Short-and Long-term Mortality Research Articles

Development and validation of prognostic machine learning models for short- and long-term mortality among acutely admitted patients based on blood tests

Several scores predicting mortality at the emergency department have been developed. However, all with shortcomings either simple and applicable in a clinical setting, with poor performance, or advanced, with high performance, but clinically difficult to implement. This study aimed to explore if machine learning algorithms could predict all-cause short- and long-term mortality based on the routine blood test collected at admission. Methods: We analyzed data from a retrospective cohort study, including patients > 18 years admitted to the Emergency Department (ED) of Copenhagen University Hospital Hvidovre, Denmark between November 2013 and March 2017. The primary outcomes were 3-, 10-, 30-, and 365-day mortality after admission. PyCaret, an automated machine learning library, was used to evaluate the predictive performance of fifteen machine learning algorithms using the area under the receiver operating characteristic curve (AUC). Results: Data from 48,841 admissions were analyzed, of these 34,190 (70%) were randomly divided into training data, and 14,651 (30%) were in test data. Eight machine learning algorithms achieved very good to excellent results of AUC on test data in a of range 0.85–0.93. In prediction of short-term mortality, lactate dehydrogenase (LDH), leukocyte counts and differentials, Blood urea nitrogen (BUN) and mean corpuscular hemoglobin concentration (MCHC) were the best predictors, whereas prediction of long-term mortality was favored by age, LDH, soluble urokinase plasminogen activator receptor (suPAR), albumin, and blood urea nitrogen (BUN). Conclusion: The findings suggest that measures of biomarkers taken from one blood sample during admission to the ED can identify patients at high risk of short-and long-term mortality following emergency admissions.

Comparison of different prognostic scores in estimating short- and long-term mortality in COVID-19 patients above 60years old in a university hospital in Belgium.

Multiple scoring systems were used for risk stratification in COVID-19 patients. The objective was to determine among 6 scores which performed the best in predicting short-and long-term mortality in hospitalized COVID-19 patients ≥ 60years. An observational, retrospective cohort study conducted between 21/10/2020 and 20/01/2021. 6 scores were calculated (Clinical Frailty Scale (CFS), Charlson Comorbidity Index (CCI), 4C Mortality Score (4CMS), NEWS score (NEWS), quick-SOFA score (qSOFA), and Quick COVID-19 Severity Index (qCSI)). We included unvaccinated hospitalized patients with COVID-19 ≥ 60years old in Brugmann hospital, detected by PCR and/or suggestive CT thorax images. Old and nosocomial infections, and patients admitted immediately at the intensive care unit were excluded. 199 patients were included, mean age was 76.2years (60-99). 47.2% were female. 56 patients (28%) died within 1year after the first day of hospitalization. The 4CMS predicted the best intrahospital, 30days and 6months mortality, with area under the ROC curve (AUROC) 0.695 (0.58-0.81), 0.76 (0.65-0.86) and 0.72 (0.63-0.82) respectively. The CCI came right after with respectively AUROC of 0.69 (0.59-0.79), 0.74 (0.65-0.83) and 0.71 (0.64-0.8). To predict mortality at 12months after hospitalization, the CCI had the highest AUROC with 0.77 (0.69-0.85), before the 4CMS with 0.69 (0.60-0.79). Among 6 scores, the 4CMS was the best to predict intrahospital, 30-day and 6-month mortality. To predict mortality at 12months, CCI had the best performance before 4CMS. This reflects the importance of considering comorbidities for short- and long-term mortality after COVID 19. This study was approved by the ethical committee of Brugmann University Hospital (reference CE 2020/228).

The impact of kidney function on the slow-flow/no-reflow phenomenon in patients treated with primary percutaneous coronary intervention: registry analysis

