Strong Predictor Of Long-term Mortality Research Articles

Developing a multi-center registry of peripheral artery disease using natural language processing: unlocking the power of the electronic health record

Abstract Background Although peripheral artery disease (PAD) is common and associated with a high risk of mortality, contemporary PAD research remains limited due to poor accuracy of diagnosis codes in the electronic health record (EHR). We previously developed and validated a novel natural language processing (NLP) algorithm that can extract ankle brachial index (ABI) and toe-brachial index (TBI) values from clinical documents and identify patients with PAD with high accuracy (positive predictive value 92.4%). Purpose Scale the NLP system for developing a nationwide registry of PAD in the Veterans Health Administration (VHA), the largest integrated health system in the U.S. that provides care to ~9 million Veterans across 130 sites. Describe the baseline characteristics and mortality outcomes among participants and identify predictors of long-term mortality. Methods A total of 1,182,025 documents from vascular and radiology procedures during 2013-2020 were processed by the NLP system. After excluding non-ABI vascular studies, patients with a known diagnosis of PAD prior to 2015, patients younger than 40 years of age, and those who do not regularly follow-up in the VHA, we identified 107,711 patients with newly diagnosed PAD during 2015-2020. Patients were followed longitudinally using the VA’s electronic health record data. The primary outcome was all-cause mortality. We used Cox proportional hazards regression to examine predictors of long-term mortality. Results The mean age was 70.5 years; 97.3% were males, and 18.5% were of Black race. The mean ABI value was 0.78 (SD: 0.26) and the mean TBI value was 0.51 (SD: 0.19). There was a high prevalence of hypertension (83.6%), heart failure (20.8%), diabetes (53.6%), renal failure (22.1%) and chronic obstructive pulmonary disease (32.4%, Table 1). At 1-year, 9.6% of patients had died and this proportion increased to 25.4% at 3 years. Although nearly all patient variables were significantly associated with mortality, older age, severe PAD at diagnosis, diabetes, heart failure, renal failure and COPD were the strongest predictors of long-term mortality. Black race was associated with lower hazard of long-term mortality. Conclusions Using a previously validated novel NLP algorithm that extracts ABI and TBI values from clinical documents, we have successfully developed a registry of newly diagnosed PAD in the VHA. Ongoing studies from our cohort will yield important insights into the association between clinical management of PAD and clinical outcomes, with the goal of identifying opportunities for improving care.

Prognostic relevance of mitral regurgitation at different follow-up timepoints after transcatheter aortic valve implantation (TAVI): implications for therapeutic decision making?

Abstract Background Transcatheter aortic valve implantation (TAVI) has developed rapidly in the last decade and is now recommended as state-of-the-art treatment for elderly patients suffering from severe symptomatic degenerative aortic stenosis (AS). The extent of mitral regurgitation (MR) following TAVI is likely to be of prognostic relevance. This raises the question whether treating MR following TAVI improves outcome of patients with significant MR. Purpose The current study was aimed to elucidate the prognostic value of MR at different follow-up (FU) timepoints after TAVI in a prospective real-world single-center registry study. Methods A total of 445 patients with severe AS, which were treated by transfemoral TAVI, were included and a wide range of clinical, laboratory, functional and imaging parameters were prospectively assessed. Mortality was recorded at 30 days, 1 year and 2 years after TAVI. Complete FU data including echocardiography were available at 6 to 8 weeks (n=334) as well as 6 months (n=235) after TAVI. Results All patients (mean age: 78.7±7.3 years, 52% female, mean STS score: 5±3.9%) were successfully treated by transfemoral TAVI using balloon- or self-expanding prostheses and showed mortality rates of 3.6% after 30 days, 16.4% after 1 year and 22.6% after 2 years. Moderate or severe (relevant) MR was detectable in 39% of the patients at baseline, in 27% of patients after 6 weeks (p=0.001) and in 28% of patients after 6 months (p=0.036, compared to baseline). Multivariate analysis identified independent predictors of 2-year mortality: clinical frailty scale and PAPsys at 6 to 8 weeks post-TAVI as well as BNP and relevant MR 6 months post TAVI. Among those parameters, MR after 6 months was the strongest predictor of long-term mortality (OR 3.192, CI 0.971–10.487, p=0.056). Kaplan-Meier survival analysis displayed significantly worse 2-year survival rates in patients suffering from relevant MR at 6 months (12.1% versus 4.8%, p=0.042). Conclusions Taken together, this real-life single-center experience underlines the prognostic value of relevant MR 6 months after TAVI with respect to long-term survival. Interestingly, MR was not predictive at the 6 to 8 weeks FU suggesting that early remodeling includes MR with prognostic relevance in those patients. Whether MR treatment, e.g., by transcatheter edge-to-edge repair, will improve patient outcomes post-TAVI has to be tested in prospective trials. Funding Acknowledgement Type of funding sources: None.

