Six-month All-cause Mortality Research Articles

6 Prognostic value of the glasgow admission prediction score: hospital length of stay, mortality and hospital readmission

IntroductionAs patient numbers presenting to emergency departments (ED) increase, with their myriad of comorbidities, early hospital admission prediction and demand modelling are crucial both in the ED and beyond. The...

Abstract 12215: Objective Stratification of Six-Month Mortality Risk among Patients Referred to Hospice

Introduction: The Intermountain Mortality Risk Scores (IMRS) are a suite of sex-specific mortality risk stratification tools created from the complete blood count (CBC), basic metabolic profile (BMP), and age. Patients referred to hospice should have probable 6-month mortality, but this is currently estimated based on clinical gestalt. Hypothesis: Use of an objective clinical decision tool like IMRS may improve estimation of 6-month mortality risk for evaluation of patient referral to hospice. Methods: Subjects were Intermountain Healthcare patients who were referred to hospice (females: n=1,753, males: n=1,522) from 2009-2014. Baseline CBC and BMP laboratory data from the time of initial referral to hospice were used to compute the previously-derived IMRS scores. Cox regression and Kaplan-Meier survival curves were used for statistical analyses to evaluate six-month all-cause mortality risk. Results: Females averaged 77.2±14.2 years of age, and males were 74.4±14.6 years. Six-month survival was 37% in females and 33% in males; stratified into IMRS deciles, survival was 44.9% in decile 1 and 27.8% in decile 10 for females, while in males survival was 39.5% and 25.2%, respectively. Females had hazard ratio (HR)=1.72 (95% CI=1.34, 2.18; p<0.001) for decile 10 vs. 1, and males had HR=1.57 (95% CI=1.18, 2.09; p=0.002). Stratified by previously-established IMRS thresholds (Figure), 12%, 38%, and 50% of females were grouped into low-, intermediate-, and high-risk groups, respectively, and 10%, 31%, 59% of males were in those groups. Conclusions: About one third of hospice patients did not die within 6 months, suggesting that additional objective evidence is needed to guide referral. IMRS, an evidence-based clinical decision tool derived in a large healthcare population, significantly stratified mortality risk in hospice patients. An electronically-deliverable stratification tool, IMRS may be useful in evaluation of patient risk prior to hospice referral.

An Admission-to-Discharge BNP Increase Is a Predictor of Six-Month All-Cause Death in ADHF Patients: Inferences from Multivariate Analysis Including Admission BNP and Various Clinical Measures of Congestion.

Background: According to some authors, a single isolated measurement of serum B-type natriuretic peptide (BNP) executed on hospital admission would not be a sufficiently accurate method to predict the outcome of patients with acute decompensated heart failure (ADHF). Aims: To verify this assumption, a retrospective study was conducted on patients hospitalized for ADHF. Our main objective was to ascertain whether there was any difference in midterm mortality among patients with increasing BNP at discharge as compared with those with decreasing BNP at discharge. Methods: Medical records were examined so as to make a partition of the ADHF patient population into two groups, the former characterized by a rise in BNP during hospitalization, and the latter exhibiting a decrease in BNP in the measurement taken at hospital discharge. Results: 177 patients were enrolled in a retrospective study. Among them, 53 patients (30%) had increased BNP at the time of discharge, whereas 124 (70%) showed decreases in serum BNP during their hospital stay. The group with patients who exhibited BNP increases at the time of discharge had a higher degree of congestion evident in the higher frequency of persistent jugular venous distention and persistent orthopnea at discharge. Moreover, patients with increased BNP at the time of discharge had a lower reduction in inferior vena cava maximum diameter (1.58 ± 2.2 mm vs. 6.32 ± 1.82 mm; p (one-way ANOVA) = 0.001). In contrast, there was no significant difference in weight loss when patients with increased BNP at discharge were compared with those with no such increase. A total of 14 patients (7.9%) died during the six-month follow-up period. Multivariable Cox proportional-hazards regression analysis revealed that a BNP increase at the time of discharge was an independent predictor of six-month all-cause mortality after adjustment for persistent jugular venous distention, persistent orthopnea, reduction in inferior vena cava maximum diameter at discharge, weight loss, serum urea, systolic blood pressure at admission, and BNP at admission (hazard ratio = 30.5424; 95% CI: 1.7409–535.8294, p = 0.0199). Conclusions: Among patients with a history of ADHF, more elevated BNP levels at the time of discharge from the hospital compared with those detected at admission identify a patient subset with a higher grade of congestion and higher six-month mortality.