Abstract Funding Acknowledgements Type of funding sources: None. Objective To analyze the impact of declining kidney function on the occurrence of the slow-flow/no-reflow phenomenon, in patients with ST elevation myocardial infarction (STEM) who had been treated with primary PCI (pPCI), and to analyze the prognostic impact of the slow-flow/no-reflow phenomenon on short- and long-term mortality in these patients. Methods We analyzed 3,115 consecutive patients. A value of estimation of the glomerular filtration rate (eGFR) at admission eGFR<90ml/min/m2 was considered to be a reduced baseline eGFR. The follow-up period was 8 years. Results The slow-flow/no-reflow phenomenon through the IRA was registered in 146 (4.7%) patients. Stimated GFR<90ml/min/m2 was an independent predictor for the occurrence of slow-flow/no-reflow phenomenon (OR2.91, 95%CI 1.25-3.95, p<0.001), and the risk for the occurrence of the slow-flow/no-reflow phenomenon increased with the decline of the kidney function: eGFR 60-89 ml/min/m2: OR1.94 (95%C 1.22-3.07, p=0.005), eGFR 45-59ml/min/m2: OR 2.55(95%CI 1.55-4.94, p<0.001), eGFR 30-44 ml/min/m2; OR 2.77(95%CI 1.43-5.25, p<0.001), eGFR 15-29 ml/min/m2: OR 5.84 (95%CI 2.84-8.01, p<0.001). In-hospital, 30-day, 1-year, and 8-year mortality were significantly higher in patients with the slow-flow/no-reflow phenomenon, as compared to patients with TIMI flow grade 3 – in-hospital mortality of 30.1% vs 2.9%, respectively, p<0.001; 30-day mortality: 31.5% vs 3.2%, respectively, p<0.001; 8-year mortality: 38.1% vs 6.9%, respectively, p<0.001 (Figure 1). The slow-flow/no-reflow phenomenon was a strong independent predictor of short-and long-term all-cause mortality: 30-day mortality (HR 2.62, 95%CI 1.78-3.57, p<0.001), 8-year mortality (HR 2.09, 95%CI 1.49-2.09, p<0.001). Conclusion Reduced baseline kidney function was an independent predictor for the occurrence of the slow-flow/no-reflow phenomenon, and its prognostic impact started with the mildest decrease of eGFR (below 90ml/min/m2), and increased with its further decline. The slow-flow/no-reflow phenomenon was a strong independent predictor for mortality in the short- and long-term follow-up of the analyzed patients.

Role of the uric acid/albumin ratio in predicting mortality of patients who underwent transcatheter aortic valve implantation

Objectives: The aim of this study was to investigate whether baseline uric acid/albumin ratio (UAR) was a predictor for mortality in patients who underwent transcatheter aortic valve implantation (TAVI) due to severe aortic stenosis. Patients and methods: The retrospective study included 240 patients (121 females, 119 males; mean age 77.5±7.6 years; range, 52 to 95 years) who underwent TAVI between January 2015 and January 2020 in two centers. Patient characteristics were compared between two groups according to mortality during follow-up (the mortality group and the survival group). The value of the UAR in predicting mortality was evaluated with receiver operating characteristic curve analysis. Predictors of mortality after TAVI were investigated with Cox regression analysis. Results: In-hospital mortality developed in 16 (6.7%) patients, and postdischarge all-cause mortality was observed in 41 (17.1%). The two-year mortality rate was determined to be 15%. The rate of systolic heart failure, systolic pulmonary artery pressure, and UAR were found to be significantly higher in the mortality group (p=0.007, p=0.036, and p<0.001, respectively). The diagnostic power of UAR in predicting mortality was poor (the area under the curve=0.671, confidence interval [CI]: 0.589-0.753, p<0.001). Independent predictors of mortality after TAVI were UAR >2.03 (hazard ratio=2.958, CI: 1.623-5.393, p<0.001) and platelet count (hazard ratio=0.996, CI: 0.992-1.000, p=0.05). Conclusion: Uric acid/albumin ratio was found to be an independent predictor for short-and long-term all-cause mortality in patients who underwent TAVI.

Association between serum potassium levels and all-cause mortality in patients with acute heart failure