National Early Warning Score 2 provides independent prognostic information in patients hospitalized with heart failure with preserved ejection fraction

Abstract Background Heart failure (HF) hospitalisation is a strong predictor of long-term mortality among HF patients. Current European Society of Cardiology HF guidelines do not include recommendations for post-discharge long-term risk prediction for acute HF, despite several cardiac biomarkers and clinical scoring systems being able to predict long-term prognosis. In Europe, the clinical scoring system National Early Warning Score 2 (NEWS2) is increasingly being used for in-hospital risk prediction, and several recent studies have demonstrated a potential to utilize NEWS2 for long-term risk prediction. Purpose To assess the long-term prognostic accuracy of NEWS2 in patients hospitalised with acute HF in comparison to N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin T (hs-cTnT), and their differences in prognostic accuracy for HF subgroups with reduced (HFrEF) and preserved (HFpEF) ejection fraction. Methods In the Akershus Cardiac Examination 2 Study, we measured hs-cTnT and NT-proBNP and calculated NEWS2 within 24 hours of admission in patients hospitalised due to acute dyspnea (n=314). Patients with acute HF as adjudicated index diagnosis were included in the current sub-study (n=143). We assessed post-discharge long-term risk of all-cause mortality by receiver operating characteristic (ROC) analysis and Cox regression models. Results During median follow-up of 26 (quartile 1–3 8–33) months, 66 patients (46%) died. Patients with poor prognosis had higher NEWS2 (mean 5.9 vs 4.4 points, p=0.004), hs-cTnT concentrations (median 49 vs 27 ng/L, p=0.002), and NT-proBNP concentrations (median 5776 vs 2593 ng/L, p<0.001) compared to patients with favourable prognosis. Stratified by HF subgroups, the area under the ROC curve (ROC AUC) for NEWS2 to predict mortality was superior for HFpEF (ROC AUC 0.79, 95% CI 0.66–0.92) compared to HFrEF (ROC AUC 0.57, 95% CI 0.45–0.69; p=0.012) (Figure). In contrast, prognostic accuracy in HFrEF and HFpEF were comparable for hs-cTnT (ROC AUC 0.64 vs 0.67, p=0.76) and NT-proBNP (ROC AUC 0.72 vs 0.71, p=0.94) (Table). After adjustment for age, sex, body mass index, systolic blood pressure, history of coronary artery disease and estimated glomerular filtration rate, NEWS2 was associated with mortality for HFpEF patients (HR 1.37, 95% CI 1.13–1.66), while no association was found for NEWS2 to predict mortality in HFrEF patients (HR 1.03, 95% CI 0.93–1.15; p for interaction=0.016). Conclusion(s) NEWS2 is a superior prognostic marker among patients hospitalised with HFpEF compared to HFrEF and might be a valuable and readily available tool to prognosticate patients at hospital discharge. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Research grant from the Norwegian Research Council and internal grants from Akershus University Hospital to Torbjørn Omland and Helge Røsjø.

Validation of prognostic value of the hemodynamic gain index in different groups of patients undergoing exercise stress testing

BackgroundRecently, the hemodynamic gain index (HGI) has shown to be a strong independent predictor of all-cause mortality and associated with metabolic equivalents (METs) in a cohort of male patients. However, the prognostic implications of the HGI have never been externally validated with subgroup analyses based on gender, body mass index (BMI) of 35 kg/m2, history of heart failure (HF), coronary artery disease (CAD) and beta-blocker use. MethodsWe identified 126,356 consecutive patients undergoing treadmill exercise testing between January 1st, 1991 and February 27th, 2015. HGI was calculated using the formula: [(SBPpeak × HRpeak) − (SBPrest × HRrest)] / (SBPrest × HRrest). Cox regression models were used to determine the associations between HGI quartiles and all-cause mortality with adjustment for cardiovascular risk factors and exercise testing parameters. ResultsMean age was 53.5 ± 12.6 years. There were 74,724 (59.1 %) male, 5940 (4.7 %) HF, 21,123 (16.7 %) CAD, and 30,568 (24.2 %) beta-blocker-using patients. During the median follow up of 7.1 years, 9929 (7.9 %) died. Median HGI was 1.93 (interquartile range [IQR] 1.40–2.54) bpm/mmHg. After adjustment for the covariates, lower HGI was independently associated with all-cause mortality in the entire cohort (quartile 1 vs 4, adjusted hazard ratio [95 % confidence interval] 1.33 [IQR 1.21–1.45], p < 0.001), and subgroups of men, women, patients with body mass index <35 kg/m2, with and without HF, CAD, and beta-blocker use. The HGI also correlates well with METs in every subgroup. ConclusionsThe HGI is a strong predictor of long-term mortality independently of traditional cardiovascular risk factors, and exercise performance across patient subgroups.

