clones that were unrelated to the AML founding clone. Conclusion Concordance between WES and TGS-based PMD assessment was high. Discordant results were generally driven by non-recurrent mutations detected by WES, and low-level mutations detected by the high coverage, error-corrected TGS. Although isolated DTA mutations were common on TGS, WES analysis showed additional LAMs accompanied these variants in most cases, indicating the persistence of an ancestral leukemic clone that may provide useful prognostic information. We also observed new, low-level mutations that emerged after therapy in 42% of patients, some of which were not part of the leukemic clone identified at diagnosis. This indicates that use of highly sensitive PMD approaches may be challenging without pre-induction mutation testing, which is required to understand the relevance of markers of persistent molecular disease. Disclosures Jacoby: AbbVie: Research Funding; Takeda: Consultancy; Jazz Pharmaceuticals: Research Funding.

Validation and comparison of BIOSTAT risk score and AHEAD score for patients with acute heart failure

Abstract Background/Introduction Acute heart failure (AHF) is one of the major causes of mortality, and identifying the patients at high risk of mortality at the time of admission is crucial to improve clinical outcomes. Although some risk prediction models for patients with AHF have been proposed mainly from randomized clinical trials, the patients in such studies tend not to be similar to those in the real world. Recently, BIOSTAT risk score and AHEAD score derived from two large-scale registry dataset are proposed as useful risk stratification tools for patients with AHF. However, these scores have not been well externally validated and their prognostic prediction performance has not been directly compared. Purpose To validate and compare prognostication of BIOSTAT risk score and AHEAD score in AHF patients. Methods Patients who consecutively admitted to the cardiac intensive-care unit in our institution with a diagnosis of AHF from 2007 to 2011 were analyzed. Among them, patients with acute coronary syndrome, dialysis, malignancy were excluded. BIOSTAT risk score was calculated using 5 factors (age, blood urea nitrogen, BNP, hemoglobin, prescription of beta blockers), and AHEAD score was also calculated with 5 factors (atrial fibrillation, hemoglobin, age, creatinine, and diabetes mellitus). We also developed AHEAD + BNP model incorporating BNP into AHEAD score. Endpoint was 1-year all-cause death. Results Overall, 591 eligible patients were enrolled (mean age was 70±14 years old, 64.8% were male) and 96 patients (16.2%) died during the follow-up of 1-year. The median [interquartile range] of AHEAD score and BIOSTAT risk score were 2 [1–3] and 3 [2–4], respectively. The areas under the curves of receiver operating characteristic curve (AUC) were 0.66 for AHEAD, 0.68 for AHEAD + BNP, and 0.72 for BIOSTAT, respectively. The calibration plots for AHEAD, AHEAD + BNP, and BIOSTAT models showed good calibration (Hosmer-Lemeshow test: p=0.89, 0.74, and 0.74, respectively). The BIOSTAT model's AUC was significantly higher compared to AHEAD (p=0.018) and marginally statistically higher compared to AHEAD + BNP (p=0.054). However, BIOSTAT model showed statistically significant net reclassification improvement compared to both AHEAD (NRI: 0.43, p&amp;lt;0.001) and AHEAD + BNP (NRI: 0.43, p&amp;lt;0.001). Conclusion The BIOSTAT score comprised of five readily available clinical variables predict 1-year mortality of patients with AHF with good discrimination and calibration. ROC curves Funding Acknowledgement Type of funding source: None

223 Evaluation of Pneumonia Scores in Patients Hospitalized for COVID-19-Related Dyspnea

The primary objective is to evaluate the performance of pneumonia risk stratification tools in patients with COVID-19 for predicting adverse outcomes within 72 hours of admission. The secondary objective is to evaluate pneumonia scores in predicting ICU admission, mortality and hospital revisits at 7 days. An exploratory objective is to evaluate patient risk factors and pneumonia risk stratification scores on likelihood of intensive care unit (ICU) admission at 72 hours and 7 days.

