Strong Predictor Of Death Research Articles

Psychopathological Differences Between Self-Injurious Behaviors and Suicide Attempts in Adolescents.

Suicidal attempts and self-injurious behavior are major public health concerns, and they are strong predictors of death in youths worldwide. Given the risk of death, there is an urgent need to understand the differences and identify effective interventions. This study aimed to investigate the relationship between the predictors associated with non-suicidal self-injury and suicide attempts among adolescents. The study recruited a total of 61 adolescents aged 12-18 years, with suicide attempts (n=32) and non-suicidal self-injury (n=29). Turgay Disruptive Behavioral Disorders Screening and Rating Scale-Parent form, Rosenberg Self-esteem Scale, and Beck Anxiety and Beck Depression Inventory assessment scales were applied. All participants were interviewed with the structured clinical interview for Diagnostic and Statistical Manual of Mental Disorders, fourth edition. The adolescents with the suicide attempts were found to have lower self-esteem, higher depression, inattention and hyperactivity-impulsivity scores than the group with non-suicidal self-injury. Higher inattention scores and rural residency were positively and significantly associated with suicide attempts, adjusting for other discrimination types (odds ratio=1.250, 95% CI=1.024-1.526; odds ratio=4.656, 95% CI=1.157-18.735). This study shows that some clinical psychiatric factors may be helpful in distinguishing adolescents with suicide attempts from adolescents with non-suicidal self-injury. Future research is needed to determine the predictive role of these variables in distinguishing suicidal attempts from self-injurious behavior.

Frailty modifies the effect of polypharmacy and multimorbidity on the risk of death among nursing home residents: Results from the SHELTER study.

Frailty, disability, and polypharmacy are prevalent in nursing home (NH) residents, often co-occurring with multimorbidity. There may be a complex interplay among them in terms of outcomes such as mortality. Aims of the study were to (i) assess whether nursing home residents with polypharmacy (5-9 medications) or hyperpolypharmacy (≥10 drugs), have an increased risk of death and (ii) whether any association is modified by the co-presence of frailty or disability. Cohort study with longitudinal mortality data including 4,023 residents from 50 European and 7 Israeli NH facilities (mean age = 83.6 years, 73.2% female) in The Services and Health for Elderly in Long Term care (SHELTER) cohort study. Participants were evaluated with the interRAI-LongTerm Care assessment tool. Frailty was evaluated with the FRAIL-NH scale. Hazard ratio (HR) of death over 12 months was assessed with stratified Cox proportional hazards models adjusted for demographics, facilities, and cognitive status. 1,042 (25.9%) participants were not on polypharmacy, 49.8% (n = 2,002) were on polypharmacy, and 24.3% (n = 979) on hyperpolypharmacy. Frailty and disability mostly increased risk of death in the study population (frailty: HR = 1.85, 95%CI 1.49-2.28; disability: HR = 2.10, 95%CI 1.86-2.47). Among non-frail participants, multimorbidity (HR = 1.34, 95%CI = 1.01-1.82) and hyperpolypharmacy (HR = 1.61, 95%CI = 1.09-2.40) were associated with higher risk of death. Among frail participants, no other factors were associated with mortality. Polypharmacy and multimorbidity were not associated with mortality after stratification for disability. Frailty and disability are the strongest predictors of death in NH residents. Multimorbidity and hyperpolypharmacy increase mortality only in people without frailty. These findings may be relevant to identify patients who could benefit from tailored deprescription.

Distinct systemic immune networks define severe vs. mild COVID-19 in hematologic and solid cancer patients.

The COVID-19 pandemic, caused by the coronavirus SARS-CoV-2, has impacted health across all sectors of society. A cytokine-release syndrome, combined with an inefficient response of innate immune cells to directly combat the virus, characterizes the severe form of COVID-19. While immune factors involved in the development of severe COVID-19 in the general population are becoming clearer, identification of the immune mechanisms behind severe disease in oncologic patients remains uncertain. Here we evaluated the systemic immune response through the analysis of soluble blood immune factors and anti-SARS-CoV-2 antibodies within the early days of a positive SARS-CoV-2 diagnostic in oncologic patients. Individuals with hematologic malignancies that went on to die from COVID-19 displayed at diagnosis severe leukopenia, low antibody production against SARS-CoV-2 proteins, and elevated production of innate immune cell recruitment and activation factors. These patients also displayed correlation networks in which IL-2, IL-13, TNF-alpha, IFN-gamma, and FGF2 were the focal points. Hematologic cancer patients that showed highly networked and coordinated anti-SARS-CoV-2 antibody production, with central importance of IL-4, IL-5, IL-12A, IL-15, and IL-17A, presented only mild COVID-19. Conversely, solid tumor patients that had elevated levels of inflammatory cytokines IL-6, CXCL8, and lost the coordinate production of anti-virus antibodies developed severe COVID-19 and died. Patients that displayed positive correlation networks between anti-virus antibodies, and a regulatory axis involving IL-10 and inflammatory cytokines recovered from the disease. We also provided evidence that CXCL8 is a strong predictor of death for oncologic patients and could be an indicator of poor prognosis within days of the positive diagnostic of SARS-CoV-2 infection. Our findings defined distinct systemic immune profiles associated with COVID-19 clinical outcome of patients with cancer and COVID-19. These systemic immune networks shed light on potential immune mechanisms involved in disease outcome, as well as identify potential clinically useful biomarkers.

