Strong Predictor Of All-cause Mortality Research Articles

Heart rate response and recovery in cycle exercise testing - normal values and association with mortality.

Chronotropic incompetence and impaired heart rate (HR) recovery are related to mortality. Guidelines lack specific reference values for HR recovery. We defined normal values and studied blunted HR response and recovery, and mortality risk. We included 9,917 subjects (45% females) aged 18-85 years who performed a cycle exercise test. We defined normal values for peak HR, HR reserve, and HR recovery at 1 and 2 minutes (HRR1 and HRR2) based on individuals apparently healthy (N=2,242). Associations between blunted HR indices (<5th percentile) and mortality over a median follow-up of 8.6 years were analysed using Cox regression and competing risk analysis. All HR indices were age-dependent and independent predictors of all-cause and CV mortality. The 5th percentiles of HR reserve, HRR1, and HRR2 correlated weakly with existing reference values. HR recovery variables were the strongest predictors of all-cause mortality (HRR1, hazard ratio 1.70 [95% confidence interval, 1.49-1.94] and HRR2, 1.57 [1.37-1.79]), including in subjects with normal exercise capacity (HRR1, 1.96 [1.61-2.39] and HRR2, 1.76 [1.46-2.12]). Combining HR indices appeared to increase the risk of all-cause (HRR1 and HRR2, 1.96 [1.68-2.29] and peak HR and HRR1, 1.87 [1.56-2.23]) and CV mortality, although no specific combination was superior for predicting CV mortality. All HR variables were age-dependent and associated with all-cause and CV mortality. Blunted HR recovery variables were the strongest predictors of all-cause mortality, even in subjects with normal exercise capacity. Combined blunted HR indices appeared to add prognostic value.

Differential prevalence and prognostic value of metabolic syndrome components among patients with MASLD

Background and AimsMetabolic-dysfunction associated steatotic liver disease (MASLD) is becoming increasingly prevalent in the general population. This study aims to describe the cardiometabolic burden of the MASLD population and to identify those at the highest risk of all-cause mortality and liver fibrosis. MethodsWe analyzed individuals with MASLD enrolled in the National Health and Nutrition Survey (NHANES) III (N=3,628) and NHANES 2017-2020 (N=2,618). MASLD was defined as hepatic steatosis (by ultrasonography or controlled attenuation parameter), together with cardiometabolic dysfunction. Primary endpoints were all-cause mortality and liver fibrosis (liver stiffness measurement ≥8kPa). Regression models were adjusted for age, sex, race, marital status, education, and smoking, and results were stratified by age groups (20-40, 40-60, 60-80). ResultsAmong the total MASLD population (median age = 48 [P25-P75: 36–62] years, 44.8% males), 65% had ≥3 cardiometabolic disorders. The most frequent were obesity (89.1%), (pre-)diabetes (66.6%), and low-HDL (54.7%). During a median follow-up of 22.3 [P25-P75: 16.9 – 24.2] years, 1,405 deaths occurred. Hypertension (aHR 1.42, 95%CI 1.26-1.61), (pre-)diabetes (aHR 1.28, 95%CI 1.09-1.49), and hypertriglyceridemia (aHR 1.19, 95% CI 1.05-1.34) were the strongest predictors of all-cause mortality. Consistent results were obtained regarding the association between cardiometabolic disorders and fibrosis. Here, increased waist circumference (aOR 3.45, 95% CI 1.44-8.25), (pre-)diabetes (aOR 1.90, 95% CI 1.44-2.25), and hypertension (aHR 1.84, 95% CI 1.40-2.43) showed the strongest associations. ConclusionsMASLD patients vary greatly in their cardiometabolic burden and consequently, in their prognosis. Our results highlight MASLD as a disease spectrum rather than as a single disease entity, necessitating an individualized treatment approach.

Coronary Artery Disease Is A Stronger Predictor of All-Cause Mortality Than Left Ventricular Ejection Fraction Among Patients With Newly Diagnosed Heart Failure: Insights From the WDHR.

In patients with newly diagnosed heart failure (HF) and left ventricular ejection fraction (LVEF) <50%, little is known whether LVEF per se or presence of coronary artery disease (CAD) provides independent prognostic information on all-cause mortality. Using the WDHR (Western Denmark Heart Registry), we identified 3620 patients with newly diagnosed HF and LVEF 10% to 49% referred for first-time coronary angiography as part of general workup of HF. Patients were stratified by LVEF (10%-35% versus 36%-49%) and presence of CAD. We estimated 10-year all-cause mortality risk and calculated hazard ratios adjusted for relevant comorbidities and risk factors (aHRs). CAD was present in 1592 (44%) patients. Lower LVEF was associated with a relative 15% increased 10-year mortality: 37% for LVEF 36% to 49% versus 42% for LVEF 10% to 35% (aHR, 1.15 [95% CI, 0.99-1.34]). This result did not change when stratified into those with CAD (52% versus 56%; aHR, 1.11 [95% CI, 0.91-1.35]) and those without CAD (27% versus 33%; aHR, 1.24 [95% CI, 0.97-1.57]). In comparison, presence and extent of CAD were associated with a relative 43% increased 10-year mortality (CAD versus no CAD, 55.0% versus 31.5%; aHR, 1.43 [95% CI, 1.25-1.64]). Compared with a matched general population, excess mortality risk was higher for patients with HF and CAD (54.7% versus 26.3%; aHR, 2.10 [95% CI, 1.85-2.39]) versus those with HF and no CAD (31.4% versus 17.2%; aHR, 1.76 [95% CI, 1.52-2.02]). Among newly diagnosed patients with HF and LVEF <50%, presence and extent of CAD are associated with substantial higher all-cause mortality risk than lower LVEF.