Objective: To investigate the relationship between different serum potassium levels at admission and discharge and all-cause mortality in patients with acute heart failure (HF). Methods: A total of 2 621 patients with acute HF who were hospitalized in the Heart Failure Center of Fuwai Hospital from October 2008 to October 2017 were analyzed. Patients were divided into three groups according to the different serum potassium levels at admission: hypokalemia with serum potassium<3.5 mmol/L (n=329), normokalemia with 3.5-5.5 mmol/L (n=2 270), and hyperkalemia with serum potassium>5.5 mmol/L (n=22). Clinical data such as patient history, comorbidities, clinical examination and drug use were collected, and systematic outpatient review or telephone follow-up was performed after patients were discharged from the hospital until January 2020. The primary outcome was all-cause death at 90 days, 2 years, and 5 years of follow-up. We compared the clinical characteristics of patients with different serum potassium levels at admission and discharge, and used a multivariate Cox proportional hazards regression model to analyze the association between serum potassium levels at admission and discharge and all-cause mortality. Results: The age of all patients was (58.0±15.3) years old, and 1 877 patients (71.6%) were male. There were 329 (12.6%) and 22 (0.8%) patients with hypokalemia and hyperkalemia at admission, and 38 (1.4%) and 18 (0.7%) at discharge, respectively. The serum potassium levels of all patients were (4.01±0.50) and (4.25±0.44) mmol/L at admission and discharge, respectively. The follow-up time[M(Q1,Q3)] of this study was 2.63(1.00,4.42)years, and a total of 1 076 all-cause deaths were recorded at the last follow-up. Compared with patients with normokalemia at discharge, discharged patients with hypokalemia and hyperkalemia were followed up for 90 days (90.3% vs 76.3% vs 38.9%), 2 years (73.8% vs 60.5% vs 33.3%) and 5 years (63.4% vs 44.7% vs 22.2%), respectively, and the difference of which in cumulative survival rates were statistically significant (all P values<0.001). The multivariate-adjusted Cox regression analysis showed that hypokalemia (HR=0.979, 95%CI: 0.812-1.179, P=0.820) and hyperkalemia (HR=1.368, 95%CI: 0.805-2.325, P=0.247) at admission were not associated with all-cause mortality risk, however, hypokalemia (HR=1.668, 95%CI: 1.081-2.574, P=0.021) and hyperkalemia (HR=3.787, 95%CI: 2.264-6.336, P<0.001) at discharge were associated with increased all-cause mortality risk. Conclusions: Both hypokalemia and hyperkalemia at discharge in hospitalized patients with acute HF were associated with increased short-and long-term all-cause mortality, and serum potassium levels should be closely monitored.

Postoperative delirium in geriatric patients with hip fractures.

Postoperative delirium (POD) is a frequent complication in geriatric patients with hip fractures, which is linked to poorer functional recovery, longer hospital stays, and higher short-and long-term mortality. Patients with increased age, preoperative cognitive impairment, comorbidities, perioperative polypharmacy, and delayed surgery are more prone to develop POD after hip fracture surgery. In this narrative review, we outlined the latest findings on postoperative delirium in geriatric patients with hip fractures, focusing on its pathophysiology, diagnosis, prevention, and treatment. Perioperative risk prediction, avoidance of certain medications, and orthogeriatric comprehensive care are all examples of effective interventions. Choices of anesthesia technique may not be associated with a significant difference in the incidence of postoperative delirium in geriatric patients with hip fractures. There are few pharmaceutical measures available for POD treatment. Dexmedetomidine and multimodal analgesia may be effective for managing postoperative delirium, and adverse complications should be considered when using antipsychotics. In conclusion, perioperative risk intervention based on orthogeriatric comprehensive care is the most effective strategy for preventing postoperative delirium in geriatric patients with hip fractures.

Frailty index based on laboratory tests improves prediction of short-and long-term mortality in patients with critical acute myocardial infarction.

Previous studies have shown that the frailty index based on laboratory tests (FI-Lab) can identify older adults at increased risk of adverse health outcomes. This study aimed to determine whether the FI-Lab is associated with mortality risk and can provide incremental improvements in risk stratification of patients with critical acute myocardial infarction (AMI). We conducted a secondary analysis of data from the Medical Information Mart for Intensive Care (MIMIC)-IV database. A 33-item FI-Lab was constructed. Outcomes of interest were in-hospital and 1-year mortality. Logistic regression models were used to investigate the association between the FI-Lab and outcomes. For the assessment of the incremental predictive value, the FI-Lab was added to several risk stratification scoring systems for critically ill patients, and the following indices were calculated: Δ C-statistic, integrated discrimination improvement (IDI), and net reclassification improvement (NRI). Out of 2,159 patients, 477 died in hospital (22.1%), and 898 died during the 1-year follow-up period. After adjustment for confounders, the FI-Lab was associated with increased in-hospital mortality [odds ratio (OR) = 1.06, 95% confidence interval (CI): 1.05-1.07] and 1-year mortality (OR = 1.05, 95% CI: 1.04-1.06) when assessed as a continuous variable (per 0.01-score increase). When assessed as a categorical variable, the FI-Lab was associated with in-hospital mortality (2nd Quartile: OR = 1.89, 95% CI: 1.18-3.03; 3rd Quartile: OR = 3.46, 95% CI: 2.20-5.46; and 4th Quartile: OR = 5.79, 95% CI: 3.61-9.28 compared to 1st Quartile) as well as 1-year mortality (2nd Quartile: OR = 1.66, 95% CI: 1.23-2.24; 3rd Quartile: OR = 2.40, 95% CI: 1.76-3.26; and 4th Quartile: OR = 3.76, 95% CI: 2.66-5.30 compared to 1st Quartile) after adjustment for confounders. The addition of the FI-Lab to all disease severity scores improved discrimination and significantly reclassified in-hospital and 1-year mortality risk. The FI-Lab was a strong predictor of short- and long-term mortality in patients with critical AMI. The FI-Lab improved the ability to predict mortality in patients with critical AMI and therefore might be useful in the clinical decision-making process.