Risk factors predicting disease severity and mortality in coronavirus disease 2019 Saudi Arabian patients.

Coronavirus disease 2019 (COVID-19) became a global pandemic that may be associated with significant associated risk factors. The aim of this study was to evaluate the factors predisposing risk to death in COVID-19 patients. This is a retrospective study that presents the demographic, clinical presentation, and laboratory findings on our patients to determine risk factors contributing to their COVID-19 outcome. We used logistic regression (odds ratios) to examine associations between clinical findings and risk of death in COVID-19 patients. All analyses were done using STATA 15. A total of 206 COVID-19 patients were investigated, 28 of them died, and 178 survived. Expired patients were older (74.04 ± 14.45 vs. 55.56 ± 18.41 in those who survived) and mainly of male gender (75% vs. 42% in those who survived). The following factors were strong predictors of death: hypertension (OR: 5.48, 95% CI: 2.10-13.59, P < 0.001), cardiac disease (OR: 5.08, 95% CI: 1.88-13.74, P = 0.001), and hospital admission (OR: 39.75, 95% CI: 5.28-299.12, P < 0.001). In addition, blood group B was more frequent in expired patients (OR: 2.27, 95% CI: 0.78-5.95, P = 0.065). Our work adds to the current knowledge about the factors predisposing to death in COVID-19 patient. In our cohort, expired patients were of older age and male gender plus they were more likely to have hypertension, cardiac disease, and hospital severe disease. These factors might be used to evaluate risk of death in patients recently diagnosed of COVID-19.

Frailty is a stronger predictor of death in younger intensive care patients than in older patients: a prospective observational study

BackgroundWhile frailty is a known predictor of adverse outcomes in older patients, its effect in younger populations is unknown. This prospective observational study was conducted in a tertiary-level mixed ICU to assess the impact of frailty on long-term survival in intensive care patients of different ages.MethodsData on premorbid frailty (Clinical Frailty Score; CFS), severity of illness (the Simplified Acute Physiology Score, third version; SAPS3), limitations of care and outcome were collected in 817 adult ICU patients. Hazard ratios (HR) for death within 180 days after ICU admission were calculated. Unadjusted and adjusted analyses were used to evaluate the association of frailty with outcome in different age groups.ResultsPatients were classified into predefined age groups (18–49 years (n = 241), 50–64 (n = 188), 65–79 (n = 311) and 80 years or older (n = 77)). The proportion of frail (CFS ≥ 5) patients was 41% (n = 333) in the overall population and increased with each age strata (n = 46 (19%) vs. n = 67 (36%) vs. n = 174 (56%) vs. n = 46 (60%), P < 0.05). Frail patients had higher SAPS3, more treatment restrictions and higher ICU mortality. Frailty was associated with an increased risk of 180-day mortality in all age groups (HR 5.7 (95% CI 2.8–11.4), P < 0.05; 8.0 (4.0–16.2), P < 0.05; 4.1 (2.2–6.6), P < 0.05; 2.4 (1.1–5.0), P = 0.02). The effect remained significant after adjustment for SAPS3, comorbidity and limitations of treatment only in patients aged 50–64 (2.1 (1.1–3.1), P < 0.05).ConclusionsPremorbid frailty is common in ICU patients of all ages and was found in 55% of patients aged under 64 years. Frailty was independently associated with mortality only among middle-aged patients, where the risk of death was increased twofold. Our study supports the use of frailty assessment in identifying younger ICU patients at a higher risk of death.

The I4RON-HF study, intravenous iron isomaltoside for inpatients veRsus outpatient Asians with heart failure

Iron deficiency (ID) impacts ~50% of heart failure (HF) patients and is a risk factor and strong predictor for death and mortality with or without anaemia. Oral iron appears to be ineffective whilst intravenous iron (IV-iron) has proven to be efficacious however data is primarily from a Caucasian population despite ID being more prevalent amongst Asians. The I4RON-HF study assesses efficacy of high-dose IV-iron versus oral iron in stable outpatients and inpatients recovering from episodes of decompensated HF.

