Univariate Analysis Research Articles

The activation of cardiac sympathetic nervous system in the non-culprit lesion is a strong prognostic predictor in patients with acute myocardial infarction

Abstract Background The activation of cardiac sympathetic nervous system is associated with poor prognosis in patients with acute myocardial infarction (AMI). However, it remains to be determined whether regional assessment of cardiac sympathetic nerve activity (CSNA) in the culprit and non-culprit lesion of the cardiac MIBG SPECT imaging could have prognostic value in patients with AMI. Purpose The purpose of this study is to investigate the prognostic impact of regional CSNA in patients with AMI. Methods We prospectively enrolled 122 patients with AMI who visited our emergency department and underwent primary percutaneous coronary intervention. The late heart-to-mediastinum ratio (HMR) and washout rate (WR) was calculated to assess CSNA in the whole heart from planar images of in the cardiac MIBG imaging. The MIBG SPECT image parameters were calculated for each coronary artery, and the average WR in the culprit and non-culprit lesion were evaluated to assess the regional status of CSNA in patients with AMI. Abnormal WR in planar image was defined as 34% or more, as previously reported. The cut-off value of late HMR in planar image, WR in the culprit and non-culprit lesions were determined by ROC analysis. The primary endpoint was major adverse cardiac event (MACE) including all cause death, myocardial infarction, hospitalization for heart failure and target lesion revascularization. Results During a mean follow-up period of 3.1±1.8 years, 25 of 122 patients underwent MACE. The late HMR (p=0.004), WR in planar image (p=0.002), WR in the culprit lesion (p=0.023), and WR in the non-culprit lesion (p<0.001) were significantly associated with MACE at univariate Cox proportional hazard analysis. The increased WR in the non-culprit lesion (defined as 28.3% or more: AUC 0.697 [0.576-0.817]) was significantly independently associated with MACE (hazard ratio: 4.36 [1.45-13.11], p=0.009) even adjusted by late HMR, WR in planar image or WR in the culprit lesion, while decreased HMR, abnormal WR in planar image and increased WR in the culprit lesion showed no significant association with MACE in the multivariate model with WR in the non-culprit lesion. Kaplan-Meier analysis revealed that patients with increased WR in the non-culprit lesion had significantly higher risk for MACE than those without increased WR (45% vs 11% p<0.001). Conclusion(s) The activation of cardiac sympathetic nervous system in the non-culprit lesion is particularly associated with poor prognosis in patients with acute myocardial infarction.MACE risk by WR in non-culprit lesion

Cluster-specific risk factors for suboptimal thromboprophylaxis in contemporary European cohort of patients with atrial fibrillation: the EHRA-PATHS Project

Abstract Background Oral anticoagulation (OAC) is essential to optimal thromboprophylaxis in patients with atrial fibrillation (AF). Owing to bleeding risk concerns, OAC use may be challenging in clinically complex high-risk AF patients. Comorbidities might lead to suboptimal OAC use. We assessed cluster-specific risk factors for non-prescribing OAC in pre-defined AF clusters in contemporary European EHRA-PATHS AF cohort. Methods The EHRA-PATHS AF cohort was constructed using data from the three prospective EurObservational Research Programme (EORP) AF registries - General Pilot, General Long-term, and AF III registry. A two-step cluster analysis was performed. A hierarchical cluster analysis with 18 variables was used to identify the optimal number of clusters, followed by a K-means cluster analysis to determine variable cluster association. Cluster-specific risk factors for non-prescribing OAC were identified using univariate and multivariate logistic regression analyses. Results Of 18.799 patients, 2086 (11.1%) were not prescribed with OAC. Among the three clusters (see Table), OAC non-prescribing was significantly more prevalent in Cluster 1 (younger healthier AF patients) compared with Cluster 2 (Elderly with less comorbidity, mostly non-cardiovascular) or Cluster 3 (Elderly with more comorbidity, mostly cardiovascular), both P<0.001, with no significant difference between Clusters 2 and 3 (P=0.161). Cluster-specific multivariable risk factors for non-prescribing OAC are shown in Table. In all three clusters AF clinical type was significantly associated with OAC non-use. In Cluster 1, OAC non-use was less likely in the presence of CHA2DS2-VASc stroke risk factors, while bleeding risk factors were predominant multivariable predictors of OAC non-use among elderly (Clusters 2 and 3). Conclusion Our findings in a large contemporary European cohort suggest that different considerations prevail in treatment decision on OAC use in AF patients in clinical practice, depending on patient’s age and AF clinical type, as well as the presence and type of underlying comorbidities. Our findings could help in formulating targeted interventions to optimize stroke prevention in different subgroups of AF patients.

Limited critical and communicative health literacy is related to poorer health among older adults