Liver-fibrosis-activated transcriptional networks govern hepatocyte reprogramming and intra-hepatic communication

Liver fibrosis is a strong predictor of long-term mortality in individuals with metabolic-associated fatty liver disease; yet, the mechanisms underlying the progression from the comparatively benign fatty liver state to advanced non-alcoholic steatohepatitis (NASH) and liver fibrosis are incompletely understood. Using cell-type-resolved genomics, we show that comprehensive alterations in hepatocyte genomic and transcriptional settings during NASH progression, led to a loss of hepatocyte identity. The hepatocyte reprogramming was under tight cooperative control of a network of fibrosis-activated transcription factors, as exemplified by the transcription factor Elf-3 (ELF3) and zinc finger protein GLIS2 (GLIS2). Indeed, ELF3- and GLIS2-controlled fibrosis-dependent hepatokine genes targeting disease-associated hepatic stellate cell gene programs. Thus, interconnected transcription factor networks not only promoted hepatocyte dysfunction but also directed the intra-hepatic crosstalk necessary for NASH and fibrosis progression, implying that molecular "hub-centered" targeting strategies are superior to existing mono-target approaches as currently used in NASH therapy.

Contemporary outcomes of endovascular abdominal aortic aneurysm repair in patients deemed unfit for open surgical repair

ObjectiveEndovascular abdominal aortic aneurysm repair (EVAR) has been preferred to open surgical repair (OSR) for the treatment of abdominal aortic aneurysms (AAAs) in high-risk patients. We compared the perioperative and long-term outcomes of EVAR for patients designated as unfit for OSR using a large national dataset. MethodsThe Vascular Quality Initiative database was queried for patients who had undergone elective EVAR for AAAs >5 cm from 2013 to 2019. The patients were stratified into two cohorts according to their suitability for OSR (fit vs unfit). The primary outcomes included perioperative (in-hospital) major adverse events, perioperative mortality, and mortality at 1 and 5 years. Patient demographics and postoperative outcomes were analyzed to identify the predictors of perioperative and long-term mortality. ResultsOf 16,183 EVARs, 1782 patients had been deemed unfit for OSR. The unfit cohort was more likely to be older and female, with a greater proportion of hypertension, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, and larger aneurysm diameters. Postoperatively, the unfit cohort was more likely to have experienced cardiopulmonary complications (6.5% vs 3%; P < .001), with greater perioperative mortality (1.7% vs 0.6%; P < .001) and 1- and 5-year mortality (13% and 29% for the unfit vs 5% and 14% for the fit cohorts, respectively; P < .001). A subgroup analysis of the unfit cohort revealed that those deemed unfit because of a hostile abdomen had significantly lower 1- and 5-year mortality (6% and 20%, respectively) compared with those considered unfit because of cardiopulmonary compromise and frailty (14% and 30%, respectively; P = .451). Reintervention-free survival at 1 and 5 years was significantly greater in the fit cohort (93% and 82%, respectively) compared with that for the unfit cohort (85% and 68%, respectively; P < .001). The designation as unfit for OSR was an independent predictor of both perioperative (odds ratio, 1.59; 95% confidence interval [CI], 1.03-2.46; P = .038) and long-term mortality (hazard ratio [HR], 1.92; 95% CI, 1.69-2.17; P < .001). Advanced age (odds ratio, 2.91; 95% CI, 1.28-6.66; P = .011) was the strongest determinant of perioperative mortality, and end-stage renal disease (HR, 2.51; 95% CI, 1.78-3.55; P < .001) was the strongest predictor of long-term mortality. Statin use (HR, 0.77; 95% CI, 0.69-0.87; P < .001) and angiotensin-converting enzyme inhibitor use (HR, 0.83; 95% CI, 0.75-0.93; P < .001) were protective of long-term mortality. ConclusionsDespite low perioperative mortality, the long-term mortality of those designated by operating surgeons as unfit for OSR was rather high for patients undergoing elective EVAR, likely owing to the competing risk of death from medical frailty. An unfit designation because of a hostile abdomen did not confer any additional risks after EVAR. Judicious estimation of the patient's life expectancy is essential when considering the treatment options for this subset of patients deemed unfit for OSR.