Age/BMI is a Stronger Predictor of Death in COVID-19 Patients than Age Alone: A Pilot Study

The objective of this study was to investigate the effect of age and BMI on the risk of death in patients with coronavirus disease 2019 (COVID-19). A cohort of 206 Saudi COVID-19 patients was included in this study. Data on age, BMI, hospitalization, comorbidities, and death were collected and analyzed. Descriptive, univariate, and multivariate logistic regression analyses were carried out. Out of the 206 studied patients, 28 died. Hypertension, cardiac disease, and hospital admission were predictors of death in univariate and multivariate logistic regression analysis. Moreover, age was a significant predictor of death, while increased BMI seemed to be protective at an older age. Therefore, a new score was suggested taking into consideration both factors, namely age/BMI score. Although older age was associated with death in univariate (OR, 1.09 [95% CI 1.05–1.12], p < 0.001) and multivariate analysis (OR, 1.05 [95% CI 1.02–1.09], p = 0.004), a higher age/BMI score was a stronger predictor of death than age alone, in both univariate (OR 4.42 [95% CI 2.50–7.80], p < 0.001) and multivariate analysis (OR 3.11 [95% CI 1.66–5.82], p < 0.001). Several factors appear to contribute to the risk of COVID-19 death. Interestingly, our new age/BMI score seems to carry a higher risk of death than age alone. This new score will be designated as the Hajeer score. Since this is a small cohort study, we recommend investigating this score in a larger cohort.

Abstract 15177: Speckle-Tracking Echocardiography Improves Risk Stratification in Patients With Chagas Cardiomyopathy

Introduction: Chagas cardiomyopathy is an important cause of death in endemic areas. Speckle-tracking echocardiography (STE)-derived strain is a sensitive tool for evaluating myocardial function which may be helpful to improve risk stratification of Chagas cardiomyopathy patients. This study evaluated whether STE has incremental value for prognosis over traditional clinical and echocardiographic parameters in patients with Chagas cardiomyopathy. Methods: Patients with Chagas disease who had evidence of heart failure were selected for the study. Clinical evaluation, electrocardiogram (ECG), and echocardiogram were performed at the time of enrollment. STE-derived global longitudinal strain (GLS) was analyzed offline. The outcome was all-cause mortality. Results: A total of 317 patients were enrolled, mean age was 66 ± 13 years and 184 (58%) were women. During a mean follow-up of 2.6 years, 114 patients died (36%) with overall mortality incidence rate of 14.0 deaths per 100 patient-years (95% CI 11.6-16.8). GLS was an important predictor of death (HR 0.90; 95% CI 0.86 to 0.95; P&lt;0.001), adding incremental prognostic value to standard echocardiographic parameters including right ventricular (RV) end-diastolic area, E/e’ ratio, left atrial (LA) volume, and left ventricular ejection fraction (LVEF). In overall population, the model including GLS had better accuracy in predicting mortality than the model including only conventional echocardiographic variables (P = 0.015). When the patients were stratified according to LVEF, GLS provided incremental prognostic information in patients with preserved (n=84; HR 0.80; 95% CI 0.64 to 0.98) or with mild to moderate reduced LVEF (n=166; HR 0.92; 95% CI 0.85 to 0.98), whereas in those who had severe LV dysfunction (n=67), GLS was no longer associated with mortality. Conclusions: In a cohort of patients with Chagas cardiomyopathy living in remote areas, GLS was a strong predictor of death, improving risk stratification beyond that provided by standard echocardiographic measurements, especially in patients with non-severe LV dysfunction. STE assessment may be used in a clinical setting to improve the risk prediction model for mortality in patients with Chagas cardiomyopathy.

Abstract 13739: Racial Disparities in Cardiac Arrest Deaths in the USA: 1999-2020

Introduction: Cardiac arrest(CA) is a strong predictor of death. Survival following CA depends on timely initiation of quality cardiopulmonary resuscitation and post CA care. Significant efforts have been made in the training of individuals at delivering CPR and improving post CA aimed at reducing mortality. To assess the impact, we set out to determine the trends in age adjusted mortality rates(AAMR, per 100,000 persons) and the average annual percentage change (AAPC, %) in the USA and by gender, race and Metro area from 1999 - 2020. Methods: Using the underlying causes of death (UCOD) database from the Centers for Disease Control and Prevention’s Wide-Ranging Online Data for Epidemiologic Research(1999-2020), we extracted all deaths with CA as UCOD using ICD-10 codes I46.0, I46.1, I46.9. AAMR was assessed using segmented regression models. STATA and Joinpoint softwares were used for analysis. Results: The CA related AAMR was 4.9 during the period 1999-2020. CA related deaths steadily declined from 7.7 in 1999 to 4.4 in 2020 with a statistically significant AAPC of -2.4%(95% CI -4.2 to -0.6). Ethnic specific AAMR were 8.7, 4.9, 2.8 and 3.4 for African Americans(AA), Whites, American Indian or Alaska Native and Asian or Pacific Islander, respectively. But for AA with an AAPC of -1.8%(CI -3.5 to 0.0), all other ethnic groups witnessed statistically significant decline in AAMR. AAMR were 5.3 and 5.5 for women and men, respectively. The AAPC were -2.7%(-4.5 to -0.8) and -2.5(-3.6 to -1.3) for women and men, respectively. The AAMR were 3.5, 5.6 and 8.1 for Large, Medium and Non-Metro areas, respectively, which all showed statistically significant decline. Conclusions: There has been a statistically significant decline in CA related AAMR in the USA from 1999-2020. Though AA harbor the highest AAMR, there has been no significant change in AAMR in the past two decades. Reasons for these racial disparities need to be investigated and addressed.

