Short-term Risk Stratification Research Articles

The prognostic value of HEART score in patients with known heart failure evaluated at the emergency department for acute chest pain

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Heart Lung and Blood Institute (United States). Background Chest pain is a common and concerning symptom in emergency care, often necessities further risk stratification for adverse cardiovascular events on short-term follow up. Patients with known heart failure (HF) constitutes a unique sub-population that would greatly benefit from short-term risk stratification to guide appropriate clinical interventions and optimize resource allocation. HEART (History, ECG, Age, Risk factors, Troponin) is a well-validated risk score that has been shown to outperform other clinical risk scores in patients with chest pain. It remains unknown if HEART score can be safely used in patients with known HF presenting to the emergency department with chest pain. Purpose We sought to evaluate the prognostic value of HEART score in patients with known HF compared to their counterparts. Method This was a prospective observational cohort study of consecutive adult patients evaluated at the emergency department for non-traumatic chest pain. HEART score was computed from charts by independent physician reviewers. The primary study outcome was major adverse cardiac events (MACE) defined as acute coronary syndrome, invasive revascularization, reinfarction, death, cardiac arrest, ventricular tachyarrhythmia, or acute exacerbation within 30 days of indexed admission. Outcomes were adjudicated by two independent reviewers (Kappa = 0.908). Classification performance between groups was compared using area under receiver operator characteristic curve (AUROC), sensitivity, and negative predictive value (NPV). Results Our cohort included 4,132 patients (age 59±16, 47% female, 33% Black). Overall, 921 patients (22.3%) experienced 30-day MACE. The classification performance of HEART score in those without HF (n = 3,329, 81%) was AUROC of 0.831 (95% CI 0.813-0.848), compared to only 0.633 (95% CI 0.592-0.673) in those with known HF (n = 803, 19%) (z score = 8.771, p < 0.001, Figure). The sensitivity and NPV of HEART score among those without HF were 87.4% and 95.3%, compared to 81.2% and 73.3%, respectively, among those with known HF. Conclusion Our findings suggest that the prognostic value of HEART score for predicting 30-day MACE is inferior and suboptimal in patients with known HF evaluated for chest pain at the emergency department compared to their counterparts. These findings emphasize the need for more tailored risk assessment and management strategies in this specific patient population. Further research is warranted to better understand the limitations and potential enhancements of the HEART score in patients with HF.Classification Performance of HEART score

Computed tomography-based body composition parameters can predict short-term prognosis in ulcerative colitis patients.

Emerging evidence suggests a potential relationship between body composition and short-term prognosis of ulcerative colitis (UC). Early and accurate assessment of rapid remission based on conventional therapy via abdominal computed tomography (CT) images has rarely been investigated. This study aimed to build a prediction model using CT-based body composition parameters for UC risk stratification. In total, 138 patients with abdominal CT images were enrolled. Eleven quantitative parameters related to body composition involving skeletal muscle mass, visceral adipose tissue (VAT), and subcutaneous adipose tissue (SAT) were measured and calculated using a semi-automated segmentation method. A prediction model was established with significant parameters using a multivariable logistic regression. The receiver operating characteristic (ROC) curve was plotted to evaluate prediction performance. Subgroup analyses were implemented to evaluate the diagnostic efficiency of the prediction model between different disease locations, centers, and CT scanners. The Delong test was used for statistical comparison of ROC curves. VAT density, SAT density, gender, and visceral obesity were significantly statistically different between remission and invalidation groups (all p < 0.05). The accuracy, sensitivity, specificity, and area under the ROC curve (AUC) of the prediction model were 82.61%, 95.45%, 69.89%, and 0.855 (0.792-0.917), respectively. The positive predictive value and negative predictive value were 70.79% and 93.88%, respectively. No significant differences in the AUC of the prediction model were found in different subgroups (all p > 0.05). The predicting model constructed with CT-based body composition parameters is a potential non-invasive approach for short-term prognosis identification and risk stratification. Additionally, VAT density was an independent predictor for escalating therapeutic regimens in UC cohorts. The CT images were used for evaluating body composition and risk stratification of ulcerative colitis patients, and a potential non-invasive prediction model was constructed to identify non-responders with conventional therapy for making therapeutic regimens timely and accurately. • CT-based prediction models help divide patients into invalidation and remission groups in UC. • Results of the subgroup analysis confirmed the stability of the prediction model with a high AUC (all > 0.820). • The visceral adipose tissue density was an independent predictor of bad short-term prognosis in UC.