P1792Delirium after transcatheter aortic valve implantation (TAVI) under general anaesthesia: incidence, predictors and relation to long-term survival

Abstract Background Patients undergoing Transcatheter Aortic Valve Implantation (TAVI) are at risk of postoperative delirium (POD). Prospectively collected data on delirium after TAVI are scarce. Purpose Aim of this study is to report the incidence and risk factors of POD after TAVI under general anaesthesia. Also we assessed the relation of POD with clinical outcome and short- and long-term survival. Methods POD was assessed prospectively in all consecutive patients treated with TAVI in our centre between 2008 and 2017, according to the Diagnostic and Statistical Manual of Mental Disorder (DSM)-IV criteria. TAVI was performed under general anaesthesia in all patients. Outcome was reported according to the updated VARC2-criteria. Survival status was checked by consulting the Municipal Civil Registries. Results POD was observed in 16.5% (116/703) of all patients. Stroke and new onset of atrial fibrillation were more often observed in patients with POD (6.9% vs. 1.9%, p=0.007 and 12.1% vs. 5.1%, p=0.005, respectively). Independent preoperative predictors of POD were prior delirium (OR 2.56 [95% CI: 1.52–4.31], p&lt;0.001), aortic valve area (AVA)&lt;0.75 cm2 (OR 2.39 [1.53–3.74], p&lt;0.001), age (1.08 [1.04–1.12], p&lt;0.001) and BMI (0.94 [0.90–0.99], p=0.018). POD was the strongest independent predictor of long-term mortality (HR 1.91 [1.36–2.70], p&lt;0.001) and was associated with impaired 30-day survival (92.2% vs. 96.8%, p=0.034) as well as 5-year survival (40.0% vs. 50.0%, p&lt;0.001). Survival: Delirium vs No Delirium Conclusion One-in-six patients suffered from POD after TAVI under general anaesthesia. Prior delirium and more calcified aortic valve were the strongest independent predictors of POD. POD was the strongest predictor of long-term mortality and was associated with impaired short- as well as long-term survival.

Delirium After Transcatheter Aortic Valve Implantation Under General Anesthesia: Incidence, Predictors, and Relation to Long-Term Survival.

BACKGROUND/OBJECTIVESProspectively collected data on postoperative delirium (POD) after transcatheter aortic valve implantation (TAVI) are scarce. The aim of this study was to report the incidence and risk factors of delirium after TAVI under general anesthesia and to assess the association of POD with clinical outcome and short‐ and long‐term survival.DESIGNProspective cohort study.SETTINGAcademic medical center.PARTICIPANTSA total of 703 subsequent patients undergoing TAVI under general anesthesia between 2008 and 2017.MEASUREMENTSDelirium was assessed according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM‐IV), criteria. Outcomes were postprocedural clinical outcome and short‐ and long‐term survival (30 days and 5 years, respectively).RESULTSPOD was observed in 16.5% (116/703), was the strongest independent predictor of long‐term mortality (hazard ratio = 1.91; 95% confidence interval [CI] = 1.36‐2.70), and was associated with impaired 30‐day and 5‐year survival (92.2% vs 96.8% [P = .025] and 40.0% vs 50.0% [P = .007], respectively). Stroke and new onset of atrial fibrillation were more often observed in delirious patients (6.9% vs 1.9% and 12.1% vs 5.1%, respectively). Strongest independent predictors of POD were prior delirium (odds ratio [OR] = 2.56; 95% CI = 1.52‐4.31) and aortic valve area less than 0.75 cm2 (OR = 2.39; 95% CI = 1.53‐3.74).CONCLUSIONOne in six patients experienced POD after TAVI under general anesthesia. POD was the strongest predictor of long‐term mortality and was associated with impaired short‐ and long‐term survival. Prior delirium and a more calcified aortic valve were the strongest independent predictors of POD. J Am Geriatr Soc 67:2325–2330, 2019

Discriminatory power of scoring systems for outcome prediction in patients with extracorporeal membrane oxygenation following cardiovascular surgery†.

Although extracorporeal membrane oxygenation (ECMO) represents a rapidly evolving treatment option in patients with refractory heart or lung failure, survival remains poor and appropriate risk stratification challenging because established risk prediction models have not been validated for this specific population. This observational single-centre registry included a total of 240 patients treated with venoarterial ECMO therapy following cardiovascular surgery and analysed the discriminatory power of the European System of Cardiac Operative Risk Evaluation (EuroSCORE) additive, the EuroSCORE II, the Sequential Organ Failure Assessment (SOFA) score, the Simplified Acute Physiology Score (SAPS) II, the SAPS III, the Acute Physiology and Chronic Health Evaluation (APACHE) II, the Risk of renal failure, Injury to the kidney, Failure of kidney function, Loss of kidney function and End-stage renal failure (RIFLE) classification, the survival after venoarterial ECMO (SAVE) score, the prEdictioN of Cardiogenic shock OUtcome foR AMI patients salvaGed by VA-ECMO (ENCOURAGE) score and the Society of Thoracic Surgeons (STS) risk model for outcome prediction. During a median follow-up time of 37 months (interquartile range 19-67), 65% of the patients died. Only the SAVE score and the SAPS II were significantly associated with the 30-day mortality rate with a hazard ratio (HR) of 1.06 [95% confidence interval (CI) 1.02-1.11; P = 0.002] for the SAVE score and an HR of 1.02 (95% CI 1.01-1.03; P = 0.004) for the SAPS II with a modest discriminatory power displayed by a C-index of 0.61 and 0.57, respectively. Seven out of 10 scoring systems revealed significant association with long-term mortality, with the SAVE score and the SAPS II remaining the strongest predictors of long-term mortality with an HR of 1.06 (95% CI 1.03-1.09; P < 0.001, C-index 0.61) for the SAVE score and an HR of 1.02 (95% CI 1.01-1.03; P < 0.001, C-index 0.58) for the SAPS II. Risk assessment based on established risk models in patients with ECMO remains difficult. Only the SAPS II and the SAVE score were exclusively found to be suitable for short- and long-term outcome prediction in this specific vulnerable patient population.