Cardiopulmonary exercise testing and cardiopulmonary morbidity in patients undergoing major head and neck surgery

Cardiopulmonary exercise testing (CPET) is used as a risk stratification tool for patients undergoing major surgery. In this study, we investigated the role of CPET in predicting day five cardiopulmonary morbidity in patients undergoing head and neck surgery. This observational cohort study included 230 adults. We recorded preoperative CPET variables and day five postoperative cardiopulmonary morbidity. Full data from 187 patients were analysed; 43 patients either had incomplete data sets or declined surgery/CPET. One hundred and nineteen patients (63.6%) developed cardiopulmonary morbidity at day five. Increased preoperative heart rate and duration of surgery were independently associated with day five cardiopulmonary morbidity. Those with such morbidity also had lower peak V̇O2 11.4 (IQR 8.4-18.0) vs 16.0 (IQR 14.0-19.7) ml.kg-1.min-1, P<0.0001 and V̇O2 at AT 10.6 (IQR 9.1-13.1) vs 11.5 (IQR 10.5-13.0) ml.kg-1.min-1, p=0.03. Logistic regression model containing peak V̇O2 and duration of surgery demonstrated that increased peak V̇O2 was associated with a reduction in the likelihood of cardiopulmonary complications OR 0.92 (95%CI 0.87 to 0.96), p=0.001. The area under the receiver operating characteristic curve for this model was 0.75(95%CI 0.68 to 0.82), p<0.0001, 64% sensitivity, 81% specificity. CPET can help to predict day five cardiopulmonary morbidity in the patients undergoing head and neck surgery. A model containing peak V̇O2 allowed identification of those with such complications.

Why Won't Emergency Physicians Discharge Patients With a Low HEART Score From an Observation Unit Without Further Evaluation?

The History, Electrocardiogram, Age, Risk Factors, Troponin (HEART) score is a prospectively validated risk stratification tool for patients presenting to the emergency department (ED) with chest pain. Data demonstrate that patients with low HEART scores (0-3) can be safely discharged from the ED. ED physicians, however, may be reluctant to discharge patients based on the score. To identify specific factors why ED physicians are reluctant to discharge patients with low-risk HEART scores from an ED observation unit (EDOU) without further evaluation. This was a single-center prospective, cross-sectional analysis of ED patients from an urban ED placed in an EDOU for evaluation of chest pain, from July 1, 2016, to August 31, 2016. ED physicians completed a questionnaire that included documentation of patient HEART score and if the patient would or would not be a good candidate for outpatient stress testing or follow-up within 72 hours without further EDOU testing or consultant evaluation. Providers selected reasons why patients were not a good candidate for outpatient stress testing/follow-up. There were 279 patient questionnaires completed, 42% (117/279) had a HEART score of 0-3. Within this group, 54.7% (64/117) of the patients were identified as not being good candidates for outpatient stress testing/follow-up within 72 hours because of concerns for poor follow-up (n = 14), concerning risk factors (n = 14), concerning symptoms (n = 11), and other (n = 7). ED physicians in this urban ED felt that over half of patients with a low-risk HEART score were not good candidates for discharge from the EDOU without further evaluation due to poor follow-up, concerning risk factors or symptoms, or coexisting conditions.

Utility of Cardiac Magnetic Resonance Imaging Versus Cardiac Positron Emission Tomography for Risk Stratification for Ventricular Arrhythmias in Patients With Cardiac Sarcoidosis

Abnormalities on cardiac magnetic resonance imaging (CMR) and positron emission tomography (PET) predict ventricular arrhythmias (VA) in patients with cardiac sarcoidosis (CS). Little is known whether concurrent abnormalities on CMR and PET increases the risk of developing VA. Our aim was to compare the additive utility of CMR and PET in predicting VA in patients with CS. We included all patients treated at our institution from 2000 to 2018 who (1) had probable or definite CS and (2) had undergone both CMR and PET. The primary endpoint was VA at follow up, which was defined as sustained ventricular tachycardia, sudden cardiac death, or any appropriate device tachytherapy. Fifty patients were included, 88% of whom had a left ventricular ejection fraction >35%. During a mean follow-up 4.1 years, 7/50 (14%) patients had VA. The negative predictive value of LGE for VA was 100% and the negative predictive value of FDG for VA was 79%. Among groups, VA occurred in 4/21 (19%) subjects in the LGE+/FDG+ group, 3/14 (21%) in the LGE+/FDG- group, and 0/15 (0%) in the FDG+/LGE- group. There were no LGE-/FDG- patients. In conclusion, CMR may be the preferred initial clinical risk stratification tool in patients with CS. FDG uptake without LGE on initial imaging may not add additional prognostic information regarding VA risk.