NHANES 2011-2014: Objective Physical Activity Is the Strongest Predictor of All-Cause Mortality.

Objectively measured physical activity (PA) is a modifiable risk factor for mortality. Understanding the predictive performance of PA is essential to establish potential targets for early intervention to reduce mortality among older adults. The study used a subset of the National Health and Nutrition Examination Survey (NHANES) 2011-2014 data consisting of participants 50 to 80 yr old ( n = 3653, 24297.5 person-years of follow-up, 416 deaths). Eight accelerometry-derived features and 14 traditional predictors of all-cause mortality were compared and ranked in terms of their individual and combined predictive performance using the 10-fold cross-validated concordance (C) from Cox regression. The top 3 predictors of mortality in univariate analysis were PA related: average Monitor-Independent Movement Summary (MIMS) in the 10 most active hours (C = 0.697), total MIMS per day (C = 0.686), and average log-transformed MIMS in the most 10 active hours of the day (C = 0.684), outperforming age (C = 0.676) and other traditional predictors of mortality. In multivariate regression, adding objectively measured PA to the top performing model without PA variables increased concordance from C = 0.776 to C = 0.790 ( P < 0.001). These findings highlight the importance of PA as a risk marker of mortality and are consistent with prior studies, confirming the importance of accelerometer-derived activity measures beyond total volume.

#1458 Adverse muscle composition predicts all-cause mortality in CKD

Abstract Background and Aims Sarcopenia is common in CKD and associates with morbidity and mortality. A rapid and standardized MRI (Magnetic Resonance Imaging) scan protocol allows an accurate muscle composition analysis by quantification of skeletal muscle volume and muscle fat infiltration (MFI). The combined observation of low muscle volume and high muscle fat infiltration, i.e. adverse muscle composition (AMC), is a prevalent muscle composition phenotype within CKD and associates to poor function, high prevalence of comorbidity, and an increased risk for coronary heart disease (CHD). It has also been shown that AMC is an independent predictor of all-cause mortality in patients with non-alcoholic fatty liver disease and in general population. In this study we aimed to investigate muscle composition as predictor of all-cause mortality within participants with CKD in the UK Biobank imaging study (UKB). Method This is a prospective study including UKB participants with CKD defined as having an eGFR cystatin C &amp;lt; 60 ml/min/1, 73 m2. A control group was created by matching each participant with CKD for sex, age, and BMI to four participants with normal eGFR. Cystatin C was analyzed based on blood samples at time of study enrolment 7-9 years prior to the MRI. Fat-tissue free thigh muscle volume and MFI were quantified using a rapid neck-to-knee water and fat separated MRI protocol and automated image analysis (AMRA® Researcher). For each participant, a personalized muscle volume z-score (sex- and body size-specific) was calculated and combined with MFI to divide the participants into four muscle composition phenotype groups; 1) normal muscle composition, 2) only low muscle volume, 3) only high MFI and 4) AMC, using previously published thresholds based on the whole UKB cohort. The thresholds were the 25th percentile (&amp;lt; -0.68 SD) for muscle volume z-score and the 75th percentile (men &amp;gt;7.69%; women &amp;gt;8.82%) for MFI. The mortality data were obtained through the UKB´s linkage to national death registries. All-cause mortality was investigated using Kaplan-Meier curves and Cox regression. Models within participants with CKD were crude and subsequently adjusted for sex, age, BMI, low hand grip strength (&amp;lt;16/27 kg for females/males), physical activity, smoking, alcohol, and previous diagnosis of cancer, prevalent CHD and type 2 diabetes, all assessed at the time of imaging. Results Conclusion AMC, determined by standardized MRI, was a strong predictor of all-cause mortality in CKD. The study results indicate that CKD patients with poor muscle health, identified as having both low muscle volume z-score and high MFI, have a significantly higher mortality risk. This vulnerable group would potentially benefit from targeted interventions and is also of specific interest when evaluating new treatments for CKD.

Circulating 3-hydroxy butyrate predicts mortality in patients with chronic heart failure with reduced ejection fraction.