Abstract 13753: Higher Social Vulnerability Index is Associated With Increased Mortality Following Cardiac Arrest

Introduction: Cardiac arrest(CA) is a strong predictor of death. Survival following CA depends on timely initiation of quality cardiopulmonary resuscitation (CPR) and post CA care. The availability of competent individuals, resources and necessary services may be greatly influenced by the characteristics of the communities in which the indexed CA occurs. The Social Vulnerability Index(SVI) is a robust index which reliably ranks counties based on diverse parameters on a scale from 0 to 1. The higher the SVI, the more disadvantaged the community is. Hypothesis: We hypothesize that there is a positive correlation between CA related AAMR( expressed per 100,000 persons) and SVI in the USA. Methods: Using the multiple causes of death database from the Centers for Disease Control and Prevention’s Wide-Ranging Online Data for Epidemiologic Research(1999-2020), we extracted county level deaths with any mention of CA with ICD-10 codes I46.0, I46.1, I46.9. County level SVI was obtained from CDC/ATSDR. SVI was stratified into quintiles. We fitted segmented regression models to evaluate the association between quintiles of SVI scores and CA-related age-adjusted mortality rate (AAMR, expressed per 100,000 persons). Analysis was done using STATA v17 and Joinpoint segmented regression softwares with p-values &lt;0.05 considered statistically significant. Results: The CA related AAMR was 104.5 per 100,000 (95% CI 104.4 - 104.6) for the entire USA, decreasing from 132.9 (132.4 - 133.3) in 1999 to 104.5 (104.2 - 104.8) in 2020. We observed a monotonous increase in AAMR with increasing SVI as shown on figure 1 with an average quintile percentage change of 20.8% (95% CI 13.1 - 29.0) with a p-value of 0.003. Conclusions: Persons who suffer cardiac arrest in counties with higher SVI are more likely to die compared to those who suffer CA in counties with lower SVI. Further research is needed to identify and address the driving factors so as to reduce existing disparity. .

Abstract 13978: Biologic versus Imaging Markers Predicting Readmission and Death in Heart Failure With Preserved Ejection Fraction

Introduction: Increased B-type Natriuretic Peptide (NT-proBNP) levels have been associated with adverse outcomes in patients with heart failure with preserved ejection fraction (HFpEF). Global longitudinal strain (GLS) and wall stress (WS) are frequently reported to be abnormal in these patients as well, but studies examining how structural changes in those with HFpEF affect morbidity and mortality have been scarce. Hypothesis: NT-proBNP is a stronger predictor of death and heart failure readmissions in HFpEF patients when compared to GLS and WS. Methods: We conducted a retrospective study of 237 patients admitted with acute decompensated heart failure, all with EF &gt; 50. Average age was 78 + 11, 69% of patients were female, and average BMI was 29 + 13. GLS was measured using speckled tracing echocardiography and WS was calculated from systolic blood pressure, end-systolic left ventricular (LV) dimension, and end-systolic posterior wall thickness. Results: During a follow-up period of 2 years, 55 patients died and 55 were readmitted with the diagnosis of acute decompensated heart failure. Mean NT-proBNP among all patients was 9982 + 16268, mean GLS -17.84 + 4.52, and mean WS was 52.27 + 25.23. 129 patients had an abnormal or borderline GLS of &gt;-18, whereas nearly all patients (230) had an abnormal WS of &lt;109. (See table for results.) Conclusion: GLS and WS are reduced in a significant proportion of HFpEF patients. However, our data suggests that compared to echocardiographic indices of LV systolic function, biomarkers have a stronger short-term prognostic value.

The I4RON-HF study, Intravenous Iron Isomaltoside for Inpatients veRsus Outpatient Asians with Heart Failure