Coronary Angiography and Revascularization Following Coronary Artery Bypass Grafting in British Columbia: Incidence, Predictors and Longer-term Outcomes

BackgroundCoronary artery bypass grafting (CABG) is established treatment for subsets of coronary artery disease (CAD). Observational data have characterised significant progression of native coronary as well as graft vessel disease during longer-term follow-up, potentially reducing the benefit of CABG. We sought to assess longer-term outcomes following CABG by determining rates of repeat coronary angiography, revascularization procedures, and survival. MethodsData for all patients undergoing isolated CABG in British Columbia between 2001 and 2009 inclusive, and with follow-up until the end of 2013, were retrieved from the British Columbia Cardiac Registry. Cox proportional hazard regression and competing risk regression were performed for survival and subsequent cardiac procedures (coronary angiography, percutaneous coronary intervention [PCI] or repeat CABG). ResultsData were available from 17,316 patients with a mean age at index CABG of 65.7 ± 9.8 years. At a median follow-up of 8.5 (range 4.0 to 12.9) years, 3185 patients (18.4%) had died, 3135 (18.1%) underwent repeat coronary angiography with or without PCI or repeat CABG, and 11,557 (66.7%) had survived without additional procedures. Of those who underwent angiography, 1459 patients (46.5%) underwent further revascularization. In multivariate analysis, the strongest predictors of long-term mortality were dialysis dependency and age >75, whereas left internal mammary artery utilization and aspirin therapy were protective. Repeat revascularization predicted survival (adjusted hazard ratio 0.76; 95% confidence interval, 0.63-0.92; P = 0.004), whereas angiography alone did not. ConclusionsFollowing CABG, patients frequently undergo repeat coronary angiography. Although only a minority of patients receive further revascularization, this appears to be associated with longer-term survival.

Inpatient screening for albuminuria and retinopathy to predict long-term mortality in type 2 diabetic patients: a retrospective cohort study

BackgroundThere is a high hospitalization rate for diabetic patients. Since retinopathy and albuminuria are both important manifestations of microvascular disease in diabetes, our aim was to investigate the effect of retinopathy and albuminuria on long-term mortality in type 2 diabetic inpatients through this observational cohort study.MethodsType 2 diabetic inpatients given a primary diagnosis of poor glucose control were consecutively enrolled during their hospitalization periods. Clinical information was collected through review of each patient’s medical records, and mortality data were obtained from the national registry in Taiwan.ResultsA total of 761 type 2 diabetic inpatients were enrolled in the study with a median follow-up period of 6.6 years (interquartile range, 4.0–9.6 years). Patients in the Albuminuria(−)/Retinopathy(+), Albuminuria(+)/Retinopathy(−) and Albuminuria(+)/Retinopathy(+) groups had significantly higher risks of all-cause mortality and cardiovascular mortality than those in the Albuminuria(−)/Retinopathy(−) group. However, among patients with albuminuria, there was no significant difference in cumulative mortality between those with and without retinopathy (P = 0.821). A decrease in the estimated glomerular filtration rate (eGFR), but not retinopathy, was an independent predictor of all-cause mortality (95% CI 0.647‒0.893; P < 0.001) and cardiovascular mortality (95% CI 0.564‒0.921; P = 0.009) in type 2 diabetic inpatients with albuminuria.ConclusionsAlbuminuria in type 2 diabetic inpatients is a strong predictor of long-term mortality after discharge from the hospital. Retinopathy is an independent predictor of mortality in type 2 diabetic inpatients without albuminuria but not in those with albuminuria. A low eGFR is a better predictor of mortality than retinopathy in type 2 diabetic inpatients with albuminuria.

Cardiogenic Shock Predicts Long-term Mortality in Hospital Survivors of STEMI Treated With Primary Percutaneous Coronary Intervention.

ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS) has a poor prognosis. Recently published data suggested, however, that CS does not affect long-term mortality in hospital survivors of STEMI. We investigated whether this could be confirmed in a larger cohort. STEMI complicated by CS leads to worse long-term survival. A prospective cohort study was performed in 7412 consecutive patients with STEMI treated by primary percutaneous coronary intervention (angioplasty). The predictive value of CS on long-term mortality was assessed in hospital survivors. Multivariate analysis, adjusting for differences in baseline variables, was performed to assess the independent prognostic value of CS. Cardiogenic shock was observed in 387 patients (5.2%). The total in-hospital mortality was 254 (3.4%), and mortality was significantly higher in patients with CS (20.0% vs 2.6%; P < 0.001). The 1-year mortality in hospital survivors was 10.3% in patients with CS and 3.9% in patients without CS (P < 0.001). After multivariate analysis, CS was still a significant predictor of long-term mortality in hospital survivors (hazard ratio: 2.6, 95% confidence interval: 1.64-4.01). Cardiogenic shock remains a strong predictor of long-term mortality in hospital survivors of STEMI treated by primary percutaneous coronary intervention.

Single measurement of serum N-terminal Pro-Brain Natriuretic Peptide: The best predictor of long-term mortality in patients with chronic systolic heart failure

BackgroundAlthough high serum natriuretic peptide (NP) has long been associated with mortality prediction, it was usually tested under acute heart failure (HF) conditions and periods of analysis were short. This may explain the lack of consensus when its routine measurement for mortality prediction is contemplated. Here we evaluated, at the first clinic visit of chronic systolic HF patients, the usefulness of a single serum NP assessment for long-term mortality prediction. MethodsIn 279 consecutive patients with chronic systolic HF, serum NT-proBNP was routinely measured once during the first clinic visit. We analyzed correlations between recorded mortality and the NT-proBNP finding, along with several known clinical echocardiographic, electrocardiographic and laboratory parameters recorded at that visit. ResultsDuring average follow-up of 34±21months 59 (21%) patients died. Serum NT-proBNP was the strongest of the tested predictors of mortality [hazard ratio 3.76, 95% Cl (1.20–11.80), p=0.008]. Nearly seven years later, mortality was still higher in patients with higher initial serum NT-proBNP (p<0.001). ConclusionsCompared to many other traditional prognostic parameters tested at the same time, the single serum NT-proBNP finding was the strongest predictor of long-term mortality. These results may justify its routine use for this purpose.

The Impact of Renal Artery Stenosis on Outcomes After Open-Heart Surgery

The aim of this study was to assess the impact of atherosclerotic renal artery stenosis (ARAS) on outcomes after open-heart surgery (OHS). Acute kidney injury after OHS portends significant morbidity and mortality. Data from all adult patients undergoing OHS from January 2000 to April 2010 who underwent renal duplex ultrasound were prospectively collected. ARAS was severe (60% to 99% stenosis) if peak systolic velocity was >200cm/s. The associations between ARAS and post-operative reduction in glomerular filtration rate (GFR), need for renal replacement therapy, length of stay, and overall short-term and long-term mortality (up to 8 years) were tested using multivariate time-to-event adjusted analysis. A total of 714 patients were evaluated, with a mean age of 67 ± 12 years (63% men) and a mean GFR of 52±25.9ml/min/1.73 m(2). A total of 206 (29%) had ARAS; of these, 79% (n= 163) had unilateral and 21% (n=43)had bilateral ARAS. ARAS was associated with peripheral artery disease (p= 0.004) and lower high-density lipoprotein levels (p= 0.04). Patients with advanced age (p= 0.01) and descending aorta grafting (p= 0.004) had significant post-operative reductions in GFR. Adjusted models showed a nonsignificant trend between ARAS and reduction inGFR (p= 0.09). ARAS was not associated with need for renal replacement therapy (p= 0.4), longer length of stay(p=0.7), or mortality (p= 0.7), but low pre-operative GFR was a strong predictor of long-term mortality. ARAS does not appear to be associated with post-operative change in GFR, need for hemodialysis, longer length of stay, or mortality in patients undergoing OHS.

Predictors of 1-year mortality in patients with contemporary guideline-adherent therapy after acute myocardial infarction: results from the OMEGA study