Targeting N-Terminal Pro-Brain Natriuretic Peptide in Older Versus Younger Acute Decompensated Heart Failure Patients

ObjectivesThe aim of this study was to analyze the prognostic value and attainability of N-terminal pro-brain natriuretic peptide (NT-proBNP) levels in young and elderly acute decompensated heart failure (ADHF) patients. BackgroundLess-effective NT-proBNP-guided therapy in chronic heart failure (HF) has been reported in elderly patients. Whether this can be attributed to differences in prognostic value of NT-proBNP or to differences in attaining a prognostic value is unclear. The authors studied this question in ADHF patients. MethodsOur study population comprised 7 ADHF cohorts. We defined absolute (<1,500 ng/l, <3,000 ng/l, <5,000 ng/l, and <15,000 ng/l) and relative NT-proBNP discharge cut-off levels (>30%, >50%, and >70%). Six-month all-cause mortality after discharge was studied for each level in Cox regression analyses, and compared between elderly (age >75 years) and young patients (age ≤75 years). Thereafter, we compared percentages of elderly and young patients attaining NT-proBNP levels (= attainability). ResultsA total of 1,235 patients (59% male, 45% >75 years of age) was studied. Admission levels of NT-proBNP were significantly higher in elderly versus younger patients. The prognostic value of absolute and relative NT-proBNP levels was similar in elderly and young patients. Attainability was significantly lower in elderly patients for all absolute levels and a >50% relative reduction, but not for >30% and >70%. For absolute levels, attainability differences between age groups were decreased to a large extent after correction for admission NT-proBNP and anemia at discharge. For relative levels, attainability differences disappeared after correction for HF etiology and anemia at discharge. ConclusionsIn young and elderly ADHF patients, it is not the prognostic value of absolute and relative NT-proBNP levels that is different, but the attainability of these levels that is lower in the elderly. This can largely be attributed to factors other than age.

Bronchial artery embolization for malignant hemoptysis: a single institutional experience.

To assess the effectiveness of bronchial artery embolization (BAE) in patients with malignant hemoptysis. An IRB-approved retrospective study at our academic institution was conducted on all patients treated by BAE for hemoptysis from lung malignancy. Outcome and safety measures were documented according to Society of Interventional Radiology (SIR) practice guidelines. A total of 26 patients (13 male, 13 female) with lung malignancy underwent BAE for hemoptysis from 2003-2013. Histologic analysis revealed 80% (21/26) of cases were from primary lung malignancies, while the remaining 20% (4/26) represented metastatic disease. Sixty-five percent (17/26) of patients underwent bronchoscopy prior to BAE. Follow-up ranged from 2 to 1,909 days, with average of 155 days. Technical success was achieved in 77% of patients (20/26). Clinical success rate was 75% (15/20). Eighty-five percent of embolized patients (17/20) were treated with particles, 15% (3/20) with gelfoam, and 20% (4/20) with coils. Single-vessel embolization was performed in 70% (14/20), two-vessel in 20% (4/20), and multiple vessels in 10% (2/20). No complications were reported. Six-month all-cause mortality of treated cases was 55% (11/20) with an in-hospital mortality of 25% (5/20). Ten percent (2/20) had remote re-bleeding events beyond 6 months. Statistically significant predictors of mortality were intubation status, hemoglobin/hematocrit at presentation, and thrombocytopenia. BAE is a safe and useful treatment for clinically significant hemoptysis in patients with primary or metastatic lung masses despite high overall mortality. Intubation status, low hemoglobin/hematocrit, and thrombocytopenia may represent clinical predictors of short term mortality following BAE. Most patients undergoing BAE for malignant hemoptysis achieve high clinical success despite suffering a high mortality from underlying disease.

High brain natriuretic pepdite level as an independent risk factor for acute kidney injury and predictor of increased six-month all-cause mortality in patients undergoing primary angioplasty for STEMI