Abstract 14946: Sex Differences in Growth Differentiation Factor-15 and Association With Acute Myocardial Infarction and Death at 90 Days in Emergency Department Patients Presenting With Acute Chest Pain and Normal Troponin Levels

Introduction: Growth differentiation factor (GDF)-15, a novel biomarker of cardiac stress, has been recently studied as a tool in predicting cardiovascular outcomes in patients with acute chest pain, when compared against high-sensitivity troponin T (hs-TnT). However, GDF-15 is not approved for cardiac indications in the United States, with limited nationwide data evaluating subpopulations by key demographic and clinical characteristics. Hypothesis: GDF-15 levels demonstrate sex-specific differences and serve as an independent predictor of 90-day acute myocardial infarction (MI) and all-cause death in patients presenting to the emergency department (ED) with acute chest pain and normal hs-TnT levels. Methods: This study was a secondary analysis of the STOP-CP (High Sensitivity Cardiac Troponin T to Optimize Chest Pain Risk Stratification) trial, which prospectively enrolled adults ≥ 21 years presenting to eight EDs in the US with suspected acute MI over a twenty-month period. Blood sampling was performed at presentation, with hs-TnT and GDF-15 assays performed at a central laboratory. The outcomes of interest were the composite of acute MI and all-cause death at 90 days. Multiple logistic regression models were fitted for timepoint with multiple independent variables including the following: age, sex, ischemic electrocardiogram, hs-TnT, GDF-15, and creatinine. Results: We studied 1,428 patients; median age was 58 years and 54% (765) were male. The composite outcome of acute MI or death occurred in 3% (37) at 90 days. In multivariable regression models in patients with baseline normal hs-TnT levels, GDF-15 was associated with acute MI or all-cause death at 90 days (Odds Ratio 1.03, 95% Confidence Interval 1.01-1.05). Median GDF-15 levels were 1266 pg/mL in males (25th percentile-75th percentile, 914-2038 pg/mL), and 1504 pg/mL in females (25th percentile-75th percentile, 987-2197 pg/mL). Conclusions: Among adult ED patients presenting with acute chest pain with normal troponin levels, the novel biomarker GDF-15 was independently associated with 90-day acute MI or death, with higher median GDF-15 levels in females compared to males. These data suggest a role for GDF-15 in short-term cardiac risk stratification.

The Relationship Between C-reactive Protein Albumin Ratio and Long-Term Mortality in Patients With Acute Coronary Syndrome.

Background Coronary artery disease (CAD) is one of the leading causes of death worldwide. CRP/albumin ratio is a sensitive indicator of inflammatory status. It has been shown that this parameter may be associated with poor short-term outcomes in CAD. In this study, we investigated the relationship between long-term mortality and the CRP/albumin ratio in patients with acute coronary syndromes (ACS). Material and methods This study was conducted on patients who applied to our hospital between January 2015 and December 2019 and were diagnosed with ACS. A total of 1689 patients were included in the study. Patients were divided into two groups according to mortality status, and long-term mortality predictors were investigated. Results The average follow-up period was 38.9±10.3 months. The mean age of the entire study group was 56.6±12.2 years, and 1440 (80.5%) of the patients were male. Comorbid diseases and blood parameters were significant between the two groups. In the regression analysis, creatine, hemoglobin, white blood cell count (WBC), neutrophil-lymphocyte ratio (NLR), and CRP albumin ratio (CAR) were found to be independent predictors. In the ROC analysis, it was observed that CAR had the best predictive value. Discussion An increased CAR level is an independent predictor of long-term mortality in ACS patients. It can be used in both short-term and long-term risk stratification for ACS patients.

Prehospital seizures: Short-term outcomes and risk stratification based in point-of-care testing.

Information for treatment or hospital derivation of prehospital seizures is limited, impairing patient condition and hindering patients risk assessment by the emergency medical services (EMS). This study aimed to determine the associated factors to clinical impairment, and secondarily, to determine risk factors associated to cumulative in-hospital mortality at 2, 7 and 30 days, in patients presenting prehospital seizures. Prospective, multicentre, EMS-delivery study involving adult subjects with prehospital seizures, including five advanced life support units, 27 basic life support units and four emergency departments in Spain. All bedside variables: including demographic, standard vital signs, prehospital laboratory tests and presence of intoxication or traumatic brain injury (TBI), were analysed to construct a risk model using binary logistic regression and internal validation methods. A total of 517 patients were considered. Clinical impairment was present in 14.9%, and cumulative in-hospital mortality at 2, 7 and 30-days was 3.4%, 4.6% and 7.7%, respectively. The model for the clinical impairment indicated that respiratory rate, partial pressure of carbon dioxide, blood urea nitrogen, associated TBI or stroke were risk factors; higher Glasgow Coma Scale (GCS) scores mean a lower risk of impairment. Age, potassium, glucose, prehospital use of mechanical ventilation and concomitant stroke were risk factors associated to mortality; and oxygen saturation, a high score in GCS and haemoglobin were protective factors. Our study shows that prehospital variables could reflect the clinical impairment and mortality of patients suffering from seizures. The incorporation of such variables in the prehospital decision-making process could improve patient outcomes.