In patients with chronic heart failure with reduced ejection fraction (HFrEF), myocardial ketone metabolism is increased and short-term treatment with the ketone body 3-hydroxy butyrate (3-OHB) has beneficial haemodynamic effects. In patients with HFrEF, we investigated whether the level of circulating 3-OHB predicted all-cause mortality and sought to identify correlations between patient characteristics and circulating 3-OHB levels. We conducted a cohort study in 218 patients with HFrEF. Plasma 3-OHB levels were measured using high-performance liquid chromatography tandem mass spectrometry. Data on all-cause mortality were obtained by reviewing the patients' medical records, which are linked to the national 'Central Person Registry' that registers the timing of all deaths in the country. Mean left ventricular ejection fraction was 35±8.6%, mean age was 67±10years, 54% were New York Heart Association II, and 27% had type 2 diabetes mellitus. Median follow-up time was 7.3 (interquartile range 6.3-8.4) years. We observed large variations in 3-OHB levels between patients (median 59μM, range: 14-694μM). Patients with 3-OHB levels above the median displayed a markedly increased risk of death compared with those with low levels {hazard ratio [HR]: 2.1 [95% confidence interval (CI): 1.3-3.5], P=0.003}. In a multivariate analysis, 3-OHB predicted mortality independently of known chronic heart failure risk factors [HR: 1.004 (95% CI: 1.001-1.007), P=0.02] and with a similar statistical strength as N-terminal pro-brain natriuretic peptide (NT-proBNP) [HR: 1.0005 (95% CI: 1.000-1.001), P=0.02]. For every 100μmol increase in plasma 3-OHB, the hazard of death increased by 49%. The following factors significantly predicted 3-OHB levels in the univariate analysis: free fatty acids (FFAs) [β: 238 (95% CI: 185-292), P<0.0001], age [β: 2.43 (95% CI: 1.14-3.72), P<0.0001], plasma insulin {β: -0.28 [95% CI: -0.54-(-0.02)], P=0.036}, body mass index {β: -3.15 [95% CI: -5.26-(-0.05)], P=0.046}, diabetes [β: 44.49 (95% CI: 14.84-74.14), P=0.003], glycosylated haemoglobin [β: 1.92 (95% CI: 0.24-3.59), P=0.025], New York Heart Association class [β: 26.86 (95% CI: 5.99-47.72), P=0.012], and NT-proBNP [β: 0.03 (95% CI: 0.01-0.04), P=0.001]. In a multivariate analysis, only FFAs predicted 3-OHB levels [β: 216 (95% CI: 165-268), P>0.001]. In patients with HFrEF, circulating 3-OHB was a strong predictor of all-cause mortality independently of NT-proBNP. Circulating FFAs were the best predictor of 3-OHB levels.

The Relationship of Fetuin-A with Coronary Calcification, Carotid Atherosclerosis, and Mortality Risk in Non-Dialysis Chronic Kidney Disease.

This study investigated the relationship of fetuin-A with coronary calcification, carotid atherosclerosis, and mortality risk in non-dialysis chronic kidney disease (CKD). The study included 135 adult patients with CKD at stages 3-5, who were divided into coronary artery calcification (CAC) and non-CAC groups. We excluded current smokers and individuals with diabetes mellitus, inflammatory conditions, liver diseases, acute kidney failure, chronic hemodialysis, and cancer. We conducted kidney function tests, complete blood counts, and measured serum levels of fetuin-A, tumor necrosis factor-alpha (TNF-α), high-sensitivity C-reactive protein (hs-CRP), interleukin-6 (IL-6), total cholesterol (TC), total triglycerides (TG), high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol. Cardiac spiral computed tomography was used to calculate the CAC score, employing the Agatston method. Carotid ultrasonography was performed to assess carotid intima-media thickness (CIMT) and to detect the presence of plaques. CAC patients had considerably higher levels of TNF-α (p<0.001), IL-6 (p<0.001), hs-CRP (p=0.006), TC, TG, parathyroid hormone (PTH) (p<0.001) and phosphorus (p<0.001) than non-CAC patients. They also had significantly lower levels of fetuin-A (p<0.001). Fetuin-A was considerably lower in CKD subgroups as CKD progressed. Fetuin-A (p=0.046), age (p=0.009), TNF-α (p=0.027), IL-6 (p=0.005), TG (p=0.002), PTH (p=0.002), and phosphorus (p=0.004) were significant predictors of CAC. CAC and fetuin-A were strong predictors of all-cause mortality and cardiovascular (CV) mortality. Fetuin-A was a significant predictor of CIMT (p=0.045). Fetuin-A reliably predicted CAC and CIMT. Fetuin-A and CAC emerged as significant risk factors for all-cause and CV mortality in non-dialysis CKD.