Predictors of long-term mortality after discharge after acute myocardial infarction (AMI) are well characterized. However, these established risk factors are based on data almost exclusively derived from older studies without consistent use of revascularization therapy and adjunctive therapy with statins, platelet inhibitors, beta-blockers and ACE inhibitors/ARBs. We therefore sought to investigate predictors of 1-year mortality in survivors of AMI treated with contemporary guideline-adherent therapy. We performed a retrospective analysis of 3,782 patients surviving acute ST-elevation and non ST-elevation myocardial infarction who were enrolled in the prospective, randomized, double-blind, controlled OMEGA trial with 104 German centers. The primary objective of the OMEGA study was to determine the effect of highly purified omega-3 fatty acid ethyl esters-90 on the rate of sudden cardiac death in patients surviving AMI and receiving current guideline-adherent treatment within the 1-year of follow-up. 80.8 % of the patients received early revascularization therapy. At discharge, 94.2 % of the patients received beta-blocker, 90.4 % ACE inhibitor/angiotensin receptor blocker, 94.3 % statin, 95.4 % aspirin and 88.4 % clopidogrel. During the 1-year follow-up 139 patients (3.7 %) died. Multivariate logistic regression analysis revealed the following independent predictors of 1-year mortality in decreasing order of importance: ejection fraction <45 % [odds ratio (OR) 2.28, 95 % confidence interval (CI) 1.53-3.41], age ≥70 years (OR 2.17, 95 % CI 1.42-3.32), no acute revascularization (OR 2.02, 95 % CI 1.33-3.08), prior stroke/transient ischemic attack (OR 1.90, 95 % CI 1.09-3.30), peripheral arterial disease (OR 1.86, 95 % CI 1.12-3.10), heart rate >85/min (OR 1.82, 95 % CI 1.23-2.71), chronic obstructive lung disease (OR 1.77, 95 % CI 1.01-3.10) and HDL cholesterol <40 mg/dl (OR 1.75, 95 % CI 1.15-2.67). In patients surviving AMI and treated with contemporary guideline-adherent therapy, 1-year mortality was low. Nevertheless, traditional risk factors such as ejection fraction <45 %, older age, no acute revascularization and comorbidities were the strongest predictors of long-term mortality supporting the findings from previous studies.

Prevalence of Dyssynchrony and Relation With Long-Term Outcome in Patients After Acute Myocardial Infarction

The impact of left ventricular (LV) dyssynchrony on the long-term outcomes of patients with acute myocardial infarction (AMI) remains unknown. The purpose of the present study was to evaluate the prevalence of LV dyssynchrony after AMI and the potential relation with adverse events. A total of 976 consecutive patients admitted with AMI treated with primary percutaneous coronary intervention were evaluated. Two-dimensional echocardiography was performed <48 hours after admission. LV dyssynchrony was assessed with speckle-tracking imaging and calculated as the time difference between the earliest and latest activated segments. Patients were followed up for the occurrence of all-cause mortality (the primary end point) or the composite secondary end point (heart failure hospitalization and all-cause mortality). Within 48 hours of admission for the index infarction, mean LV dyssynchrony was 61 ± 79 ms, and 14% of the patients demonstrated a ≥130-ms time difference, defined as significant LV dyssynchrony. During a mean follow-up period of 40 ± 17 months, 82 patients (8%) reached the primary end point. In addition, 36 patients (4%) were hospitalized for heart failure. The presence of LV dyssynchrony was associated with an increased risk for all-cause mortality and hospitalization for heart failure during long-term follow-up (adjusted hazard ratio 1.06, 95% confidence interval 1.05 to 1.08, p <0.001, per 10-ms increase). Moreover, LV dyssynchrony provided incremental value over known clinical and echocardiographic risk factors for the prediction of adverse outcomes. In conclusion, LV dyssynchrony is a strong predictor of long-term mortality and hospitalization for heart failure in a population of patients admitted with ST-segment elevation AMI treated with primary percutaneous coronary intervention.

Atrial fibrillation as prognostic factor of myocardial infarction and/or acute heart failure

Abstract Atrial fibrillation (AF) is a supraventricular tachyarrhythmia characterized by uncoordinated atrial activation with consequence deterioration of atrial mechanical function. It has an incidence of approximately 6 million people in European Union as a result of the aging population and affects about 1 percent of patients younger than 60 years and about 8 percent of patients older than 80 years [2, 10]. AF is also the most common supraventricular arrhythmia in patients with acute myocardial infarction (MI) and/or acute heart failure (AHF), complicating its course with an incidence between 6–21% in hospitalized patients with MI although recent advances in pharmacological treatment of myocardial infarction has probably changed the impact of this arrhythmia and vice versa. These two diseases (AF + MI) are a growing health concern all over the world and when one considers the occurrence of these two diseases simultaneously, the relevance of AF in the course of MI and vice versa cannot be overemphasized in cardiovascular health care and more importantly its treatment and prevention. Aim: This article therefore aims to correlate data from controlled studies to summarize the incidence of AF in MI and vice versa and the impact of pharmacotherapy. Data from our registry Brno (3502 patients with MI and/or AHF) show that AF is not a predictor of short-term mortality in patients with myocardial infarction and/or heart failure, but is a strong predictor of long-term mortality.