Guest Editorial - Pulmonary Embolism: the risk of what we don't yet know!

Pulmonary embolism (PE) is a common and potentially life-threatening condition encountered routinely in acute care. The diagnosis and management of PE has been the topic of National Institute of Health Care Excellence and European Cardiology Society guidelines. The recommendations within these guidelines have allowed standardisation of care and have facilitated the delivery of protocolised care pathways. Whilst some elements of care are determined by consensus view, there have been large randomised controlled trials and well-designed observational studies which have helped us understand the role of risk factors for PE, short term risk-stratification after initial diagnosis and treatment options in hospital as well as in the months after discharge from Acute Medicine. Few other conditions in acute care are informed by the same levels of evidence, yet there are many unresolved questions.

Use of the HEAR Score for 30-Day Risk-Stratification in Emergency Department Patients

BackgroundThe 2021 American College of Cardiology/American Heart Association chest pain guidelines recommend risk scores such as HEAR (History, Electrocardiogram, Age, Risk factors) for short-term risk stratification, yet limited data exist integrating them with high-sensitivity cardiac troponin T (hs-cTnT). MethodsRetrospective, multicenter (n = 2), observational, US cohort study of consecutive emergency department patients without ST-elevation myocardial infarction who had at least one hs-cTnT (limit of quantitation [LoQ] <6 ng/L, and sex-specific 99th percentiles of 10 ng/L for women and 15 ng/L for men) measurement on clinical indications in whom HEAR scores (0-8) were calculated. The composite major adverse cardiovascular event (MACE) outcome was 30-day prognosis. ResultsAmong 1979 emergency department patients undergoing hs-cTnT measurement, 1045 (53%) were low risk (0-3), 914 (46%) intermediate risk (4-6), and 20 (1%) high risk (7-8) based on HEAR scores. HEAR scores were not associated with increased risk of 30-day MACE in adjusted analyses. Patients with quantifiable hs-cTnT (LoQ-99th) had an increased risk for 30-day MACE (3.4%) irrespective of HEAR scores. Those with serial hs-cTnT <99th percentile remained at low risk (range 0%-1.2%) across all HEAR score strata. Higher scores were not associated with long-term (2-year) events. ConclusionsHEAR scores are of limited value in those with baseline hs-cTnT <LoQ or hs-cTnT >99th percentile to define short-term prognosis. In those with baseline quantifiable hs-cTnT within the reference range (<99th percentile), a higher risk (>1%) for 30-day MACE exists even in those with low HEAR scores. With serial hs-cTnT measurements, HEAR scores overestimate risk when hs-cTnT remains <99th percentile.

Short-Term Risk Stratification of Non–Flow-Limiting Coronary Stenosis by Angiographically Derived Radial Wall Strain

BackgroundDeferred revascularization of mildly stenotic coronary vessels based exclusively on physiological evaluation is associated with up to 5% residual incidence of future adverse events at 1 year. ObjectivesWe aimed to evaluate the incremental value of angiography-derived radial wall strain (RWS) in risk stratification of non–flow-limiting mild coronary narrowings. MethodsThis is a post hoc analysis of 824 non–flow-limiting vessels in 751 patients from the FAVOR III China (Comparison of Quantitative Flow Ratio Guided and Angiography Guided Percutaneous Intervention in Patients With Coronary Artery Disease) trial. Each individual vessel had ≥1 mildly stenotic lesion. The primary outcome was vessel-oriented composite endpoint (VOCE), defined as the composite of vessel-related cardiac death, vessel-related myocardial infarction (nonprocedural), and ischemia-driven target vessel revascularization at 1-year follow-up. ResultsDuring 1-year follow-up, VOCE occurred in 46 of 824 vessels, with a cumulative incidence of 5.6%. Maximum RWS (RWSmax) was predictive of 1-year VOCE with an area under the curve of 0.68 (95% CI: 0.58-0.77; P < 0.001). The incidence of VOCE was 14.3% in vessels with RWSmax >12% vs 2.9% in those with RWSmax ≤12%. In the multivariable Cox regression model, RWSmax >12% was a strong independent predictor of 1-year VOCE in deferred non–flow-limiting vessels (adjusted HR: 4.44; 95% CI: 2.43-8.14; P < 0.001). The risk of deferred revascularization based on combined normal RWSmax and Murray–law-based quantitative flow ratio (μQFR) was significantly reduced compared with μQFR alone (adjusted HR: 0.52; 95% CI: 0.30-0.90; P = 0.019). ConclusionsAmong vessels with preserved coronary flow, angiography-derived RWS analysis has the potential to further discriminate vessels at risk of 1-year VOCE. (Comparison of Quantitative Flow Ratio Guided and Angiography Guided Percutaneous Intervention in Patients With Coronary Artery Disease [FAVOR III China Study]; NCT03656848)