Periodic Repolarization Dynamics (PRD) identifies patients who profit from ICD implantation, A meta-analysis of the predictive value of PRD

Abstract Background Periodic repolarization dynamics (PRD) is an electrocardiographic marker that quantifies sympathetic-activity associated instabilities of cardiac repolarization. PRD is a strong predictor of mortality in patients with ischemic (ICM) and non-ischemic cardiomyopathy (NICM) and has been proposed to identify patients who benefit from prophylactic ICD implantation. Purpose To conduct a systematic review and meta-analysis concerning the prognostic value of PRD for predicting all-cause mortality in relation to prophylactic ICD-implantation. Methods This meta-analysis follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. A total of 25 articles were screened and 7 randomized and non-randomized controlled trials identified. Finally, a total of 5 could be included in the analysis (Fig.1). Patients were stratified into patients with or without prophylactic ICD-implantation (Fig.2). The prognostic value of PRD for predicting all-cause mortality was extracted from published data as hazard ratio (HR) per 1 deg2 increase in PRD. We used inverse-variance-weighted average meta-analysis to calculate fixed and random effect models to estimate the overall predictive value of PRD in both groups. The interaction between PRD and prophylactic ICD-implantation for predicting mortality was calculated using meta-regression analysis. All analyses were performed using CRAN R v. 4.1.2 and the meta-package v 5.2.0. Results We included 4,338 patients in this meta-analysis, of whom 3,167 (73%) suffered from ICM and 1,171 (27%) from NICM. 1,906 (44%) patients were treated with an ICD. During an estimated mean follow-up time of 3.2 years, 604 (14%) patients died. Fig. 2 (left) shows patients without ICD treatment (N = 2,432, 56%). In these patients, a 1 deg2 increase in PRD was significantly associated with an overall 8% increase in mortality (fixed effect HR 1.08; 95% CI 1.06-1.10; p&amp;lt; 0.001, random effect HR 1.08; 95% CI 1.06-1.11; p &amp;lt; 0.001). Fig. 2 (right) displays the prognostic value of PRD in patients treated by ICD (N = 1,906). In these patients, a 1 deg2 increase in PRD was significantly associated with an overall 3% increase in mortality (fixed-effect HR 1.03; 95% CI 1.01-1.05; p&amp;lt; 0.001, random-effect HR 1.03; 95% CI 1.00-1.06; p &amp;lt; 0.001). An increase in PRD was not significantly associated with an increase in mortality in patients from the EU-CERT-ICD and DANISH trial. There was a significant interaction between PRD and prophylactic ICD-implantation for predicting all-cause mortality (p = 0.008). Conclusion In patients with ICM and NICM, PRD is a strong predictor of all-cause mortality in patients with and without prophylactic ICD. The significant interaction between PRD and prophylactic ICD-implantation most probably implies a reduction in the risk identified by PRD through ICD implantation. Consequently, PRD could prove a useful tool for identifying patients that might benefit from ICD treatment.Figure 1Figure 2

Troponin elevation as a marker of short deterioration and one-year death in a high-risk surgical patient cohort in a low and middle income country setting: a postoperative approach to increase surveillance.

Myocardial injury after noncardiac surgery is common and mostly asymptomatic. The ideal target population that will benefit from routine troponin measurements in low and middle income countries (LMICs) is unclear. This study aims to evaluate the clinical outcomes of a cohort of high-risk surgical patients according to high-sensitivity troponin T (hsTnT) in an LMIC setting. We conducted a prospective cohort study of 442 high-risk patients undergoing noncardiac surgery at a Brazilian hospital between February 2019 and March 2020. High-sensitivity troponin T levels were measured preoperatively, 24hr, and 48hr after surgery and stratified into three groups: normal (< 20ng·L-1); minor elevation (20-65ng·L-1); and major elevation (> 65ng·L-1). We performed survival analysis to determine the association between myocardial injury and one-year mortality. We described medical interventions and evaluated unplanned intensive care unit (ICU) admission and complications using multivariable models. Postoperative myocardial injury occurred in 45% of patients. Overall, 30-day mortality was 8%. Thirty-day and one-year mortality were higher in patients with hsTnT ≥ 20ng·L-1. One-year mortality was 18% in the unaltered troponin group vs 31% and 41% for minor and major elevation groups, respectively. Multivariable analysis of one-year survival showed a hazard ratio (HR) of 1.94 (95% confidence interval [CI], 1.22 to 3.09) for the minor elevation group and a HR of 2.73 (95% CI, 1.67 to 4.45) for the troponin > 65ng·L-1 group. Patients with altered troponin had more unplanned ICU admissions (13% vs 5%) and more complications (78% vs 48%). This study supports evidence that hsTnT is an important prognostic marker and a strong predictor of all-cause mortality after surgery. Troponin measurement in high-risk surgical patients could potentially be used as tool to scale-up care in LMIC settings. ClinicalTrials.gov (NCT04187664); first submitted 5 December 2019.

Long-term impact of SARS-CoV-2 infection on cardiorespiratory fitness: a meta-analysis.