Abstract Background and purpose Iron deficiency (ID) impacts ∼50% of heart failure (HF) patients [1] and is a risk factor and strong predictor for death and mortality with or without anaemia [2]. Oral iron appears to be ineffective whilst intravenous iron (IV-iron) has proven to be efficacious however data is primarily from a Caucasian population [3] despite ID being more prevalent amongst Asians. The I4RON-HF study assesses efficacy of high-dose IV-iron versus oral iron in stable outpatients and inpatients amongst an Asian population recovering from episodes of decompensated HF. Methods This is a single-centre randomized controlled study, where patients who had symptomatic heart failure (Ejection Fraction &amp;lt;50% and New York Heart Association class 2–3) were randomized into two groups. The intervention arm received anywhere from 500mg to 1500mg of IV Iron Isomaltoside as a single infusion, whereas the control arm received routine iron supplements. The primary study endpoint was the percentage of patients achieving iron repletion at 4,8 and 12 months after enrolment. Secondary endpoints included clinical parameters (6-minute walk test, NYHA status and 2D-Echocardiogram), and biochemical parameters (Serum NTproBNP, Cardiac Troponin-T and hemogloblin) at 4,8 and 12 months. Results A total of 65 patients were enrolled (male 55%), 33 in the interventional arm and 32 in the control arm. There were no patients lost to follow up. 96.9% of patients in the IV Iron arm achieved the primary endpoint at 4 months, compared to 68.7% in the control group. These findings we consistent at 8 months (90.9% vs 65.6%) and 12 months (90.9% vs 56.2%). Looking at the secondary endpoints, the IV Iron cohort recorded a 11.14% increase in Hemogloblin levels versus the control arm which recorded a reduction of 16.23%. There was also lower NTproBNP levels in the IV iron group (81.6% reduction) versus the control group (66.3% reduction). Clinically, the patients who received IV iron had a 42.98% increase in their 6-minute walk test from baseline, compared to an increase of 8.61% in the control arm. There were no significant echocardiographic changes. Conclusion These findings in our single-centre study support the efficacy of IV iron over oral supplements in the treatment of iron deficiency amongst Asian heart failure patients. The secondary endpoints also indicate better clinical and biochemical outcomes when iron stores are successfully repleted. Lastly, this study demonstrates the feasibility and safety of outpatient administration of high-dose IV-iron. Results from large-scale clinical studies looking at hard endpoints (mortality, HF hospitalization) are expected to further advance understandings. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): National Heart Institute (Institut Jantung Negara) FoundationCompai Pharma

Renal dysfunction: a predictor of adverse outcomes in ACHD patients with acute decompensated heart failure

Abstract Background Renal dysfunction (RD) is a predictor of adverse outcomes in patients with acquired heart failure (HF). Studies in adult congenital heart disease (ACHD) have demonstrated the link between RD and increased mortality. However, there is a paucity of data regarding the prognostic significance of RD in ACHD and HF. We assessed the impact of RD on outcomes in ACHD patients presenting with acute decompensated HF requiring intravenous (IV) diuresis in a tertiary centre between 2010–2021. Methods This was a retrospective analysis on RD and outcomes during the index hospital admission and after discharge. Chronic kidney disease (CKD) was defined as an eGFR &amp;lt;60mL/min/1.73 m2 using the MDRD equation. Cox regression analysis was used to identify predictors of death after discharge. Results We included 176 HF admissions, 76 (43.2%) female, age 47.7±14.5 years. Complex CHD was present in 50.6%. The most frequent underlying congenital heart defects were: transposition of the great arteries (including congenitally corrected, 19.9%), univentricular (14.2%), and tetralogy of Fallot (13.6%). Eisenmenger syndrome was present in 18.8%, a systemic right ventricle in 22.2%, 40.9% had pulmonary arterial hypertension (PAH), and 38.1% were cyanotic. At the time of the index admission 92 (52.3%) had RD (eGFR &amp;lt;60 mL/min/1.73 m2 and/or serum creatinine &amp;gt;88 μmol/L), 63 (38.2%) had a history of CKD. Patients with RD on admission were older (49.8 [42.3–60.9] vs. 46.0 [33.8–53.6] years, p=0.02) and more likely to have a history of arrhythmia (71.7% vs. 53.6%, p=0.02), but did not differ to those without RD in terms of diabetes mellitus or systemic hypertension. Admission BNP was higher in patients with RD (594 [258–1216] vs. 354 [158–633] ng/L, p=0.01). Patients with RD were more likely to have at least moderate systemic (31.8% vs. 11.8%, p=0.005) or pulmonary (58.4% vs. 36.4%, p=0.01) ventricular dysfunction. They were also more likely to have systemic ventricular dilatation (28.6% vs. 11.8%, p=0.02) or a larger RA area (29 [21–34] vs. 21 [16–31] cm2, p=0.008). Inpatients with RD required higher doses of IV furosemide (160 [80–200] vs. 80 [70–160] mg, p=0.03) and there was a trend for more frequent inotropic support (19.6% vs. 8.3%, p=0.06). In-hospital mortality was relatively low (4.5%), however, 94 (56.0%) patients died and 73 (43.5%) were rehospitalised for HF at a median follow-up of 2.8 [0.01–12.0] years. CKD (HR 2.43, 95% CI: 1.59–3.71, p&amp;lt;0.0001) and RD on admission (HR 1.7, 95% CI: 1.13–2.58, p=0.01) were strong predictors of death (Figure 1). On multivariable Cox analysis, PAH, CKD, and peak inpatient diuretic dose remained predictive of mortality. Conclusions ACHD patients admitted with acute decompensated HF are a high-risk cohort for acute re-admission and mortality. Preexisting RD and need for high dose IV diuretics conveys an even worse prognosis. Earlier interventions based on evidence of RD in ACHD may modulate this spiral trajectory and warrants further investigation. Funding Acknowledgement Type of funding sources: None.