Objectives: The aim of the present study was to evaluate the predictive effect of brain natriuretic pepdite (BNP) for prevalance of acute kidney injury (AKI) development and six-month all-cause mortality after primary percutan coronary intervention (PCI) for ST elevation myocardial infarction (STEMI) in a modest population. Background: The prognostic value of BNP has been well documented in patients with acute coronary syndrome. However, its value in development of AKI and six-month all-cause mortality in patients with STEMI undergoing primary PCI remains unclear. Methods: We prospectively enrolled 424 consecutive STEMI patients (mean age 53.6±12.1 years) undergoing primary PCI. The study population was divided into tertiles based on admission BNP values. The high BNP group (n=141) was defined as a value in the third tertile (>56.6 pg/ mL), and the low BNP group (n=283) included those patients with a value in the lower two tertiles (≤ 56.6 pg/ mL). Clinical characteristics and in-hospital and six-month outcomes of primary PCI were analyzed. Results: In Cox multivariate analysis; a high admission BNP value (>56.6 pg/ mL) was found to be a powerful independent predictor of AKI devolopment (odds ratio: 1.002, 95% confidence interval: 1.000- 1.003, p= 0.02) and six-month all-cause mortality (odds ratio: 9.1, 95% confidence interval: 1.85-43.9, p=0.006). Conclusions: These results suggest that a high admission BNP level was associated with increased prevalance of AKI devolopment and six-month all-cause mortality in patients with STEMI undergoing primary PCI.

Prognostic value of elevated mean platelet volume in patients undergoing primary angioplasty for ST-elevation myocardial infarction

Objective The aim of this study was to evaluate the prognostic value of mean platelet volume (MPV) in patients with STEMI undergoing primary percutaneous coronary intervention (PCI).Methods We prospectively enrolled 495 consecutive STEMI patients. The study population was divided into tertiles based on admission MPV values. The high MPV group (n = 148) was defi ned as a value in the third tertile (> 8.9), and the low MPV group (n = 347) included those patients with a value in the lower two tertiles (≤ 8.9). Clinical characteristics, in-hospital and six-month outcomes of primary PCI were analysed.Results Higher six-month all-cause mortality rates were observed in the high MPV group In Cox multivariate analysis; a high admission MPV value (> 8.9) was found to be a powerful independent predictor of six-month all-cause mortality.Conclusions These results suggest that a high admission MPV level was associated with increased six-month all-cause mortality in patients with STEMI undergoing primary PCI.

Abstract 91: Temporal Trends in Patient Characteristics and Outcomes Among Medicare Beneficiaries Undergoing Primary Prevention Implantable Cardioverter-Defibrillator Placement in the United States: 2006-2010 Results from the NCDR ®

Background: Trends in the use and outcomes of ICDs in community practice settings are not well characterized. Our objective was to determine the temporal trends in characteristics and outcomes among patients undergoing primary prevention ICD therapy. Methods: We identified Medicare beneficiaries aged 65 years and older with an ejection fraction &lt;35% undergoing ICD implantation for primary prevention between 2006 and 2010 in the NCDR ICD Registry™. Using a probabilistic method, eligible subjects were matched to Medicare claims data to capture outcomes using age, gender, admission date or procedure date, and hospital Medicare provider number. We tested the significance of trends in characteristics over time with χ2 tests for categorical variables and ANOVA for continuous variables. Standardized outcome rates were calculated adjusting for demographics and characteristics. Results: A total of 117,100 patients were included in the analysis. Between 2006 and 2010, small but significant increases were observed in the prevalence of hypertension, diabetes, and NYHA Class III symptoms, and decreases in the prevalence of ischemic heart disease and NYHA Class IV symptoms (Table 1). There was minimal change in age, gender, and race of patients receiving ICDs over the study period; fewer single lead and more biventricular devices were used over time. Risk-standardized six-month re-hospitalization and complication rates decreased and risk-standardized six-month all-cause mortality was stable over the study period (Table 1). Conclusions: Modest changes in patient characteristics undergoing primary prevention ICD implantation were observed between 2006 and 2010. There have simultaneously been significant improvements in outcomes after accounting for these patient trends, suggesting the possibility that there have been improvements in care of this patient population.

Adjustment of the GRACE score by growth differentiation factor 15 enables a more accurate appreciation of risk in non-ST-elevation acute coronary syndrome