The prognostic value of delta-lactate in critically ill children.

This study aimed to test delta-lactate (ΔL) as a short-term risk stratification method in critically ill children. An exploratory study of patients admitted to paediatric intensive care unit (PICU) was conducted. ΔL was calculated as the difference between the maximum lactate concentrations on Days 1 and 2. According to the ΔL cutoff, two groups were considered: low mortality risk (LMR) - ΔL≥ 0.05 mmol/L - and high mortality risk (HMR) - ΔL< 0.05 mmol/L. Mortality, both during PICU stay and at 28 days, was statistically associated with elevated serum lactate on D1 and D2, per se. For the 93 cases with elevated lactate on Day 1, and a ΔL cutoff of 0.05 mmol/L, the area under the ROC curve was 0.698 (95% confidence interval, 0.47-0.93). HMR patients scored higher PIM3, were not discharged home until 28 days, counted fewer ventilation-free days and needed renal replacement therapy more often. Elevated lactate levels at admission, as well as applying the optimal cutoff for ΔL, allowed to predict short-term mortality: if an increase or minimal decrease in lactate maximum levels occurred from D1 to D2, death was almost eight times more probable. In critically ill children, delta-lactate predicts short-term outcome.

Abstract 14283: Influence of the HEAR Score for 30-day Risk-Stratification in Emergency Department Patients Evaluated With High-Sensitivity Cardiac Troponin T

Background: The 2021 ACC/AHA chest pain guidelines recommend risk scores such as HEAR (History, Electrocardiogram, Age, Risk Factors) for short term risk-stratification yet limited data exists integrating them with high-sensitivity cardiac troponin T (hs-cTnT). Methods: Retrospective, multicenter (n=2), observational, U.S. cohort study of consecutive ED patients without ST-elevation myocardial infarction (MI) who had at least one hs-cTnT (limit of quantitation, LoQ, &lt;6 ng/L, and sex-specific 99 th percentiles of 10 ng/L for women and 15 ng/L for men) measurement on clinical indication in whom HEAR scores (0-8) were calculated. The composite major adverse cardiovascular (MACE) outcome was 30-day MI and death. Results: Among 1,979 ED patients undergoing hs-cTnT measurement, 1045 (53%) were classified as low-risk (0-3), 914 (46%) as intermediate-risk (4-6), and 20 (1%) as high-risk (7-8) based on HEAR scores. HEAR scores were not associated with an increased risk of 30-day MACE after adjusted analyses. Outcomes according to risk-strata based on HEAR scores and baseline hs-cTnT are shown in Table 1. Patients with quantifiable hs-cTnT (LoQ-99 th ) had an increased risk for 30-day MACE (3.4%) despite being estimated to be low-risk (0-3) per HEAR scores. Conversely, those with serial hs-cTnT&lt;99 th percentile remained at low-risk (range 0% to 1.2%) for 30-day MACE across HEAR score strata. Conclusions: HEAR scores are of limited value in those with baseline hs-cTnT&lt;LoQ or hs-cTnT&gt;99 th percentile where hs-cTnT identifies very low and high-risk patients irrespective of HEAR scores. In those with baseline quantifiable hs-cTnT within the reference range (&lt;99 th percentile), a higher risk (&gt;1%) for 30-day MACE exists even in those with low HEAR scores. With serial hs-cTnT measurements, HEAR scores overestimate risk when hs-cTnT remains &lt;99 th percentile.