Bleeding after percutaneous coronary intervention and selection of candidates for long-term dual antithrombotic treatment

Abstract Background The European Society of Cardiology recommends addition of a second antithrombotic drug (a P2Y12 inhibitor or rivaroxaban 2.5 mg twice daily) on top of aspirin in selected patients with chronic coronary syndrome (CCS) at high residual risk of ischemic events. However, this treatment increases bleeding risk, and identifying subsets of patients with the most favorable trade-off between ischemic and bleeding risk thus is essential. We hypothesized that patients undergoing percutaneous coronary intervention (PCI) who tolerate subsequent dual antiplatelet therapy (aspirin plus a P2Y12 inhibitor) without any bleeding complications selected themselves as candidates for prolonged dual antithrombotic therapy. Methods and results We included 30,531 patients with CCS treated with dual antiplatelet therapy after first-time PCI with a drug-eluting stent in Western Denmark (3.5 million inhabitants) from 1999 to 2018. Of these, 1,220 (4%) were hospitalized for bleeding within one year after PCI (bleeders) and 29,311 (96%) were not (non-bleeders). Patients were followed for maximum nine years (median follow-up 5.4 years). Bleeders had an increased nine-year risk of death (adjusted hazard ratio [aHR] 1.54, 95% CI 1.37–1.73) and hospitalization for bleeding (aHR 2.53, 95% CI 2.20–2.90). These associations were particularly strong for women. Looking at types of bleeding, the strongest predictors of death were gastrointestinal bleeding, cerebral bleeding, and anemia due to bleeding. Risks of myocardial infarction and ischemic stroke did not differ between bleeders and non-bleeders (Table). We then stratified non-bleeders according to their thromboembolic risk using the CHADS-P2A2RC score – a validated clinical risk prediction model developed to estimate thromboembolic risk in patients without atrial fibrillation. Non-bleeders with a high estimated thromboembolic risk (CHADS-P2A2RC score ≥4) had higher nine-year risks of myocardial infarction (hazard ratio [HR] 1.88, 95% CI 1.78–2.07), ischemic stroke (HR 3.02, 95% CI 2.66–3.43), hospitalization for bleeding (HR 1.98, 95% CI 1.81–2.16) and, in particular, death (HR 4.48, 95% CI 4.21–4.77) than non-bleeders with a low-to-moderate predicted risk (CHADS-P2A2RC score &amp;lt;4). Conclusions Patients with CCS experiencing a bleeding event during the first year after first-time PCI had a substantially higher long-term risk of death and recurrent bleeding, but not a higher risk of ischemic events. Therefore, bleeding events during the first year after PCI may guide the preclusion of selected patients from long-term dual antithrombotic therapy. Among non-bleeders, the risk of ischemic events rose proportionately more than the risk of bleeding when comparing high-risk with low-risk patients. This is an important finding for clinicians, for whom accurate identification of patients at highest risk of ischemic events is an essential step in treatment allocation. Funding Acknowledgement Type of funding sources: None.

247.7: Trends and Risk Factors for Mortality While Awaiting Heart Transplantation: A UNOS Registry Analysis

Background: Orthotopic heart transplantation (OHT) remains the gold standard treatment of end-stage heart failure. In order to address organ scarcity, allocation systems aim to decrease waitlist mortality while maintaining acceptable post-transplant outcomes. The purpose of this study was to examine the characteristics of patients who suffered mortality on the waitlist versus those who underwent transplantation, as well as the impact of recent changes in the United States heart allocation policies on these outcomes. Methods: The United Network for Organ Sharing database was queried, and adult, isolated OHT candidates listed for transplant within the United States from 11/5/2015 to 9/30/2021 were analyzed. Baseline characteristics among candidates that either were transplanted, or had been removed from the waitlist due to death clinical deterioration were compared. Comparisons were also made between heart allocation policy (pre or post-10/18/2018) time eras. Multivariable competing risk regression was conducted to identify risk-adjusted predictors of transplantation from the waitlist. Additionally, predictors of the outcome of death or de-listing from the waitlist due to clinical decline were also modeled. Results: During the study period, a total of 13,575 recipients were transplanted (6,926 under the old policy and 6,649 under the new). A total of 1,875 candidates died or were de-listed (1,235 listed under the old policy and 640 listed under the new). In a comparison of baseline characteristics at time of listing, candidates that were transplanted differed significantly to those who were de-listed due to death or clinical decline with respect to age, heart failure etiology, mechanical circulatory support bridging, and baseline comorbidity (Table). In a multivariable model, waitlisting under the new allocation policy was associated with reduced hazards for death or de-listing (HR 0.57, 95% CI 0.51-0.63; P<0.001), and increased hazards for undergoing transplantation (HR 1.36; 95% CI 1.31-1.41; P<0.001). The two largest predictors of transplantation were bridging with an intra-aortic balloon pump (HR 2.13, 95% CI 1.97-2.31; P<0.001) and AB blood type (HR 1.43, 95% CI 1.30-1.57; P<0.001). The strongest predictors of death or de-listing were diagnosis of hypertrophic cardiomyopathy (HR 3.77, 95% CI 2.69-5.29; P<0.001) or biventricular hemodynamic support in the form of either extracorporeal membrane oxygenation (HR 2.59, 95% CI 1.96-3.42; P<0.001), total artificial heart (HR 2.36, 95% CI 1.28-4.35; P=0.006), or combined right and left ventricular assist device support (HR 2.45, 95% CI 1.71-3.50; P<0.001). Conclusions: Since the United States 2018 heart allocation policy change, waitlisted candidates are more likely to be transplanted and less likely be de-listed due to death or clinical decline. Need for biventricular mechanical circulatory support at time of waitlisting are associated with higher risk of death or falling too ill for transplantation.