Wearable Patch-Based Estimation of Oxygen Uptake and Assessment of Clinical Status during Cardiopulmonary Exercise Testing in Patients With Heart Failure

BackgroundTo estimate oxygen uptake (VO2) from cardiopulmonary exercise testing (CPX) using simultaneously recorded seismocardiogram (SCG) and electrocardiogram (ECG) signals captured with a small wearable patch. CPX is an important risk stratification tool for patients with heart failure (HF) owing to the prognostic value of the features derived from the gas exchange variables such as VO2. However, CPX requires specialized equipment, as well as trained professionals to conduct the study. Methods and ResultsWe have conducted a total of 68 CPX tests on 59 patients with HF with reduced ejection fraction (31% women, mean age 55 ± 13 years, ejection fraction 0.27 ± 0.11, 79% stage C). The patients were fitted with a wearable sensing patch and underwent treadmill CPX. We divided the dataset into a training–testing set (n = 44) and a separate validation set (n = 24). We developed globalized (population) regression models to estimate VO2 from the SCG and ECG signals measured continuously with the patch. We further classified the patients as stage D or C using the SCG and ECG features to assess the ability to detect clinical state from the wearable patch measurements alone. We developed the regression and classification model with cross-validation on the training–testing set and validated the models on the validation set. The regression model to estimate VO2 from the wearable features yielded a moderate correlation (R2 of 0.64) with a root mean square error of 2.51 ± 1.12 mL · kg–1 · min–1 on the training–testing set, whereas R2 and root mean square error on the validation set were 0.76 and 2.28 ± 0.93 mL · kg–1 · min–1, respectively. Furthermore, the classification of clinical state yielded accuracy, sensitivity, specificity, and an area under the receiver operating characteristic curve values of 0.84, 0.91, 0.64, and 0.74, respectively, for the training–testing set, and 0.83, 0.86, 0.67, and 0.92, respectively, for the validation set. ConclusionsWearable SCG and ECG can assess CPX VO2 and thereby classify clinical status for patients with HF. These methods may provide value in the risk stratification of patients with HF by tracking cardiopulmonary parameters and clinical status outside of specialized settings, potentially allowing for more frequent assessments to be performed during longitudinal monitoring and treatment.

Prognostic value of fragmented QRS complex in patients with acute myocardial infarction

Several factors and risk stratification tools have been studied to determine the prognosis of acute coronary syndrome. Fragmented QRS (fQRS) is amarker of myocardial scar and its prognostic role has recently been demonstrated. The present study aimed to investigate the association between the presence of fQRS in electrocardiogram and the prognosis of ST-segment elevation and non-ST-segment elevation myocardial infarction (STEMI and NSTEMI). Atotal of 661 patients with myocardial infarction (MI) were enrolled in aretrospective study. Based on the presence of fQRS in admission electrocardiogram, patients were divided into two groups. All patients were followed up for 6months, and all major adverse cardiovascular events (MACE) were recorded. The mean age of patients was 61.3 ± 1.2 years, and 71.7% were male. In the acute phase, the detection rates of regional wall motion abnormality and aortic valve insufficiency were higher in positive fQRS compared to negative fQRS group (p = 0.003). The incidence of total MACE was significantly higher in the positive fQRS compared to the negative fQRS group among all patients and in both STEMI and NSTEMI subgroups (p < 0.001). Based on multivariate analysis, the presence of fQRS and hypertension were the strongest predictors of total MACE at 6‑month follow-up (odds ratio [OR] = 5.929; 95% confidence interval [CI] = 3.620-9.709; p < 0.001 and OR = 2.220; 95% CI = 1.390-3.547; p < 0.001, respectively). Regardless of the type of MI, it was found that the presence of fQRS on admission electrocardiogram can be implemented in risk stratification tools in patients with acute MI.

Heart rate n-variability (HRnV) and its application to risk stratification of chest pain patients in the emergency department