Preliminary experience of robotic lateral neck dissection via combined axillary-retroauricular approach for N1b papillary thyroid carcinoma

Objective: To evaluate the feasibility, safety, and short-term efficacy of robotic lateral neck dissection via combined axillary-retroauricular approach for N1b papillary thyroid carcinoma (PTC). Methods: Thirty patients with cT1-2N1bM0 PTC who received robotic lateral neck dissection via combined axillary-retroauricular approach were included in the Department of Otorhinolaryngology of Sun Yat-sen Memorial Hospital from December 2016 to December 2020. There were 10 males and 20 females, with a median age of 34.5 years and a median body mass index of 25.55 kg/m2. The clinical, surgical, complications, pathology and follow-up data were analysed with SPSS 25.0 software package. Results: The median operative time of 30 patients was 255.50 min, the median operative blood loss was 69.00 ml, and the median postoperative hospital stay was 6.00 days. The incidence of postoperative temporary recurrent laryngeal nerve paralysis was 3.33% (1/30), temporary hypoparathyroidism was 16.67%(5/30), temporary accessory nerve injury was 3.33% (1/30), hematoma was 3.33% (1/30) and chylous leakage was 3.33% (1/30). The median visual analogue scale (VAS) score was 8.00, and the follow-up time was 13-38 months, with a median of 25.5 months. One case showed cervical lymph node recurrence 14 months after surgery. The most recent dynamic recurrence risk stratification showed 21 patients (70.00%) had excellent responses. Conclusions: Robotic lateral neck dissection via combined axillary-retroauricular approach for unilateral cN1b PTC is safe, feasible and aesthetic. The short-term efficacy and dynamic recurrence risk stratification results of short-term follow-up are satisfactory. It can provide a surgical option for cN1b PTC patients.

Tumor Necrosis Factor-Related Apoptosis-Inducing Ligand (TRAIL): A Novel Biomarker for Prognostic Assessment and Risk Stratification of Acute Pulmonary Embolism.

Background: Tumor necrosis factor (TNF)-related apoptosis-inducing ligand (TRAIL) is associated with poor prognosis in cardiovascular diseases. However, the predictive value of TRAIL for the short-term outcome and risk stratification of acute pulmonary embolism (PE) remains unknown. Methods: This study prospectively included 151 normotensive patients with acute PE. The study outcome was a composite of 30-day adverse events, defined as PE-related death, shock, mechanical ventilation, cardiopulmonary resuscitation, and major bleeding. Results: Overall, nine of 151 (6.0%) patients experienced 30-day adverse composite events. Multivariable logistic regression showed that TRAIL was an independent predictor of study outcome (OR 0.19 per SD; 95% CI 0.04–0.90). An ROC curve revealed that TRAIL’s area under the curve (AUC) was 0.83 (95% CI 0.76–0.88). The optimal cut-off value for TRAIL was 18 pg/mL, with a sensitivity, specificity, negative predictive value, positive predictive value, positive likelihood ratio, and negative likelihood ratio of 89%, 69%, 99%, 15%, 2.87, and 0.16, respectively. Compared with the risk stratification algorithm outlined in the 2019 ESC guidelines, our biomarker-based risk stratification strategy (combining TRAIL and hs-cTnI) has a similar risk classification effect. Conclusion: Reduced plasma TRAIL levels predict short-term adverse events in normotensive patients with acute PE. The combination of the 2019 ESC algorithm and TRAIL aids risk stratification in normotensive patients with acute PE.

CARDIAC ABNORMALITIES IN COVID-19 AND RELATIONSHIP TO OUTCOME

Abstract Objective To characterize the clinical and transthoracic echocardiographic features and 30-day outcomes of hospitalized patients with coronavirus disease 2019 (COVID-19). Methods Retrospective cohort study that included consecutive inpatients with COVID-19 infection who underwent clinically indicated transthoracic echocardiography at 10 sites in the Mayo Clinic Health System between March 10 and August 5, 2020. Echocardiography was performed at bedside by cardiac sonographers according to an abbreviated protocol. Echocardiographic results, demographic characteristics, laboratory findings, and clinical outcomes were analyzed. Results There were 179 patients, aged 59.8±16.9 years and 111 (62%) men; events within 30 days occurred in 70 (39%) patients, including prolonged hospitalization in 43 (24%) and death in 27 (15%). Echocardiographic abnormalities included left ventricular ejection fraction less than 50% in 29 (16%), regional wall motion abnormalities in 26 (15%), and right ventricular systolic pressure (RVSP) of 35 or greater mm Hg in 44 (44%) of 101 in whom it was measured. Myocardial injury, defined as the presence of significant troponin level elevation accompanied by new ventricular dysfunction or electrocardiographic abnormalities, was present in 13 (7%). Prior echocardiography was available in 36 (20%) patients and pre-existing abnormalities were seen in 28 (78%) of these. In a multivariable age-adjusted model, area under the curve of 0.81, prior cardiovascular disease, troponin level, D-dimer level, and RVSP were related to events at 30 days. Conclusion Bedside Doppler assessment of RVSP appears promising for short-term risk stratification in hospitalized patients with COVID-19 infection undergoing clinically indicated echocardiography. Pre-existing echocardiographic abnormalities were common; caution should be exercised in attributing such abnormalities to the COVID-19 infection in this comorbid patient population.