The "Diabetes Comorbidome": A Different Way for Health Professionals to Approach the Comorbidity Burden of Diabetes.

(1) Background: The disease burden related to diabetes is increasing greatly, particularly in older subjects. A more comprehensive approach towards the assessment and management of diabetes’ comorbidities is necessary. The aim of this study was to implement our previous data identifying and representing the prevalence of the comorbidities, their association with mortality, and the strength of their relationship in hospitalized elderly patients with diabetes, developing, at the same time, a new graphic representation model of the comorbidome called “Diabetes Comorbidome”. (2) Methods: Data were collected from the RePoSi register. Comorbidities, socio-demographic data, severity and comorbidity indexes (Cumulative Illness rating Scale CIRS-SI and CIRS-CI), and functional status (Barthel Index), were recorded. Mortality rates were assessed in hospital and 3 and 12 months after discharge. (3) Results: Of the 4714 hospitalized elderly patients, 1378 had diabetes. The comorbidities distribution showed that arterial hypertension (57.1%), ischemic heart disease (31.4%), chronic renal failure (28.8%), atrial fibrillation (25.6%), and COPD (22.7%), were the more frequent in subjects with diabetes. The graphic comorbidome showed that the strongest predictors of death at in hospital and at the 3-month follow-up were dementia and cancer. At the 1-year follow-up, cancer was the first comorbidity independently associated with mortality. (4) Conclusions: The “Diabetes Comorbidome” represents the perfect instrument for determining the prevalence of comorbidities and the strength of their relationship with risk of death, as well as the need for an effective treatment for improving clinical outcomes.

The risk profile of patients with COVID-19 as predictors of lung lesions severity and mortality-Development and validation of a prediction model.

ObjectiveWe developed and validated a prediction model based on individuals' risk profiles to predict the severity of lung involvement and death in patients hospitalized with coronavirus disease 2019 (COVID-19) infection.MethodsIn this retrospective study, we studied hospitalized COVID-19 patients with data on chest CT scans performed during hospital stay (February 2020-April 2021) in a training dataset (TD) (n = 2,251) and an external validation dataset (eVD) (n = 993). We used the most relevant demographical, clinical, and laboratory variables (n = 25) as potential predictors of COVID-19-related outcomes. The primary and secondary endpoints were the severity of lung involvement quantified as mild (≤25%), moderate (26–50%), severe (>50%), and in-hospital death, respectively. We applied random forest (RF) classifier, a machine learning technique, and multivariable logistic regression analysis to study our objectives.ResultsIn the TD and the eVD, respectively, the mean [standard deviation (SD)] age was 57.9 (18.0) and 52.4 (17.6) years; patients with severe lung involvement [n (%):185 (8.2) and 116 (11.7)] were significantly older [mean (SD) age: 64.2 (16.9), and 56.2 (18.9)] than the other two groups (mild and moderate). The mortality rate was higher in patients with severe (64.9 and 38.8%) compared to moderate (5.5 and 12.4%) and mild (2.3 and 7.1%) lung involvement. The RF analysis showed age, C reactive protein (CRP) levels, and duration of hospitalizations as the three most important predictors of lung involvement severity at the time of the first CT examination. Multivariable logistic regression analysis showed a significant strong association between the extent of the severity of lung involvement (continuous variable) and death; adjusted odds ratio (OR): 9.3; 95% CI: 7.1–12.1 in the TD and 2.6 (1.8–3.5) in the eVD.ConclusionIn hospitalized patients with COVID-19, the severity of lung involvement is a strong predictor of death. Age, CRP levels, and duration of hospitalizations are the most important predictors of severe lung involvement. A simple prediction model based on available clinical and imaging data provides a validated tool that predicts the severity of lung involvement and death probability among hospitalized patients with COVID-19.