Abstract 14644: The Association Between Neighborhood Distress and Outcomes Following Peripheral Vascular Intervention

Introduction: Peripheral arterial disease (PAD) is associated with an elevated risk of mortality. Low socioeconomic status (SES) is associated with increased prevalence and severity of PAD, and low SES has been associated with poor post procedural outcomes in cardiovascular disease. The Distressed Communities Index (DCI) uses seven common proxies of SES, such as educational attainment, housing stability, median income, and employment rate, to generate an aggregate score at a zip code level. Hypothesis: We hypothesized that increased levels of neighborhood distress, as measured by the DCI, is associated with an increased risk of mortality and amputation after PVI. Methods : We queried the Vascular Quality Initiatives (VQI) database, linked with Medicare claims data for patients who had undergone PVI. A total of 16,980 patients with PVI were found and 53 Excluded because ≥ 1 missing data for covariate used in modelling and 381 because DCI Missing. Patient 5-digit zip codes were used to obtain a DCI score (range 1-100, with higher scores indicating greater distress) from the Economic Innovation group. We examined the association between DCI and 2-year mortality and major amputation. Results: At 24 months, 2 964 (17.5%) had died 1 669 (9.9%) and had a major amputation DCI score was positively associated 2-year mortality risk. A 10-point higher DCI score was associated with increased mortality risk (unadjusted HR=1.02; 95%CI [1.01,1.03]) and a higher risk of amputation (unadjusted HR=1.05; 95%CI [1.04,1.07]). Fig. Conclusions: Higher level of community deprivation was associated with increased risk of short-and long-term mortality and amputation outcomes following PVI. PAD care pathways should integrate improved risk assessments and integrated care models for patients from distressed communities to help address health disparities.

Early detection of inflammation-prone STEMI patients using the CRP Troponin Test (CTT)

Abstract Background Elevated concentrations of C-reactive protein (CRP) early after acute coronary syndrome (ACS) may reflect the magnitude of the inflammatory response to myocardial damage and are associated with worse outcome. However, the routine measurement of both CRP and cardiac troponin simultaneously in the setting of ST segment myocardial infarction (STEMI) is not used broadly. Here, we sought to identify and characterize individuals who are prone to an elevated inflammatory response following STEMI using the CRP Troponin test (CTT) and determine their short- and long-term outcome. Material and methods We retrospectively examined 1,186 patients with the diagnosis of acute STEMI, who had at least two successive measurements of combined CRP and cardiac troponin (up to 6 hours apart), all within the first 48 hours of admission. We used Chi-Square Automatic Interaction Detector (CHAID) tree analysis to determine which parameters, timing (baseline vs. serial measurements), and cut-offs should be used to predict mortality. Results Patients with high CRP concentrations (above 90th percentile, &amp;gt;33mg/L) had higher 30 day- and all-cause mortality rates regardless of their troponin test status (above or below 118,000 ng/L); 14.4% vs 2.7%, p&amp;lt;0.01. Furthermore, patients with both high CRP and high Troponin levels on their second measurement had the highest 30-day mortality rates compared to the rest of the cohort; 21.4% vs. 3.7%, p&amp;lt;0.01. These patients also had the highest all-cause mortality rates after a median follow up of 4.5 years compared to the rest of the cohort; 42.9% vs 12.7%, p&amp;lt;0.01 (Figure 1). Conclusions In conclusion, serial measurements of both CRP and cardiac troponin might detect patients at increased risk for short-and long-term mortality following STEMI. We suggest the future use of the combined CRP Troponin-test (CTT) as a potential early marker for inflammatory-prone patients with worse outcomes following ACS. This sub-type of patients might benefit from early anti-inflammatory therapy such as colchicine and anti-IL-1β agents. Funding Acknowledgement Type of funding sources: None.

Early Detection of Inflammation-Prone STEMI Patients Using the CRP Troponin Test (CTT).