Cardiac Abnormalities in COVID-19 and Relationship to Outcome

ObjectiveTo characterize the clinical and transthoracic echocardiographic features and 30-day outcomes of hospitalized patients with coronavirus disease 2019 (COVID-19). MethodsRetrospective cohort study that included consecutive inpatients with COVID-19 infection who underwent clinically indicated transthoracic echocardiography at 10 sites in the Mayo Clinic Health System between March 10 and August 5, 2020. Echocardiography was performed at bedside by cardiac sonographers according to an abbreviated protocol. Echocardiographic results, demographic characteristics, laboratory findings, and clinical outcomes were analyzed. ResultsThere were 179 patients, aged 59.8±16.9 years and 111 (62%) men; events within 30 days occurred in 70 (39%) patients, including prolonged hospitalization in 43 (24%) and death in 27 (15%). Echocardiographic abnormalities included left ventricular ejection fraction less than 50% in 29 (16%), regional wall motion abnormalities in 26 (15%), and right ventricular systolic pressure (RVSP) of 35 or greater mm Hg in 44 (44%) of 101 in whom it was measured. Myocardial injury, defined as the presence of significant troponin level elevation accompanied by new ventricular dysfunction or electrocardiographic abnormalities, was present in 13 (7%). Prior echocardiography was available in 36 (20%) patients and pre-existing abnormalities were seen in 28 (78%) of these. In a multivariable age-adjusted model, area under the curve of 0.81, prior cardiovascular disease, troponin level, D-dimer level, and RVSP were related to events at 30 days. ConclusionBedside Doppler assessment of RVSP appears promising for short-term risk stratification in hospitalized patients with COVID-19 infection undergoing clinically indicated echocardiography. Pre-existing echocardiographic abnormalities were common; caution should be exercised in attributing such abnormalities to the COVID-19 infection in this comorbid patient population.

Protein-based cardiogenic shock patient classifier.

Cardiogenic shock (CS) is associated with high short-term mortality and a precise CS risk stratification could guide interventions to improve patient outcome. Here, we developed a circulating protein-based score to predict short-term mortality risk among patients with CS. Mass spectrometry analysis of 2654 proteins was used for screening in the Barcelona discovery cohort (n = 48). Targeted quantitative proteomics analyses (n = 51 proteins) were used in the independent CardShock cohort (n = 97) to derive and cross-validate the protein classifier. The combination of four circulating proteins (Cardiogenic Shock 4 proteins-CS4P), discriminated patients with low and high 90-day risk of mortality. CS4P comprises the abundances of liver-type fatty acid-binding protein, beta-2-microglobulin, fructose-bisphosphate aldolase B, and SerpinG1. Within the CardShock cohort used for internal validation, the C-statistic was 0.78 for the CardShock risk score, 0.83 for the CS4P model, and 0.84 (P = 0.033 vs. CardShock risk score) for the combination of CardShock risk score with the CS4P model. The CardShock risk score with the CS4P model showed a marked benefit in patient reclassification, with a net reclassification improvement (NRI) of 0.49 (P = 0.020) compared with CardShock risk score. Similar reclassification metrics were observed in the IABP-SHOCK II risk score combined with CS4P (NRI =0.57; P = 0.032). The CS4P patient classification power was confirmed by enzyme-linked immunosorbent assay (ELISA). A new protein-based CS patient classifier, the CS4P, was developed for short-term mortality risk stratification. CS4P improved predictive metrics in combination with contemporary risk scores, which may guide clinicians in selecting patients for advanced therapies.

Combined Use of High-Sensitive Cardiac Troponin, Copeptin, and the Modified HEART Score for Rapid Evaluation of Chest Pain Patients.