EARLY MORNING HEMODYNAMIC CHANGES AND LEFT VENTRICULAR HYPERTROPHY AND MORTALITY IN HEMODIALYSIS PATIENTS

Objective: An exaggeration of the early morning increase in BP, a phenomenon accompanied by a parallel rise in heart rate (HR), is a marker of high cardiovascular risk. The early morning changes in these parameters have not been investigated in the hemodialysis population. Design and method: In a pilot, single center, study including a series of 58 patients we measured the pre-awakening BP and HR surges and the nocturnal dipping of the same parameters as well as other established indicators of autonomic function (weighted 24 h systolic BP and HR variability) and tested their relationship with the left ventricular mass index (LVMI) and with the risk of death over a median follow up of 40 months. Results: The pre-awakening HR surge (r = -0.46, P = 0.001) but not the corresponding BP surge (r = -0.1, P = 0.98) associated with LVMI and the risk of death [HR (1 unit): 0.89, 95% CI: 0.83–0.96, P = 0.001]. The link between the pre-awakening HR surge with these outcome measures was robust and largely independent of established risk factors in the hemodialysis population including the systolic BP dipping. Weighted 24 h systolic BP (SD) and HR (SD) variability did not correlate with LVMI (all P&gt; 0.11) nor with the risk of death (P &gt; 0.11). Overall, among markers of early morning hemodynamic changes and of hemodynamic variability, the pre-awakening HR surge was the strongest correlate of LVMI and a the strongest predictor of death. Conclusions: This pilot study suggests that low early morning changes in HR, a biomarker reflecting sympathetic activity, entail a high risk for LVH and mortality in the hemodialysis population.

Superinfections caused by carbapenem-resistant Enterobacterales in hospitalized patients with COVID-19: a multicentre observational study from Italy (CREVID Study).

ObjectivesTo describe clinical characteristics and outcomes of COVID-19 patients who developed secondary infections due to carbapenem-resistant Enterobacterales (CRE).MethodsRetrospective observational study including COVID-19 patients admitted to 12 Italian hospitals from March to December 2020 who developed a superinfection by CRE. Superinfection was defined as the occurrence of documented bacterial infection >48 h from admission. Patients with polymicrobial infections were excluded. Demographic, clinical characteristics and outcome were collected. Isolates were classified as KPC, metallo-β-lactamase (MBL) and OXA-48-producing CRE. A Cox regression analysis was performed to identify factors independently associated with 30 day mortality.ResultsOverall, 123 patients (median age 66 years, IQR 59–75) were included. The majority of infections occurred in the ICU (81, 65.9%), while 42 (34.1%) in medical wards. The most common types of infection were bloodstream infections (BSI) (n = 64, 52%), followed by urinary-tract infections (UTI) (n = 28, 22.8%), hospital-acquired/ventilator-associated pneumonia (HAP/VAP) (n = 28, 22.8%), intra-abdominal infections (n = 2, 1.6%) and skin infections (n = 1, 0.8%). Sixty-three (51.2%) infections were caused by KPC-, 54 (43.9%) by MBL-, and 6 (4.8%) by OXA-48-producing CRE. Thirty-day mortality was 33.3% (41/123). On Cox regression analysis, HAP/VAP compared with UTI (HR 7.23, 95% CI 2.09–24.97, P = 0.004), BSI compared with UTI (HR 3.96, 95% CI, 1.33–11.77, P = 0.004), lymphopenia on admission (HR 3, 95% CI 1.44–6.26, P = 0.003) and age (HR 1.05, 95% CI 1.02–1.08, P = 0.002) were predictors of 30 day mortality.ConclusionsSuperinfections by CRE were associated with high risk of 30 day mortality in patients with COVID-19. HAP/VAP was the strongest predictor of death in these patients.

Phenotyping CLAD after single lung transplant: Limits and prognostic assessment of the 2019 ISHLT classification system.

Phenotyping chronic lung allograft dysfunction (CLAD) in single lung transplant (SLTX) is challenging, due to the native lung contribution to pulmonary function test (PFT). We aimed to assess the applicability and prognostic performance of International Society for Heart and Lung Transplantation (ISHLT) classification in SLTX. In this retrospective study of adult, first, SLTX performed 2009-2017, patients with persistent drop in FEV1≥20% were assessed by 2 independent adjudicators to determine CLAD status and phenotype. Interobserver agreement (IOA) was calculated (Cohen's Kappa) for CLAD, phenotype and presence of RAS (resttrictive allograft syndrome)-like opacities (RLO). Association of CLAD phenotypes with time to death or retransplant (ReTx), adjusted for age at SLTX, sex, CMV mismatch and native lung condition, were assessed using Cox proportional hazards models. Of 172 SLTX recipients, 92 experienced a persistent drop in FEV1>20%. Following adjudication, 67 were diagnosed with CLAD. We noted a moderate IOA for CLAD diagnosis (Kappa 0.69) and poor IOA for phenotype adjudication (Kappa 0.52). The final phenotype adjudication was 31 bronchiolitis obliterans syndrome (BOS) (46.3%), 13 RAS (19.4%), 2 mixed (3%), 2 Undefined (3%), and 19 remained Unclassified (28.3%). Using these adjudicated phenotypes, RAS was significantly associated with a higher risk of death/ReTx compared to other groups (HR 2.98, 95%CI [1.39-6.4]). The adjudication of RLO had the best IOA (Kappa 0.73). The presence of RLO was a strong predictor of death or ReTx (HR 2.37, 95%CI [1.2-4.5]), regardless of the final phenotype. PFT interpretation is challenging in SLTX. A classification essentially relying on imaging, which harbored good IOA, obtained better prognostic performance than a classification using published physiological cut-offs.