Elevated concentrations of C-reactive protein (CRP) early during an acute coronary syndrome (ACS) may reflect the magnitude of the inflammatory response to myocardial damage and are associated with worse outcome. However, the routine measurement of both CRP and cardiac troponin simultaneously in the setting of ST-segment myocardial infarction (STEMI) is not used broadly. Here, we sought to identify and characterize individuals who are prone to an elevated inflammatory response following STEMI by using a combined CRP and troponin test (CTT) and determine their short- and long-term outcome. We retrospectively examined 1186 patients with the diagnosis of acute STEMI, who had at least two successive measurements of combined CRP and cardiac troponin (up to 6 h apart), all within the first 48 h of admission. We used Chi-Square Automatic Interaction Detector (CHAID) tree analysis to determine which parameters, timing (baseline vs. serial measurements), and cut-offs should be used to predict mortality. Patients with high CRP concentrations (above 90th percentile, >33 mg/L) had higher 30 day and all-cause mortality rates compared to the rest of the cohort, regardless of their troponin test status (above or below 118,000 ng/L); 14.4% vs. 2.7%, p < 0.01. Furthermore, patients with both high CRP and high troponin levels on their second measurement had the highest 30-day mortality rates compared to the rest of the cohort; 21.4% vs. 3.7%, p < 0.01. These patients also had the highest all-cause mortality rates after a median follow-up of 4.5 years compared to the rest of the cohort; 42.9% vs. 12.7%, p < 0.01. In conclusion, serial measurements of both CRP and cardiac troponin might detect patients at increased risk for short-and long-term mortality following STEMI. We suggest the future use of the combined CTT as a potential early marker for inflammatory-prone patients with worse outcomes following ACS. This sub-type of patients might benefit from early anti-inflammatory therapy such as colchicine and anti-interleukin-1ß agents.

Prevalence and Mortality of Hypochloremia Among Patients with Coronary Artery Disease: A Cohort Study.

PurposeHypochloremia is a predictor for short-term mortality in patients with cardiovascular disease, but its association with coronary artery disease (CAD) is still unclear. We aimed to assess the impact of hypochloremia on all-cause mortality (short-and long-term) among patients with CAD.Patients and MethodsBased on the registry at Guangdong Provincial People’s Hospital in China, we analyzed data of 49,025 hospitalized patients who underwent coronary angiography (CAG) and were diagnosed with CAD from January 2007 to December 2018. To assess the association between hypochloremia and the study endpoints, a logistic-regression model (for 30-day all-cause mortality) and a Cox regression model (for long-term all-cause mortality) were fitted.ResultsOverall, 4.4% of the study population showed hypochloremia (<98 mmol/L). During a median follow-up of 5.2 (3.1–7.8) years, a total of 6486 (13.2%) patients died. Patients with hypochloremia were generally older and at risk for diabetes, cardiorenal dysfunction, and morbidity than those without hypochloremia. After adjustment for confounders, hypochloremia remained a significant predictor of mortality risk (30-day all-cause death: adjusted odds ratio [aOR], 1.99; 95% confidence interval, 1.08–3.18; P=0.017 and long-term all-cause death: adjusted hazard ratio [aHR], 1.32; 95% confidence interval, 1.19–1.47; P<0.001).ConclusionHypochloremia is mildly common in patients with CAD and is associated with increased short-and long-term mortality. Meanwhile, it is necessary to further investigate effective and preventive measures and the potential mechanisms of hypochloremia in patients with CAD.

Outcomes of Heart Transplant from Donors with a History of Heavy Alcohol Use: Don't Throw the Baby Out with the Bathtub Gin

<h3>Purpose</h3> Donors with a history of heavy alcohol use (DHAU) may have subclinical cardiomyopathy, resulting in poor outcomes after heart transplantation (HT). We sought to assess short-and long-term mortality, graft failure and cardiac allograft vasculopathy (CAV) in HT recipients from DHAU. <h3>Methods</h3> The cohort included adult primary transplants between 2008 and 2017 from the ISHLT TTX registry. Between-group differences were evaluated by Wilcoxon-rank sum tests and Fisher's exact tests for continuous and dichotomous/polytomous variables, respectively. The freedom from death was characterized using the Kaplan-Meier survival methods with log-rank tests; Cox proportional hazard regression was used to quantify of DHAU. The incidence rate of CAV was characterized using a competing risk model with Gray's tests, and the association of DHAU was assessed using cause-specific hazard regression. <h3>Results</h3> A total of 21,744 HT recipients were included, of which, 3,523 were classified as DHAU. The median (IQR) follow-up time was 3.8 (1.8 - 6.2) years. Among DHAU, there was a higher proportion of heavy smokers (32% <i>vs</i>. 11%, <i>p</i><0.001), cocaine use (35% <i>vs</i>. 14%, <i>p</i><0.001) and a higher proportion of angiograms completed (49% <i>vs</i>. 23%, <i>p</i><0.001). When stratified by DHAU, 1-year graft failure (<i>p</i>= 0.76) and 5-year survival were similar (<i>p</i>=0.25). The proportion of recipients experiencing CAV within 5 years and 10 years was significantly higher in recipients with DHAU (HR [95% CI] = 1.30 [1.20, 1.42], <i>p</i>< 0.001) (Figure 1). When adjusted for covariates, these recipients from DHAU were more likely to experience CAV (HR [95% CI] = 1.17 [1.07, 1.27], p< 0.001) within 5-years of HT (Table 1). <h3>Conclusion</h3> A donor history of heavy alcohol use was not a risk factor for poor short-term outcomes; however, DHAU are associated with an increased risk of developing CAV. Recipients of such donors may benefit from more intensive monitoring and earlier initiation of CAV related therapies.