Background Clinical short-term risk stratification is a recommended approach in patients with chest pain and possible acute myocardial infarction (AMI) to further improve high safety of biomarker-based rule-out algorithms. The study aim was to assess clinical performance of baseline concentrations of high-sensitivity cardiac troponin T (hs-TnT) and copeptin and the modified HEART score (mHS) in early presenters to the emergency department with chest pain. Methods This cohort study included patients with chest pain with onset maximum of 6 h before admission and no persistent ST-segment elevation on electrocardiogram. hs-TnT, copeptin, and the mHS were assessed from admission data. The diagnostic and prognostic value for three baseline rule-out algorithms: (1) single hs-TnT < 14 ng/l, (2) hs-TnT < 14 ng/l/mHS ≤ 3, and (3) hs-TnT < 14 ng/l/mHS ≤ 3/copeptin < 17.4 pmol/l, was assessed with sensitivity and negative predictive value. Primary diagnostic endpoint was the diagnosis of AMI. Prognostic endpoint was death and/or AMI within 30 days. Results Among 154 enrolled patients, 44 (29%) were classified as low-risk according to the mHS; AMI was diagnosed in 105 patients (68%). For ruling out AMI, the highest sensitivity and NPV from all studied algorithms were observed for hs-TnT/mHS/copeptin (100%, 95% CI 96.6–100, and 100%, 95% CI 75.3–100). At 30 days, the highest event-free survival was achieved in patients stratified with hs-TnT/mHS/copeptin algorithm (100%) with 100% (95% CI 75.3–100) NPV and 100% (95% CI 96.6–100) sensitivity. Conclusions The combination of baseline hs-TnT, copeptin, and the mHS has an excellent sensitivity and NPV for short-term risk stratification. Such approach might improve the triage system in emergency departments and be a bridge for inclusion to serial blood sampling algorithms.

Accuracy of the Canadian new risk score as in hospital prognostic score for the Egyptian patients with acute coronary syndrome

ObjectivesPatients with acute coronary syndrome (ACS) need to be risk stratified to deliver the most appropriate therapy. There is no appropriate score for early-risk stratification at the time of the first medical contact with ACS patients. Canada Acute Coronary Syndrome Risk Score (Canadian-ACS) is a new risk score for early prognostication in acute coronary syndromes. The aim of our study is to evaluate the accuracy and validity of Canadian-ACS risk score as a prognostic score for in-hospital risk stratification of patients with ACS, as compared to TIMI AND GRACE risk scores in the Egyptian patients. MethodsOur study included 79 patients having acute coronary syndrome admitted to CCU. Calculations of The Canada Acute Coronary Syndrome Risk Score (Canadian-ACS) and ranged from 0 to 4, with 1 point assigned for the presence of: age ≥75 years, Killip class >1, systolic blood pressure <100mm Hg, and heart rate >100 beats/min. ResultsIn our study, there is a strong association between Canadian-ACS and TIMI risk score with sensitivity 85.7% and specificity 100.0% and Grace risk score with sensitivity 78.1%% and specificity 85.1%. The negative predictive value of a Canadian-ACS score ≥1 is ≥84.4% for short-term in hospital morbidity and mortality, and for score ≥2 at ≥98%. Conclusionthe Canadian-ACS is a valid accurate and simple prognostic risk score for short-term risk stratification in patients with ACS independent of hypertension, diabetes, smoking and troponin level.

The short-term and long-term prognostic risk stratification of patients with resectable gastric cancer.