No-Reflow Phenomenon: Maintaining Vascular Integrity

The no-reflow phenomenon relates to the inability to reperfuse regions of the myocardium after ischemia, despite removal of the large epicardial coronary artery occlusion. The mechanism involves microvascular obstruction. In experimental studies, using markers for flow (thioflavin S, carbon black, microspheres), perfusion defects associated with no-reflow demonstrated ultrastructural evidence of localized endothelial swelling and blebs that appeared to obstruct flow. In humans no-reflow is more complicated due to the microemboli of atherosclerotic debris and thrombi generated by percutaneous coronary intervention. The no-reflow zone expands during the first few hours of reperfusion suggesting an element of reperfusion injury. In animal models, extensive no-reflow was associated with worse infarct expansion. The phenomenon of no-reflow following reperfusion therapy for myocardial infarction in humans has been demonstrated by magnetic resonance imaging, echo contrast agents, thallium, technecium-99m-labeled albumin microspheres, Thrombolysis In Myocardial Infarction (TIMI) scores, and myocardial blush grade. Patients exhibiting no-reflow following reperfusion therapy for myocardial infarction have greater left ventricular dilation and remodeling, more congestive heart failure, shock, and reduced survival. Certain vasodilators (adenosine, nitroprusside, nicorandil, and calcium blockers) are used acutely in the catheterization laboratory and appear to improve no-reflow, but systematic studies on therapy for no-reflow are needed. There is now clinical evidence that no-reflow is a strong predictor of long-term mortality that is independent of and beyond that provided by infarct size. Identifying and treating no-reflow may have important benefits including enhancing delivery of nutrients and cells required for healing and reducing infarct expansion and ventricular remodeling, which ultimately may reduce congestive heart failure and mortality.

Histopathology of aspirated thrombus and its association with ST‐segment recovery in patients undergoing primary percutaneous coronary intervention with routine thrombus aspiration

In patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) with thrombus aspiration, the histopathology of aspirated thrombus was previously related to long-term mortality. In this study, we sought to investigate the association between histopathology of aspirated thrombus and ST-segment recovery, a marker of microvascular dysfunction, immediately at the end of the PCI procedure. We included 892 STEMI patients who underwent primary PCI with routine thrombus aspiration and for whom combined data on histopathology of aspirated thrombus and ST-segment recovery were available. Patients were categorized according to histopathology of aspirated thrombus: fresh only (<1 day), older (>1 day), or no material aspirated. ST-segment recovery was defined as incomplete if <50%. Incomplete ST-segment recovery occurred in 134 of 363 patients (37%) with fresh thrombus, in 104 of 238 patients (44%) with older thrombus, and in 142 of 291 patients (49%) with no material. Unadjusted odds ratios for incomplete ST-segment recovery of patients with older thrombus and no material, when compared with patients with fresh thrombus, were 1.33 (95% CI, 0.95-1.85; P = 0.097) and 1.63 (95% CI 1.19-2.23; P = 0.002), respectively. Both associations were unchanged after multivariable adjustment for clinical predictors of ST-segment recovery. ST-segment recovery was a strong predictor of long-term mortality, independent of the histopathology of aspirated thrombus. This study shows that ST-segment recovery immediately at the end of the PCI procedure was a significant prognosticator, independent of the histopathology of aspirated thrombus. We found that the histopathology of aspirated thrombus (fresh, older, no material) was associated with ST-segment recovery in STEMI patients undergoing primary PCI with thrombus aspiration.

Insulin resistance, adiponectin and adverse outcomes following elective cardiac surgery: a prospective follow-up study

BackgroundInsulin resistance and adiponectin are markers of cardio-metabolic disease and associated with adverse cardiovascular outcomes. The present study examined whether preoperative insulin resistance or adiponectin were associated with short- and long-term adverse outcomes in non-diabetic patients undergoing elective cardiac surgery.MethodsIn a prospective study, we assessed insulin resistance and adiponectin levels from preoperative fasting blood samples in 836 patients undergoing cardiac surgery. Population-based medical registries were used for postoperative follow-up. Outcomes included all-cause death, myocardial infarction or percutaneous coronary intervention, stroke, re-exploration, renal failure, and infections. The ability of insulin resistance and adiponectin to predict clinical adverse outcomes was examined using receiver operating characteristics.ResultsNeither insulin resistance nor adiponectin were statistically significantly associated with 30-day mortality, but adiponectin was associated with an increased 31-365-day mortality (adjusted odds ratio 2.9 [95% confidence interval 1.3-6.4]) comparing the upper quartile with the three lower quartiles. Insulin resistance was a poor predictor of adverse outcomes. In contrast, the predictive accuracy of adiponectin (area under curve 0.75 [95% confidence interval 0.65-0.85]) was similar to that of the EuroSCORE (area under curve 0.75 [95% confidence interval 0.67-0.83]) and a model including adiponectin and the EuroSCORE had an area under curve of 0.78 [95% confidence interval 0.68-0.88] concerning 31-365-day mortality.ConclusionsElevated adiponectin levels, but not insulin resistance, were associated with increased mortality and appear to be a strong predictor of long-term mortality. Additional studies are warranted to further clarify the possible clinical role of adiponectin assessment in cardiac surgery.Trial RegistrationThe Danish Data Protection Agency; reference no. 2007-41-1514.