Association Between Obesity and Short-And Long-Term Mortality in Patients With Acute Respiratory Distress Syndrome Based on the Berlin Definition.

PurposeAcute respiratory distress syndrome (ARDS) is one of the most common causes of death in intensive care units (ICU). Previous studies have reported the potential protective effect of obesity on ARDS patients. However, these findings are inconsistent, in which less was reported on long-term prognosis and diagnosed ARDS by Berlin definition. This study aimed to investigate the relationship between obesity and short-term and long-term mortality in patients with ARDS based on the Berlin Definition.MethodsThis is a retrospective cohort study from the Medical Information Mart for Intensive Care III (MIMIC-III) database, in which all the patients were diagnosed with ARDS according to the Berlin definition. The patients were divided into four groups according to the WHO body mass index (BMI) categories. The multivariable logistic regression and Cox regression analysis were used to investigate the relationship between BMI and short-term and long-term mortality.ResultA total of 2,378 patients with ARDS were enrolled in our study. In-hospital mortality was 27.92%, and 1,036 (43.57%) patients had died after 1-year follow-up. After adjusting for confounders, the in-hospital and 1-year mortality risks of obese patients were significantly lower than those of normal weight (OR 0.72, 95%CI 0.55–0.94, P=0.0168; HR 0.80, 95%CI 0.68–0.94 P=0.0084; respectively), while those mortality risks of underweight patients were higher than normal weight patients (P=0.0102, P=0.0184; respectively). The smooth curve showed that BMI, which was used as a continuous variable, was negatively correlated with in-hospital and 1-year mortality. The results were consistent after being stratified by age, gender, race, type of admission, severity of organ dysfunction, and severity of ARDS. The Kaplan-Meier survival curves showed that obese patients had significant lower 1-year mortality than normal weight patients.ConclusionWe found that obesity was associated with decreased risk of short-term and long-term mortality in patients with ARDS.

Neutrophil: Lymphocyte Ratio Predicts Coronary Artery Disease Severity in Non-ST Elevation Myocardial Infarction Using Syntax Score

Background: Inflammation plays a pivotal role in the initiation and progression of atherosclerosis. Neutrophil:lymphocyte ratio (NLR) is a prognostic marker for several cardiovascular diseases, including non-ST-elevation myocardial infarction (NSTEMI). Syntax score (Sx score) is an anatomical score system for coronary artery disease (CAD) severity and can predict short-and long-term mortality in CAD intervention. Aim:To investigate the association between NLR and Sxscore as a measure of CAD severity in patients with NSTEMI. Methods:A prospective study was performed over 12 months on patients presenting with NSTEMI. Complete blood count (for NLR calculation), s. urea, s. creatinine, s. lipid profile, and s. cardiac enzymes were withdrawn upon admission. Coronary angiography with Sx score calculation was done during the index hospitalization. Results:We studied 111 consecutive patients, 85 males (76.6%) with a mean age of 55.3 ± 9.8 years. In univariate analysis, a high Sx score (≥ 33) was significantly associated withs. cholesterol, s. LDL, s. HDL, s. creatinine,s. CK, s. CK-MB, and NLR. In multivariate analysis, NLR was the only significant predictor of high Sx score [HR: 4.19 and 95% CI: 1.7-10.5, p: 0.002]. In the ROC analysis, the NLR cutoff of >7.1 had 100% sensitivity and 94% specificity to predict a high Sx score (AUC 0.97, P 7.1 predicts a high Sx score with 100% sensitivity and 94% specificity, thus helping in early and better risk stratification of NSTEMI.