23 Background: Some studies suggest anastomotic leakage (AL) may adversely affect long-term survival in patients undergoing radical gastrectomy (RG) for gastric cancer (GC). Therefore, we assume that common risk evaluation system for short-term and long-term prognosis can be devised in patients with GC that have undergone RG. Methods: Five hundred and twenty patients undergone RG against GC during May 2012 to March 2017 were enrolled. Patients’ characteristics, preoperative laboratory data, operative information and pathological factors were analyzed. Also AL with Clavien-Dindo classification Grade≥III (AL≥III), disease free survival (DFS) and disease specific survival (DSS) were examined. Results: By bringing patients under classification of “with or without relapse” and “with or without AL≥III”, we identified preoperative body weight (BW), serum C-reactive protein (CRP) and albumin (Alb) level were independent risk factors of both relapse and AL≥III. Stratifying patients with recurrence, we obtained crude hazard ratio (HR) of 1.04 (95% CI: 1.02-1.06) for 1kg-increase of BW, 1.51 (95% CI: 1.08-1.40) for 1mg/dl-increase of CRP and 1.23 (95% CI: 1.34-1.64) for 1g/dl-decrease of Alb. With these HR and median value of each parameters of none-relapse group, we defined ABC score (ABCs) is calculated by following formula; ABCs = (4.1-Alb)*51+(58.5-BW)*4+(CRP-0.05)*23. AL≥III were observed in 3.1% of the cases and ABCs of patients with AL≥III was significantly low (with AL≥III; -22.4, without AL≥III; 9.03, p = 0.045). We determine a cut off value of ABCs to -7 on the basis of the ROC curve. Patients with ABCs≤-7 had significantly high risk of AL≥III and we found ABCs≤-7 is an independent risk factor of AL≥III (HR 1.775, p = 0.003). Also, we stratified patients as Low group (L), Mid group (M), High group (H), by approximate tertile value of ABCs, -20 and 30. We found significant shortening of DFS and DSS in order of L, M and H (DFS; L vs M p = 0.006, Mid vs High p = 0.03, DSS; L vs M p = 0.002, L vs H p &lt; 0.001). Moreover, HR for disease specific death for ABCs≥-20 was 4.2 (p = 0.003) in multivariate analysis. Conclusions: ABCs can be a risk evaluation system for short-term and long-term prognosis in patients with GC that have undergone RG.

Pre-admission proteinuria impacts risk of non-recovery after dialysis-requiring acute kidney injury

Renal recovery after dialysis-requiring acute kidney injury (AKI-D) is an important clinical and patient-centered outcome. Here we examined whether the pre-admission proteinuria level independently influences risk for non-recovery after AKI-D in a community-based population. All adult members of Kaiser Permanente Northern California who experienced AKI-D between January 1, 2009 and September 30, 2015 were included. Pre-admission proteinuria levels were determined by dipstick up to four years before the AKI-D hospitalization and the outcome was renal recovery (survival and dialysis-independence four weeks and more) at 90 days after initiation of renal replacement therapy. We used multivariable logistic regression to adjust for baseline estimated glomerular filtration rate (eGFR), age, sex, ethnicity, short-term predicted risk of death, comorbidities, and medication use. Among 5,347 adults with AKI-D, the mean age was 66 years, 59% were men, and 50% were white. Compared with negative/trace proteinuria, the adjusted odds ratios for non-recovery (continued dialysis-dependence or death) were 1.47 (95% confidence interval 1.19-1.82) for 1+proteinuria and 1.92 (1.54-2.38) for 2+ or more proteinuria. Among survivors, the crude probability of recovery ranged from 83% for negative/trace proteinuria with baseline eGFR over 60 mL/min/1.73m2 to 25% for 2+ or more proteinuria with eGFR 15-29 mL/min/1.73m2. Thus, the pre-AKI-D level of proteinuria is a graded, independent risk factor for non-recovery and helps to improve short-term risk stratification for patients with AKI-D.

Short-Term Adverse Outcomes After Deep Brain Stimulation Treatment in Patients with Parkinson Disease

Despite ongoing progress in our understanding of long-term outcomes after neuromodulation procedures, acute adverse outcomes shortly after deep brain stimulation (DBS) treatment have remained remarkably limited. To identify risk factors associated with acute 30-day outcomes after DBS treatment in patients with Parkinson disease (PD). We evaluated patients who underwent DBS treatment for PD from 2005 to 2014 through the American College of Surgeons National Surgical Quality Improvement Program database. We used bivariate analysis and multivariate logistic regression to identify short-term postoperative outcomes, including 30-day complication, discharge destination, and unplanned readmission. Overall, 650 patients with PD underwent DBS procedures and complications were identified in 32 patients (4.9%). Of 481 patients who had complete discharge data, 18 patients (3.7%) were discharged to a facility and 16 patients (3.3%) experienced an unplanned readmission. Patients with PD who were obese (P= 0.045), who had preoperative anemia (P= 0.008), and who experienced longer operative durations (P= 0.01) had increased odds of postoperative complications. Inpatient status (P=0.001), dependent functional status (P < 0.001), and anemia (P= 0.043) were all associated with discharge to a facility other than home. Longer operative duration (P=0.013), anemia (P= 0.036), and dependent functional status (P = 0.03) were significantly associated with unplanned readmission. As expected, complications increased the likelihood of unplanned readmission (P < 0.001). This study provides individualized estimates of the risks associated with short-term adverse outcomes based on patient demographics and comorbidities. These data can be used as an adjunct for short-term risk stratification of patients with PD being considered for DBS treatment.