Despite surviving Coronavirus disease 2019 (COVID-19), its long-term impact is of concern. Low cardiorespiratory fitness is a strong predictor of all-cause mortality, and likely affected by multisystem impairments following COVID-19 infection. Accumulating evidence has identified the impact of COVID-19 on cardiorespiratory fitness level. However, the findings have been controversial. Conclusive evidence is still needed. This review aimed to systematically summarize and synthesize whether the SARS-CoV-2 infection diminishes cardiorespiratory fitness in COVID-19 survivors. The study design was a systematic review and meta-analysis. A search was carried out using PubMed, CINAHL, Scopus, Embase and the Cochrane Library, together with reference lists (searching from their inception to January 2023). Observational studies investigating the impact of COVID-19 on outcomes relevant to cardiorespiratory fitness (i.e., peak oxygen uptake) were included. Weighted mean difference (WMD) and 95% confidence interval (CI) were used to identify a pooled effect estimate. Use of a random effects model was considered as the main method. Grading of Recommendation Assessment, Development and Evaluation approach was employed to determine the certainty of evidence. This meta-analysis was registered with PROSPERO (registration number: CRD42023393108). Seven eligible studies (4 cross-sectional, 2 cohort, and 1 case-control studies) involving 4,773 participants were included in this meta-analysis. A pooled effect estimates showed that patients in the surviving COVID-19 group had a significant reduction in peak oxygen uptake when compared to their counterparts in the non-COVID-19 group (WMD -6.70, 95%CI -9.34 to -4.06, low certainty). A subgroup analysis by age found that COVID-19 survivors in the young- to middle-aged and middle- to older-aged subgroups had significant reductions in peak oxygen uptake when compared to their counterparts in the non-COVID-19 group (WMD -5.31, 95%CI -7.69 to -2.94, low certainty; WMD -15.63, 95%CI -28.50 to -2.75, very low certainty, respectively). Subgroup analyses by symptom found that patients with moderate to severe symptoms in the surviving COVID-19 group had significantly lower peak oxygen uptake than their counterparts in the non-COVID-19 group (WMD -15.63, 95%CI -28.50 to -2.75, very low certainty). The current meta-analysis concluded that patients in the COVID-19 survivors had poorer cardiorespiratory fitness than their counterparts in the non-COVID-19 group, but there is considerable uncertainty of evidence. Poorer cardiorespiratory fitness is likely to be more pronounced in COVID-19 survivors who are getting older and had severe symptoms, but it is uncertain whether such finding has a valuable in clinical context. https://www.crd.york.ac.uk/PROSPERO/, CRD42023393108.

Sleep regularity is a stronger predictor of mortality risk than sleep duration: A prospective cohort study.

Abnormally short and long sleep are associated with premature mortality, and achieving optimal sleep duration has been the focus of sleep health guidelines. Emerging research demonstrates that sleep regularity, the day-to-day consistency of sleep-wake timing, can be a stronger predictor for some health outcomes than sleep duration. The role of sleep regularity in mortality, however, has not been investigated in a large cohort with objective data. We therefore aimed to compare how sleep regularity and duration predicted risk for all-cause and cause-specific mortality. We calculated Sleep Regularity Index (SRI) scores from > 10 million hours of accelerometer data in 60 977 UK Biobank participants (62.8 ± 7.8 years, 55.0% female, median[IQR] SRI: 81.0[73.8-86.3]). Mortality was reported up to 7.8 years after accelerometer recording in 1859 participants (4.84 deaths per 1000 person-years, mean (±SD) follow-up of 6.30 ± 0.83 years). Higher sleep regularity was associated with a 20%-48% lower risk of all-cause mortality (p < .001 to p = 0.004), a 16%-39% lower risk of cancer mortality (p < 0.001 to p = 0.017), and a 22%-57% lower risk of cardiometabolic mortality (p < 0.001 to p = 0.048), across the top four SRI quintiles compared to the least regular quintile. Results were adjusted for age, sex, ethnicity, and sociodemographic, lifestyle, and health factors. Sleep regularity was a stronger predictor of all-cause mortality than sleep duration, by comparing equivalent mortality models, and by comparing nested SRI-mortality models with and without sleep duration (p = 0.14-0.20). These findings indicate that sleep regularity is an important predictor of mortality risk and is a stronger predictor than sleep duration. Sleep regularity may be a simple, effective target for improving general health and survival.

Cardiac Computed Tomography Angiography in CAD Risk Stratification and Revascularization Planning.

Functional stress testing is frequently used to assess for coronary artery disease (CAD) in symptomatic, stable patients with low to intermediate pretest probability. However, patients with highly vulnerable plaque may have preserved luminal patency and, consequently, a falsely negative stress test. Cardiac computed tomography angiography (CCTA) has emerged at the forefront of primary prevention screening and has excellent agency in ruling out obstructive CAD with high negative predictive value while simultaneously characterizing nonobstructive plaque for high-risk features, which invariably alters risk-stratification and pre-procedural decision making. We review the literature detailing the utility of CCTA in its ability to risk-stratify patients with CAD based on calcium scoring as well as high-risk phenotypic features and to qualify the functional significance of stenotic lesions. Calcium scores ≥ 100 should prompt consideration of statin and aspirin therapy. Spotty calcifications < 3 mm, increased non-calcified plaque > 4 mm3 per mm of the vessel wall, low attenuation < 30 HU soft plaque and necrotic core with a rim of higher attenuation < 130 HU, and a positive remodeling index ratio > 1.1 all confer additive risk for acute plaque rupture when present. Elevations in the perivascular fat attenuation index > -70.1 HU are a strong predictor of all-cause mortality and can further the risk stratification of patients in the setting of a non-to-minimal plaque burden. Lastly, a CT-derived fractional flow reserve (FFRCT) < 0.75 or values from 0.76 to 0.80 in conjunction with additional risk factors is suggestive of flow-limiting disease that would benefit from invasive testing. The wealth of information available through CCTA can allow clinicians to risk-stratify patients at elevated risk for an acute ischemic event and engage in advanced revascularization planning.