BackgroundChest pain is one of the most common complaints among patients presenting to the emergency department (ED). Causes of chest pain can be benign or life threatening, making accurate risk stratification a critical issue in the ED. In addition to the use of established clinical scores, prior studies have attempted to create predictive models with heart rate variability (HRV). In this study, we proposed heart rate n-variability (HRnV), an alternative representation of beat-to-beat variation in electrocardiogram (ECG), and investigated its association with major adverse cardiac events (MACE) in ED patients with chest pain.MethodsWe conducted a retrospective analysis of data collected from the ED of a tertiary hospital in Singapore between September 2010 and July 2015. Patients > 20 years old who presented to the ED with chief complaint of chest pain were conveniently recruited. Five to six-minute single-lead ECGs, demographics, medical history, troponin, and other required variables were collected. We developed the HRnV-Calc software to calculate HRnV parameters. The primary outcome was 30-day MACE, which included all-cause death, acute myocardial infarction, and revascularization. Univariable and multivariable logistic regression analyses were conducted to investigate the association between individual risk factors and the outcome. Receiver operating characteristic (ROC) analysis was performed to compare the HRnV model (based on leave-one-out cross-validation) against other clinical scores in predicting 30-day MACE.ResultsA total of 795 patients were included in the analysis, of which 247 (31%) had MACE within 30 days. The MACE group was older, with a higher proportion being male patients. Twenty-one conventional HRV and 115 HRnV parameters were calculated. In univariable analysis, eleven HRV and 48 HRnV parameters were significantly associated with 30-day MACE. The multivariable stepwise logistic regression identified 16 predictors that were strongly associated with MACE outcome; these predictors consisted of one HRV, seven HRnV parameters, troponin, ST segment changes, and several other factors. The HRnV model outperformed several clinical scores in the ROC analysis.ConclusionsThe novel HRnV representation demonstrated its value of augmenting HRV and traditional risk factors in designing a robust risk stratification tool for patients with chest pain in the ED.

Abstract P158: USING CHA 2 DS 2 - VASC SCORE TO PREDICT CLINICAL OUTCOMES IN PATIENTS WITH INFECTIVE ENDOCARDITIS

Background: The CHA 2 DS 2 - VASC score is a well-validated stroke risk stratification tool in patients with non-valvular atrial fibrillation. Most of the clinical variables used have been associated with poor outcomes in patients with infective endocarditis (IE). We aim to determine its usefulness in predicting outcomes in patients with IE. Methods: We included 35,570 patients with IE from the national inpatient sample (2009 - 2012). CHA 2 DS 2 - VASC score was calculated for each patient. Hierarchical two-level logistic and linear models were used to estimate outcomes for CHA 2 DS 2 - VASC scores 1 to 8, using score 0 as the referent score. Outcomes of interest were overall in-hospital mortality, cardiogenic shock, atrioventricular block (AVB) and valve replacement. All clinical characteristics were defined per the ICD-9-CM codes. Results: The mean age of the sample was 59.81 +/- 18 years. Of the 35570 patients with IE, overall mortality rate was 11.4% (n= 4038/35570), cardiogenic shock 2.6 % (n=912/35570), AVB 4% (n=1426/35570) and 10.3% (n=3652/35570) required valve replacement. Higher CHA2DS2-VASc score were associated with increased mortality from 8.1 % for a score of 0 to 21.7 % for score of 8. Cardiogenic shock increased from 5.2% for a score of 0 to 24 % for a score of 3. AVB increased from 5.5% for score of 0 to 17.5% for score of 4. While valve replacement surgery increased from 1.3% for score of 0 to 3.8% for score of 5. Figure, 1 revealed the adjusted odds ratios for outcomes per CHA 2 DS 2 - VASC score 1 to 8, using 0 as the referent score, a higher score was significantly associated with increased odds for overall mortality, cardiogenic shock, AVB, and valve replacement. Conclusion: In patients with infective endocarditis, CHA2DS2-VASc score can serve as a risk assessment tool to predict outcomes. &lt;!--EndFragment--&gt;