Impact of pre-hospital resuscitation on short-and long-term mortality in patients with cardiogenic shock and multivessel disease. Results of the CULPRIT trial

Abstract Background There are only a few prospective data on the outcome of patients with cardio-pulmonary resuscitation (CPR) admitted with acute myocardial infarction (AMI) complicated by cardiogenic shock and an invasive strategy including primary percutaneous coronary intervention (PCI). Therefore, we evaluated the impact of pre-hospital CPR on outcomes in a large group of patients with AMI complicated by cardiogenic shock. Methods We used the data of the prospective CULPRIT-Shock trial and registry and including patients with acute myocardial infarction complicated by cardiogenic shock. The primary endpoint was 30-day mortality or renal replacement therapy. Results Between 2013 and 2017, a total of 1055 patients were included in the randomized trial (n=686) and in the registry (n=369), 550 (54%) had CPR, 40 had no information regarding CPR. Baseline characteristics, procedural features and outcomes in the two groups with and without CPR are given in the table. Conclusion Patients with pre-hospital CPR represent more than half of the population with AMI complicated by cardiogenic shock. They are younger, have less risk factors and more often LAD as infarct vessel. Despite the younger age and a high success rate of PCI patients with CPR have a high 30-day mortality. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Deutsches Zentrum fuer Herz-Kreislauf-Forschung - DZHK

Impact of atrial fibrillation on outcomes of patients treated by transcatheter mitral valve repair: A systematic review and meta-analysis.

Background:Conflicting data have been reported related to the impact of atrial fibrillation (AF) on outcomes after transcatheter mitral valve repair with MitraClip (MC) implantation. In this study, we assessed the prognosis of MC-treated patients according to the presence of pre-existing AF.Methods:Randomized and observational studies reporting outcomes of pre-existing AF or sinus rhythm in patients undergoing MC treatment were identified with an electronic search. Outcomes of interest were short-and long-term mortality, stroke, bleeding, rehospitalization, myocardial infarction (MI), cardiogenic shock, acute procedure success, the hospital stay, and the number of Clips implanted.Results:Eight studies (8466 individuals) were eligible. Compared to sinus rhythm, long-term mortality, the risk of bleeding, rehospitalization, and longer hospital stay were significantly higher in AF groups, whereas similar correlations were found in the analysis of other outcomes.Conclusion:AF may be related with worse outcomes in patients undergoing MC implantation, including long-term mortality, major bleeding, and rehospitalization. AF should be taken into account when referring a patient for MC treatment.

Surgical Myocardial Revascularization in Patients with Severe Left Ventricular Dysfunction: Experience in the Cardiac Surgery Department of the Military Hospital Mohammed V of Rabat

Patients with coronary artery disease associated with severe left ventricular dysfunction, candidates for surgical myocardial revascularization, are with high operative risk. The aim of this study was to assess short and long-term morbidity and mortality and to identify their predictive factors. Methods: We conducted a retrospective study in the cardiac surgery department of the Military Instruction Hospital Mohammed V- Rabat, between 2000 and 2015. The statistical analysis was executed by SPSS. There were 74 patients (mean age 74±10 years, ejection fraction [FE]: 30.07%±4 .5, Euroscore: 6.6±2.9). Results: Hospital mortality was 9.5%, with a follow up time of 59.2 ± 36 months. The survival rate at 10 years was 57%. There was also an improvement in their clinical symptoms and echocardiographic parameters (postoperative FE: 40.36%±11.2). Conclusion: In this group of patients with high operative risk, the long-term results of several studies demonstrate the superiority of surgical treatment on medical treatment.

The predictive efficacy of multidimensional prognostic index in the elderly with heart failure and reduced ejection fraction in a real world sample: the Post-Acute Long-Term Care setting

The multidimensional prognostic index (MPI) is an accurate predictor of mortality validated in hospitalized older patients. Aim of this study was to evaluate the reliability of the MPI in predicting shortand long-term mortality in patients with heart failure (HF), particularly in those with reduced left ventricular ejection fraction (HFrEF). The study population included all patients older than 65 years admitted in a Post-Acute Long-Care Unit from 2013 to 2018. Patients were divided into two groups: patients with HF (N=143) and patients without HF as controls (N=1254). Furthermore, patients affected by HF were subdivided according to echocardiographic left ventricular ejection fraction (LVEF), i.e. reduced, mid-range and preserved LVEF (respectively HFrEF, HFmrEF, HFpEF). All patients underwent a comprehensive geriatric assessment (CGA) to calculate the MPI based on information on functional, cognitive, nutritional and mobility status, comorbidity, poli-pharmacy and co-habitation. Mortality rates in the HF group was 46% in patients MPI-1 or MPI-2 groups versus 59% in patients included in the MPI- 3 group. In particular, of 32 HF patients with HFrEF 67.7% were in the MPI-3 class compared to 43% of 14 patients with HFmrEF group and to 41% of 63 patients with HFpEF. These findings suggest that MPI is a reliable predictor of mortality in HF patients and that it was particularly useful in the subgroup of patients with HFrEF.