The aim of the study was to evaluate whether knowledge of the circulating concentration of growth differentiation factor 15 (GDF-15) adds predictive information to the Global Registry of Acute Coronary Events (GRACE) score, a validated scoring system for risk assessment in non-ST-elevation acute coronary syndrome (NSTE-ACS). We also evaluated whether GDF-15 adds predictive information to a model containing the GRACE score and N-terminal pro-B-type natriuretic peptide (NT-proBNP), a prognostic biomarker already in clinical use. The GRACE score, GDF-15, and NT-proBNP levels were determined on admission in 1122 contemporary patients with NSTE-ACS. Six-month all-cause mortality or non-fatal myocardial infarction (MI) was the primary endpoint of the study. To obtain GDF-15- and NT-proBNP-adjusted 6-month estimated probabilities of death or non-fatal MI, statistical algorithms were developed in a derivation cohort (n = 754; n = 66 reached the primary endpoint) and applied to a validation cohort (n = 368; n = 33). Adjustment of the GRACE risk estimate by GDF-15 increased the area under the receiver-operating characteristic curve (AUC) from 0.79 to 0.85 (P < 0.001) in the validation cohort. Discrimination improvement was confirmed by an integrated discrimination improvement (IDI) of 0.055 (P = 0.005). A net 31% of the patients without events were reclassified into lower risk, and a net 27% of the patients with events were reclassified into higher risk, resulting in a total continuous net reclassification improvement [NRI(>0)] of 0.58 (P = 0.002). Addition of NT-proBNP to the GRACE score led to a similar improvement in discrimination and reclassification. Addition of GDF-15 to a model containing GRACE and NT-proBNP led to a further improvement in model performance [increase in AUC from 0.84 for GRACE plus NT-proBNP to 0.86 for GRACE plus NT-proBNP plus GDF-15, P = 0.010; IDI = 0.024, P = 0.063; NRI(>0) = 0.42, P = 0.022]. We show that a single measurement of GDF-15 on admission markedly enhances the predictive value of the GRACE score and provides moderate incremental information to a model including the GRACE score and NT-proBNP. Our study is the first to provide simple algorithms that can be used by the practicing clinician to more precisely estimate risk in individual patients based on the GRACE score and a single biomarker measurement on admission. The rigorous statistical approach taken in the present study may serve as a blueprint for future studies exploring the added value of biomarkers beyond clinical risk scores.

Presentation and Outcome of Tuberculous Meningitis in a High HIV Prevalence Setting

Background Mycobacterium tuberculosis is a common, devastating cause of meningitis in HIV-infected persons. Due to international rollout programs, access to antiretroviral therapy (ART) is increasing globally. Starting patients with HIV-associated tuberculous meningitis (TBM) on ART during tuberculosis (TB) treatment may increase survival in these patients. We undertook this study to describe causes of meningitis at a secondary-level hospital in a high HIV/TB co-infection setting and to determine predictors of mortality in patients with TBM.MethodsA retrospective review of cerebrospinal fluid findings and clinical records over a six-month period (March 2009–August 2009). Definite, probable and possible TBM were diagnosed according to published case definitions.ResultsTBM was diagnosed in 120/211 patients (57%) with meningitis. In 106 HIV-infected patients with TBM, six-month all-cause mortality was lower in those who received antiretroviral therapy (ART) during TB treatment; hazard ratio = 0.30 (95% CI = 0.08–0.82). Factors associated with inpatient mortality in HIV-infected patients were 1) low CD4+ count at presentation; adjusted odds ratio (AOR) = 1.4 (95% confidence interval [CI] = 1.03–1.96) per 50 cells/µL drop in CD4+ count and, 2) higher British Medical Research Council TBM disease grade (2 or 3 versus 1); AOR = 4.8 (95% CI = 1.45–15.87).InterpretationStarting ART prior to or during TB treatment may be associated with lower mortality in patients with HIV-associated TBM. Advanced HIV and worse stage of TBM disease predict in-hospital mortality in patients presenting with TBM.

Clinical significance of cardiac troponins I and T in acute heart failure

Elevated cardiac troponin (cTn) levels are relatively common in acute heart failure (AHF). To evaluate the prevalence and prognostic significance of elevated cTnI and cTnT in AHF. FINN-AKVA is a prospective, multicenter study in AHF. In this analysis, 364 non-ACS patients with measurements of cTnI and cTnT taken on admission and 48 h thereafter were analyzed. Of the 364 AHF patients, 51.1% had cTnI and 29.7% cTnT levels above the cut-off value. Six-month all-cause mortality was 18.7%. Both cTnI (OR 2.0, 95% CI 1.2-3.5, p=0.01) and cTnT (OR 2.6, 95% CI 1.5-4.4, p=0.0006) were associated with adverse outcome. The mortality risk was proportional to the magnitude of cTn release. On multivariable analysis, Cystatin C (OR 6.3, 95% CI 3.2-13, p<0.0001), logNT-proBNP (OR 1.4, 95% CI 1.0-1.8, p=0.03) and systolic blood pressure on admission (/10 mm Hg increase, OR 0.9, 95% CI 0.8-0.9, p=0.0004) were independent risk markers, whereas the troponins were not significantly associated with increased mortality. cTn elevations are frequent in AHF patients without ACS. cTnI is more often elevated than cTnT. Both cTnI and cTnT elevations are associated with increased mortality proportional to the degree elevation but they do not act as independent risk markers.