Frailty As A Predictor Of Postoperative Outcomes Following Liver Resection

Presenter: Tyler McKechnie BSc | McMaster University Background: Frailty, defined as a state of decreased physiologic reserve, characterized by a loss of resiliency in the face of acute stress is a condition that is frequently encountered by liver surgeons. We sought to evaluate frailty as a predictor of postoperative complications following liver resection using the modified frailty index (mFI). Methods: This is a retrospective cohort study of consecutive adult patients undergoing liver resection between 2011 and 2018 at a single academic institution. An mFI consisting of 11 variables adapted for the National Surgical Quality Improvement Program database from the Canadian Study of Health and Aging Frailty Index was used. These variables have been previously validated and include patient comorbidities and functional abilities. Patients were stratified into two groups, high mFI (≥0.27) and low mFI ( < 0.27). Postoperative complications were graded using Clavien-Dindo. The effect of mFI on postoperative complications and 90-day mortality was evaluated using multiple logistic regression and expressed as odds ratio (OR) and 95% confidence interval (CI). Results: Among 409 liver resections, there were 58/409 (14%) patients with a high mFI (mFI ≥0.27). Low mFI patients were significantly younger (63 vs. 70 years, p<0.001) and more likely to meet >4 METS (90% vs. 60%, p<0.001). There were no differences between the high versus low mFI group in the type of liver resection performed, open (37% vs. 35%) or laparoscopic (57% vs. 55%), in the number of liver segments resected (3 vs. 4, p=0.417) or in the operative room time (257 vs. 293 min, p=0.097), respectively. Median length of hospital stay was significantly longer for the high mFI group (9.5 vs. 5 days, p<0.001). When compared to patients with low mFI, patients with a high mFI had a significantly higher proportion of postoperative complications (79% vs. 46%, p<0.001). This was true for minor complications (69% vs. 42%, p<0.001), major complications (50% vs. 13%, p<0.001) and 90-day postoperative mortality (12% vs. 3.4%, p=0.04). By multivariate analysis, longer operating time, per 30-minute increase (OR 1.15, 95%CI 1.03 to 1.27), higher number of liver segments resected (OR 1.43, 95%CI 1.12 to 1.82), and high mFI, per unit increase (OR 6.74, 95%CI 2.76 to 16.51) were independent predictors for the development of major complications and 90-day mortality. Conclusion: The mFI predicts postoperative outcomes following liver resection and can be used as a risk stratification tool for patients being considered for surgery.

The classic prognostic factors in advanced Hodgkin\u2019s lymphoma patients are losing their meaning at the time of Pet-guided treatments

The International Prognostic Score (IPS) is the most commonly used risk stratification tool for patients with advanced Hodgkin lymphoma (HL). It incorporates seven clinical parameters independently associated with a poorer outcome: male sex, age, stage IV, hemoglobin level, white blood cell and lymphocyte counts, and albumin level. Since the development of the IPS, there have been significant advances in therapy and supportive care. Recent studies suggest that the IPS is less discriminating due to improved outcomes with ABVD therapy. The aim of the present study was to asses if classic prognostic factors maintain their prognostic meaning at the time of response-adapted treatment based on interim PET scans. We evaluated the prognostic significance of IPS in the 520 advanced stage HL patients enrolled in the PET-guided, HD0801 trial in which PET2-positive patients underwent a more intense treatment with an early stem-cell transplantation after 2 cycles of ABVD. We observed that in these patients, the IPS completely loses its prognostic value together with all the single parameters that contribute to the IPS. Furthermore, neutrophils, monocytes, lymphocytes, and the ratio among them also no longer had any predictive value. We believe that the substantial improvement in survival outcomes in PET2-positive patients treated with early autologous transplantation could explain the complete disappearance of the residual prognostic significance of the IPS.

Atrial fibrillation is frequent but does not affect risk stratification in pulmonary embolism.

Although prior studies indicate a high prevalence of atrial fibrillation (AF) in patients with pulmonary embolism (PE), the exact prevalence and prognostic impact are unknown. We aimed to investigate the prevalence, risk factors and prognostic impact of AF on risk stratification, in-hospital adverse outcomes and mortality in 528 consecutive PE patients enrolled in a single-centre registry between 09/2008 and 09/2017. Overall, 52 patients (9.8%) had known AF and 57 (10.8%) presented with AF on admission; of those, 34 (59.6%) were newly diagnosed with AF. Compared to patients with no AF, overt hyperthyroidism was associated with newly diagnosed AF (OR 7.89 [2.99-20.86]), whilst cardiovascular risk comorbidities were more frequently observed in patients with known AF. Patients with AF on admission had more comorbidities, presented more frequently with tachycardia and elevated cardiac biomarkers and were hence stratified to higher risk classes. However, AF on admission had no impact on in-hospital adverse outcome (8.3%) and in-hospital mortality (4.5%). In multivariate logistic regression analyses corrected for AF on admission, NT-proBNP and troponin elevation as well as higher risk classes in risk assessment models remained independent predictors of an in-hospital adverse outcome. Atrial fibrillation is a frequent finding in PE, affecting more than 10% of patients. However, AF was not associated with a higher risk of in-hospital adverse outcomes and did not affect the prognostic performance of risk assessment strategies. Thus, our data support the use of risk stratification tools for patients with acute PE irrespective of the heart rhythm on admission.

The HEART score in the era of the European Society of Cardiology 0/1-hour algorithm.