Association Between Preoperative Opioid and Benzodiazepine Prescription Patterns and Mortality After Noncardiac Surgery

The number of patients prescribed long-term opioids and benzodiazepines and complications from their long-term use have increased. Information regarding the perioperative outcomes of patients prescribed these medications before surgery is limited. To determine whether patients prescribed opioids and/or benzodiazepines within 6 months preoperatively would have greater short- and long-term mortality and increased opioid consumption postoperatively. This retrospective, single-center, population-based cohort study included all patients 18 years or older, undergoing noncardiac surgical procedures at a national hospital in Iceland from December 12, 2005, to December 31, 2015, with follow-up through May 20, 2016. A propensity score-matched control cohort was generated using individuals from the group that received prescriptions for neither medication class within 6 months preoperatively. Data analysis was performed from April 10, 2018, to March 9, 2019. Patients who filled prescriptions for opioids only, benzodiazepines only, both opioids and benzodiazepines, or neither medication within 6 months preoperatively. Long-term survival compared with propensity score-matched controls. Secondary outcomes were 30-day survival and persistent postoperative opioid consumption, defined as a prescription filled more than 3 months postoperatively. Among 41 170 noncardiac surgical cases in 27 787 individuals (16 004 women [57.6%]; mean [SD] age, 56.3 [18.8] years), a preoperative prescription for opioids only was filled for 7460 cases (17.7%), benzodiazepines only for 3121 (7.4%), and both for 2633 (6.2%). Patients who filled preoperative prescriptions for either medication class had a greater comorbidity burden compared with patients receiving neither medication class (Elixhauser comorbidity index >0 for 16% of patients filling prescriptions for opioids only, 22% for benzodiazepines only, and 21% for both medications compared with 14% for patients filling neither). There was no difference in 30-day (opioids only: 1.3% vs 1.0%; P = .23; benzodiazepines only: 1.9% vs 1.5%; P = .32) or long-term (opioids only: hazard ratio [HR], 1.12 [95% CI, 1.01-1.24]; P = .03; benzodiazepines only: HR, 1.11 [95% CI, 0.98-1.26]; P = .11) survival among the patients receiving opioids or benzodiazepines only compared with controls. However, patients prescribed both opioids and benzodiazepines had greater 30-day mortality (3.2% vs 1.8%; P = .004) and a greater hazard of long-term mortality (HR, 1.41; 95% CI, 1.22-1.64; P < .001). The rate of persistent postoperative opioid consumption was higher for patients filling prescriptions for opioids only (43%), benzodiazepines only (23%), or both (66%) compared with patients filling neither (12%) (P < .001 for all). The findings suggest that opioid and benzodiazepine prescription fills in the 6 months before surgery are associated with increased short-and long-term mortality and an increased rate of persistent postoperative opioid consumption. These patients should be considered for early referral to preoperative clinic and medication optimization to improve surgical outcomes.

Myocardial injury after non-cardiac surgery: Time to shed the ignorance

Perioperative cardiovascular complications are common and place a significant burden on public healthcare systems. A large proportion of such complications are due to a new clinical entity, i.e. myocardial injury after non-cardiac surgery (MINS). It is important to understand MINS, its prognosis and management in the perioperative period. A literature review of MINS was done. MINS is defined as an elevated postoperative cardiac troponin level that was considered as resulting from myocardial ischaemia without evidence of a non-ischaemic cause for the troponin elevation. The perioperative milieu (surgical stress response, sympathetic activation, hypercoagulability, hypotension, bleeding, anaemia and pain) contributes to the pathophysiology of a relative myocardial hypoperfusion and ischaemia, which differentiates MINS from myocardial infarction in non-surgical patients. Globally, >7% of adults ≥45 years of age suffer MINS, with South African (SA) studies confirming similar event rates. More than 80% of MINS patients are asymptomatic for myocardial ischaemia, and therefore would not fulfil the universal definition of myocardial infarction, despite having a similar prognosis to those with the latter condition. Accurate diagnosis of MINS therefore relies on routine daily postoperative cardiac troponin surveillance for 48 -72 hours postoperatively in patients with a >5% risk of major perioperative cardiovascular complications. This approach is cost-effective in SA. One in 10 patients with MINS dies within 30 days of surgery, and 1 in 5 develops major cardiovascular complications. Short-and long-term mortality could be improved by simple treatment strategies, including cardiovascular therapy intensification, and by ensuring aspirin use and statin therapy. All recommendations promote the involvement of a multidisciplinary team. MINS is a common, serious perioperative cardiovascular complication with public healthcare implications that has been underappreciated in SA. A multidisciplinary approach with simple treatment strategies should be adopted.