Conocimiento de la enfermedad venosa crónica en los profesionales sanitarios en España

IntroductionChronic venous disease (CVD) is classified as the most prevalent vascular disease in humans. It has been associated with an increased incidence of cardiovascular diseases and is a strong predictor of all-cause mortality, representing a public health problem of the first magnitude. The objective of this study was to analyze the actions in the management of CVD in the daily clinical practice of health professionals in Spain. Material and methodsObservational, descriptive and cross-sectional study with data collection through an opinion survey of 22 questions completed electronically through a Google® form for professionals involved in chronic venous disease care. Three hundred surveys were analyzed. The quantitative variables were represented with means and standard deviation and the qualitative ones with percentages and confidence intervals. ResultsThree hundred surveys analyzed. 65.3% were women. The most participatory age group was over 55 years of age. 85% of those surveyed considered that CVD is an underdiagnosed and undertreated disease, with an added negative impact in terms of follow-up during the Covid-19 pandemic, since 91.7% considered that it had not been adequate. 47% of the participants did not know the CEAP classification and 56.3% did not know the venous clinical severity scale (VCSS). 92.7% of physicians prescribed compression stockings and 74.7% phlebotonic drugs. Hidrosmine was the best known and most prescribed venoactive drug (51.7%). 73% of the doctors recognized that they did not use any algorithm or protocol for the diagnosis, treatment and monitoring of CVD in their usual clinical practice and 91% stated that they were not trained in their workplaces. 54.3% of the physicians believed that one of the main limitations that made follow-up of the disease difficult was the lack of coordination with the vascular surgeons. ConclusionsUpdating and responding to the training needs of professionals regarding CVD is essential to guarantee quality care continuity in the care of our patients.

Heart rate variability: reference values and role for clinical profile and mortality in individuals with heart failure

AimsTo establish reference values and clinically relevant determinants for measures of heart rate variability (HRV) and to assess their relevance for clinical outcome prediction in individuals with heart failure.MethodsData from the MyoVasc study (NCT04064450; N = 3289), a prospective cohort on chronic heart failure with a highly standardized, 5 h examination, and Holter ECG recording were investigated. HRV markers were selected using a systematic literature screen and a data-driven approach. Reference values were determined from a healthy subsample. Clinical determinants of HRV were investigated via multivariable linear regression analyses, while their relationship with mortality was investigated by multivariable Cox regression analyses.ResultsHolter ECG recordings were available for analysis in 1001 study participants (mean age 64.5 ± 10.5 years; female sex 35.4%). While the most frequently reported HRV markers in literature were from time and frequency domains, the data-driven approach revealed predominantly non-linear HRV measures. Age, sex, dyslipidemia, family history of myocardial infarction or stroke, peripheral artery disease, and heart failure were strongly related to HRV in multivariable models. In a follow-up period of 6.5 years, acceleration capacity [HRperSD 1.53 (95% CI 1.21/1.93), p = 0.0004], deceleration capacity [HRperSD: 0.70 (95% CI 0.55/0.88), p = 0.002], and time lag [HRperSD 1.22 (95% CI 1.03/1.44), p = 0.018] were the strongest predictors of all-cause mortality in individuals with heart failure independently of cardiovascular risk factors, comorbidities, and medication.ConclusionHRV markers are associated with the cardiovascular clinical profile and are strong and independent predictors of survival in heart failure. This underscores clinical relevance and interventional potential for individuals with heart failure.ClinicalTrials.gov identifierNCT04064450.

Neutrophil reactive oxygen formation, bacterial infections and mortality in malnourished hemodialysis patients: Evaluation of clinical outcomes.