The European Society of Cardiology's 0/1-hour algorithm improves the early triage of patients towards "rule-out" or "rule-in" of non-ST-segment elevation myocardial infarction. The HEART score is a risk stratification tool for patients with undifferentiated chest pain. We sought to evaluate the performance of the European Society of Cardiology 0/1-hour algorithm and the HEART score to evaluate chest pain patients in the emergency department. In this prospective study, we applied the European Society of Cardiology 0/1-hour algorithm and the HEART score in 1355 consecutive patients who presented to the emergency department with symptoms suggestive of acute coronary syndrome without ST-segment elevation. Patients were followed for non-ST-segment elevation myocardial infarctions and major adverse cardiac events at 30 days: death, non-ST-segment elevation myocardial infarction, or unplanned coronary revascularization. The European Society of Cardiology 0/1-hour algorithm classified 921 (68.0%) patients as "rule-out" and the HEART score classified 686 (50.6%) patients as "low-risk". The 30-day incidence of non-ST-segment elevation myocardial infarctions was 0.32% in the European Society of Cardiology 0/1-hour algorithm "rule-out" patients versus 0.29% in the HEART score "low-risk" patients (p=0.75). The rate of major adverse cardiac events was 7.7% in the European Society of Cardiology 0/1-hour algorithm "rule-out" patients versus 1.1% in the HEART score "low-risk" patients (p<0.001). The European Society of Cardiology 0/1-hour algorithm identified more patients with low risk of non-ST-segment elevation myocardial infarctions at 30 days whereas for major adverse cardiac events, the HEART score had a greater capacity to detect low-risk patients.

P1698Age shock index is a simple bedside clinical risk stratification tool in patients with non-ST-segment elevation myocardial infarction

Abstract Introduction Shock index (SI), (heart rate (HR)/systolic blood pressure (SBP)), has been reported to predict worse outcomes in different acute settings. Two derivatives, named modified SI (MSI), defined as HR/mean BP; and Age SI, defined as SI multiplied by age, were later developed, but only the former was tested for short-term outcomes in patients with myocardial infarction (MI). We hypothesize that Age SI may demonstrate higher prognostic accuracy than SI and MSI due to the added prognostic value of age in this population. Purpose Compare the prognostic performance of admission age SI, MSI and SI for predicting in-hospital mortality in patients with NSTEMI. Methods Retrospective cohort study of consecutive patients admitted to the Cardiology department of a tertiary care hospital with the diagnosis of NSTEMI between October 2010 and September 2018. Very high-risk patients in need of emergent treatment were excluded. Of the initial cohort of 2476 patients, we excluded 5 who presented cardiac arrest before or at hospital admission, 4 with cardiogenic shock, 95 with acute pulmonary oedema, 10 with SBP &lt;80 mmHg, 1 with HR &lt;40bpm and 1 with HR &gt;160bpm. The primary outcome was all-cause in-hospital mortality. The discriminatory capacity of Age SI, MSI, SI for the primary outcome was assed using the ROC-AUC and compared with the DeLong method, and the value with highest Youden-index was considered the optimal cut-off point. Calibration was assessed using the Hosmer-Lemeshow (HL) test and adjustment for confounding variables was performed using logistic regression analysis. Results 2359 patients were included [mean age 66±13 years; 1732 (73.4%) men], of whom 40 (1.7%) died during hospitalization. Discrimination by ROC-AUC was highest for Age SI (0.78 [95% CI 0.71–0.86)], compared to MSI (0.69 [95% CI 0.61–0.78]) and SI (0.69 [95% CI 0.61–0.78)], p&lt;0.01 for comparison. All indexes demonstrated adequate calibration (HL: Age SI 7.4; MSI 4.5; SI 6.4; p&gt;0.5). The optimal cut-off for Age SI was 40, which was present in 684 patients (29%) and had 75% sensitivity, 72% specificity, 4.5% positive and 99.5% negative predictive value (NPV) for in-hospital mortality (4.4% vs 0.6%, p&lt;0.001). After adjusting for covariates, an Age SI higher than 40 was associated with increased in-hospital mortality (adjusted OR 3.2, 95% IC 1.06–9.55), p=0.039). Mortality and Age Shock Index Conclusion Age SI demonstrated better discriminatory capacity and equal calibration, compared to SI and MSI for in-hospital mortality. An age SI higher than 40 was associated with a 3-fold increased risk of in-hospital death. This cut-off demonstrated excellent negative predictive value (99.5%) and may allow very early risk assessment in patients with non-ST-segment elevation MI (NSTEMI), before laboratorial values are available for GRACE calculation. This may guide initial therapy and help select the most appropriate initial site of care.