Patients with end stage kidney disease undergoing maintenance hemodialysis (MHD) are prone to malnutrition and infections. The objective of this study was to evaluate the effect of polymorphonuclear (PMN) cell dysfunction on clinical outcomes of MHD patients, in association with nutritional status. This prospective study investigated 39 MHD patients by evaluating the oxidative activity of their PMN cells using Phorbol 12-Myristate-13-Acetate (PMA) stimulation. Blood samples were taken from each participant at dialysis initiation. Demographics, laboratory data, and clinical outcomes during a 24-month follow-up period were obtained from electronic medical records. Phagocytic activity was described in percentiles of mean fluorescence intensity (MFI) of PMA levels. There were no differences in comorbidities between patients with low or high MFI-PMA percentiles. Patients in the lowest (25th) MFI-PMA percentile (N = 10) had poorer nutritional status and more frequent severe infections compared to the other 29 patients (4.3 ± 3.4 events versus 2 ± 2.2 events, p = 0.017). Furthermore, they had more frequent hospitalizations (>3) due to infections (70% versus 41%, p = 0.073) and their mortality rate was higher (80% versus 31%, p = 0.007). The odds ratio for all-cause mortality was 8.85. In multivariate analysis, the MFI-PMA percentile and ischemic heart disease were the strongest predictors of all-cause mortality (p = 0.02 and p = 0.005, respectively). Low MFI-PMA levels were associated with poor nutritional status and adverse clinical outcomes and might serve as a prognostic biomarker, predicting severe infections and mortality among malnourished MHD patients.

A Moderate Walking Test Predicts Survival in Women With Cardiovascular Disease

Cardiovascular disease (CVD) is the principal cause of death in U.S. women. Peak oxygen uptake is strongly related to mortality and CVD. This study aimed to investigate the association between estimated peak oxygen uptake, determined using a moderate 1-km walking test, and all-cause mortality in female patients with stable CVD. Of the 482 women in our registry between 1997 and 2020, we included 430 participants in the analysis (aged 67 [34-88] years). A Cox proportional hazard model was used to determine the variables significantly associated with mortality. On the basis of the peak oxygen uptake estimated using the 1-km walking test, the sample was subdivided into tertiles, and mortality risk was calculated. The discriminatory accuracy of peak oxygen uptake in estimating survival was assessed by receiver operating characteristic curves. All results were adjusted for demographic and clinical covariates. A total of 135 deaths from any cause occurred over a median of 10.4 years (IQR=4.4-16.4), with an average annual mortality of 4.2%. Estimated peak oxygen uptake was a stronger predictor of all-cause mortality than demographic and clinical variables (c-statistic-0.767; 95% CI=0.72, 0.81; p<0.0001). The survival rate decreased from the highest tertile of fitness to the lowest. Compared with the lowest group, hazard ratios (95% CIs) for the second and third tertiles were 0.55 (0.37, 0.83) and 0.29 (0.16, 0.51), respectively (p for trend <0.0001). Higher peak oxygen uptake levels were associated with a lower risk of all-cause mortality. The indirect estimation of peak oxygen uptake using the 1-km walking test is feasible and can be applied for risk stratification among female patients undergoing secondary prevention programs.

Adverse muscle composition is a significant risk factor for all-cause mortality in NAFLD

Adverse muscle composition (MC) (i.e., low muscle volume and high muscle fat) has previously been linked to poor functional performance and comorbidities in non-alcoholic fatty liver disease (NAFLD). In this study we aimed to investigate associations of all-cause mortality with liver fat, NAFLD, and MC in the UK Biobank imaging study. Magnetic resonance images of 40,174 participants were analyzed for liver proton density fat fraction (PDFF), thigh fat-free muscle volume (FFMV) z-score, and muscle fat infiltration (MFI) using the AMRA® Researcher. Participants with NAFLD were sex-, age-, and BMI-matched to participants without NAFLD with low alcohol consumption. Adverse MC was identified using previously published cut-offs. All-cause mortality was investigated using Cox regression. Models within NAFLD were crude and subsequently adjusted for sex, age, BMI (M1), hand grip strength, physical activity, smoking, alcohol (M2), and previous cancer, coronary heart disease, type 2 diabetes (M3). A total of 5,069 participants had NAFLD. During a mean (±SD) follow-up of 3.9 (±1.4) years, 150 out of the 10,138 participants (53% men, age 64.4 [±7.6] years, BMI 29.7 [±4.4] kg/m2) died. In the matched dataset, neither NAFLD nor liver PDFF were associated with all-cause mortality, while all MC variables achieved significance. Within NAFLD, adverse MC, MFI and FFMV z-score were significantly associated with all-cause mortality and remained so in M1 and M2 (crude hazard ratios [HRs] 2.84, 95% CI 1.70-4.75, p <0.001; 1.15, 95% CI 1.07-1.24, p <0.001; 0.70, 95% CI 0.55-0.88, p <0.001). In M3, the relationship was attenuated for adverse MC and FFMV z-score (adjusted HRs 1.72, 95% CI 1.00-2.98, p=0.051; 0.77, 95% CI 0.58-1.02, p=0.069) but remained significant for MFI (adjusted HR 1.13, 95% CI 1.01-1.26, p=0.026). Neither NAFLD nor liver PDFF was predictive of all-cause mortality. Adverse MC was a strong predictor of all-cause mortality in individuals with NAFLD. Individuals with fatty liver disease and poor muscle health more often suffer from poor functional performance and comorbidities. This study shows that they are also at a higher risk of dying. The study results indicate that measuring muscle health (the patient's muscle volume and how much fat they have in their muscles) could help in the early detection of high-risk patients and enable targeted preventative care.

Evaluation of risk stratification program based on trajectories of functional capacity in patients with acute coronary syndrome: The REACP study.

As a validated assessment tool for functional disability (activities of daily living), the Barthel index (BI) assessed initially at admission has the potential to stratify patients with high-risk acute coronary syndrome (ACS). Dynamic trajectory evaluation of functional capacity in hospitals may provide more prognostic information. We aimed to establish a novel dynamic BI-based risk stratification program (DBRP) during hospitalization to predict outcomes among ACS patients. A total of 2,837 ACS patients were included from the Retrospective Multicenter Study for Early Evaluation of Acute Chest Pain. The DBRP rating (low, medium, and high-risk categories) was calculated from dynamic BI at admission and discharge. The primary outcome was all-cause mortality, and the secondary outcome was cardiac mortality. Of all the included patients, 312 (11%) died during a median follow-up period of 18.0 months. Kaplan-Meier analysis revealed that the cumulative mortality was significantly higher in patients in the higher risk category according to the DBRP. Multivariable Cox regression analysis indicated that, compared to the low-risk category, the higher risk category in the DBRP was an independent strong predictor of all-cause mortality after adjusting for confounding factors (medium-risk category: hazard ratio [HR]: 1.756, 95% confidence interval [95% CI]: 1.214-2.540; P = 0.003; high-risk category: HR: 5.052, 95% CI: 3.744-6.817; P < 0.001), and the same result was found for cardiac mortality. The DBRP was a useful risk stratification tool for the early dynamic assessment of patients with ACS. [http://www.chictr.org.cn], identifier [ChiCTR1900024657].

O020 Sleep regularity is a stronger predictor of all-cause mortality than sleep duration or sleep efficiency in ~60 000 UK Biobank participants

Abstract Sleep duration and sleep efficiency are observed risk factors for all-cause mortality, but the role of sleep regularity is unknown. Irregular sleep patterns are associated with ageing, cancer, depressed mood, and cardio-metabolic diseases, and may therefore increase risk of mortality. We extracted Sleep Regularity Index (SRI) scores, sleep duration, and sleep efficiency from one week of actigraphy in 60,997 UK Biobank participants (62.8±7.8 years, 55.6% female). Using Cox Proportional Hazards models, we assessed whether SRI, sleep duration, and sleep efficiency predicted all-cause mortality up to 7.6 years post-actigraphy. A one standard deviation increase in SRI score (+10.7), indicating more regular sleep patterns, predicted a 20.4±2.0% reduced hazard of all-cause mortality (p &amp;lt; .0001). This relationship remained robust after controlling for age, sex, ethnicity, education, income, and employment status (+1SD in SRI predicted an 18.7±2.4% hazard reduction, p &amp;lt; .0001). SRI was a relatively stronger predictor of mortality hazard than sleep duration (explaining 19.0±2.1% vs. 12.4±2.6% of hazard reduction) or sleep efficiency (19.0±2.1% vs. 13.1±2.6%) in two additional Cox models. Sleep regularity may play a causal role in mortality, via contribution to poor health outcomes, or it may be a marker of poor health leading to mortality. These findings suggest that sleep regularity should be monitored and/or adjusted alongside traditional sleep metrics for optimal health and longevity.

Pulmonary Capillary Wedge Pressure during Exercise Is Prognostic for Long-Term Survival in Patients with Symptomatic Heart Failure.

Aims: Exercise stress testing can stratify specific populations of heart failure patients for mortality risk, but is not universally applied. The aim of the present study was to investigate the prognostic capabilities of invasive exercise testing in a real-world cohort of suspected heart failure patients in whom non-cardiac causes of dyspnea were excluded. Methods: We retrospectively analyzed the survival of 682 patients who underwent right heart catheterization at rest and during exercise between 2007 and 2017 for dyspnea and expected heart failure. Pulmonary capillary wedge pressure (PCWP) at rest and the PCWP response to exercise, expressed as the ratio of PCWP at peak exercise to workload normalized to body weight (PCWL (mmHg/W/kg)), were determined. Mortality data were retrieved from the official German death registry. Results: Over a median follow-up period of 8.5 years, PCWL is a stronger predictor of all-cause mortality than PCWP. Patients featuring a reduced left ventricular ejection fraction (LVEF; <50%), but favorable response to exercise (PCWL <34.7 mmHg/W/kg), have a similar mortality risk to patients with a normal LVEF and low PCWL (hazard ratio (HR) 1.180, 95% CI 0.48–2.91, p = 0.719). Irrespective of LVEF, an increased PCWL during exercise was associated with a significantly increased mortality (HR 1.950 with preserved LVEF, 95% CI 1.12–3.34, p = 0.018; and HR 3.212 with impaired LVEF, 95% CI 1.75–5.70, p < 0.001). Conclusions: In patients with clinical heart failure, invasive exercise testing improves the prediction of mortality. Subjects with a favorable response to exercise have a relatively low mortality irrespective of left ventricular systolic function.