Abstract Background Health literacy-related challenges are expected to increase with age due to a discrepancy between individual capacity and health care demands. Knowledge about associations between health literacy and age-related health outcomes among older adults is scarce. This is important to address and promote optimal health in older adults. The study aims to investigate the association between health literacy and health status among older adults and explore differences between the younger old and the oldest old adults. Methods Cross-sectional study using SWEOLD population-based data from 2022, a national representative sample of people 77+ years in Sweden. Univariate and multivariate logistic regression analysis assessed associations between communicative- and critical health literacy and health outcomes. Models were adjusted for age, sex, and socioeconomic status, and stratified by age. Results Significant adjusted associations were found between inadequate and problematic health literacy and less than good self-rated health (OR 2.64, 95%CI: 1.61-4.33; 2.11, 95%CI: 1.40.3.17), and requiring assistance with medicine management (OR 5.26, 95%CI: 2.67-10.38, 2.14, 95%CI 1.08-4.22). Among the younger old (77-84 years) inadequate and problematic HL was associated with having lifestyle-related conditions (OR 1.77, 95%CI: 1.07-2.93, 2.75, 95%CI: 1.33-2.71). Among the oldest old (85+), inadequate health literacy was associated with higher likelihood of poor activities of daily living (ADL) (OR 4.48, 95%CI: 1.99-10.07) and frailty (OR 3.51, 95%CI: 1.43-8.47). Level of frailty increases earlier in age for individuals with limited HL than among those with sufficient HL. Conclusions Limited health literacy is a prevalent issue in the older population and is associated with negative health-related outcomes. To mitigate development of poor health and frailty and to promote healthy ageing, care organisations need to meet the needs of this population in a health literacy friendly way. Key messages • Limited health literacy among the older population is associated with several negative health-related outcomes. • Care organisations need to work actively to mitigate the development of poor health while promoting healthy aging among the older population in a health literacy-friendly and age sensitive manner.

Nationwide analysis of in-hospital mortality and renal infarction trends following cardiac output assist device placement from 2017 to 2020

Abstract Background Cardiac output assist devices (COAD) have become a crucial therapeutic option for advanced heart failure patients. However, the clinical outcomes and complications associated with cardiac output device placement, especially in relation to renal health, remain a subject of concern. Purpose We aimed to examine temporal trends of in-hospital mortality and renal infarct (RI) among heart failure in patients who underwent placement of cardiac output assist devices, including intra-aortic balloon pumps and impeller-based devices, between 2017 and 2020. Methods The National Inpatient Sample was queried from 2017 to 2020 to identify all adults who underwent COAD using the International Classification of Diseases 10th Revision codes. The Cochran-Armitage test was used to assess the linear trend of in-hospital RI among patients with COAD. Multivariate and univariate regression analysis was conducted to assess the yearly association of COAD with in-hospital mortality and RI with COAD. The Elixhauser comorbidity index was used to adjust for confounders. Linear logistic results are represented as adjusted odds ratios (ORs) with their respective 95% Confidence Intervals (CI). Results Of the 176,225 patients who underwent COAD, 385 (0.2%) experienced RI, predominantly male (72%) with a mean age of 58. Trend analysis showed an upward trend in RI (trend: 0.21%, p < 0.001) associated with COAD from 2017 to 2020. In 2018, 0.19% of patients had RI (OR = 3, 95% CI 2.1-6.1, p < 0.001), 0.23% in 2019 (OR = 4.6, 95% CI 2.5-7, p < 0.001), and 0.29% in 2020 (OR = 3.6, 95% CI 2.3-5.9, p < 0.001), compared to 0.17% in 2017 (OR = 2.3, 95% CI 1.1-4.7) demonstrated in Figure 1. Mortality among RI and COAD patients was 40% in 2017 (OR 3, 95% CI 1.2-8.9, p = 0.04), decreased to 24% in 2018 (OR 1.2, p = 0.69), but increased to 43% in 2019 (OR 3.2, 95% CI 1.2-7.9, p = 0.01) and remained high at 42% in 2020 (OR 2.9, 95% CI 1.3-6.9, p = 0.019) as illustrated in Table 1. Overall, in-hospital mortality was 38% (OR 2.5, 95% CI 1.5-4, p < 0.001). Conclusions Our study identified a rising trend in in-hospital RI rates among patients with cardiac output assist devices from 2017 to 2020, accompanied by a significant risk of in-hospital mortality. Despite these complications occurring in a small percentage of individuals, they highlight the critical need for vigilant monitoring and proactive management in this patient population.Figure 1

Prognostic impact of SGLT2-inhibitor therapy on survival in patients with transthyretin amyloid cardiomyopathy

Abstract Background Sodium-glucose co-transporter 2 inhibitors (SGLT2i) significantly improve cardiovascular outcomes in patients with heart failure across the whole spectrum of ejection fraction. Recently published data indicates the safety and tolerability of SGLT2i therapy in patients with transthyretin amyloid cardiomyopathy (ATTR-CM). However, there is a lack of evidence regarding the impact of SGLT2i therapy on clinical outcomes in those patients. Purpose This study aims to investigate the association between SGLT2i therapy and clinical outcomes in patients with ATTR-CM. Methods This is an analysis of a prospective registry conducted at an expert center for hypertrophic cardiomyopathies. We included all participants with a confirmed diagnosis of ATTR-CM, who were enrolled until December 2022. Prior and concomitant SGLT2i treatment was systemically assessed according to the patient interview and medical records. Patients’ outcomes were retrieved from local medical and health insurance records. Results We enrolled 116 patients, of whom 7 patients (6%) were treated with SGLT2i at inclusion and 44 patients (38%) were started on SGLT2i therapy during the observational period while 65 patients (56%) were SGLT2i-naïve. There were no significant differences in baseline characteristics between groups, as shown in the table. Median (interquartile range) age was 80 (76-82) years with 15% females. Median N-terminal pro-brain natriuretic peptide (NT-proBNP) was 2844 (1519-5033) pg/ml, median estimated glomerular filtration rate (eGFR) 58 (46-69) ml/min/1,73m2, and median troponin T 56 (34-83) pg/ml. During a median follow-up of 2.6 (1.8-3.7) years, 28 patients (24%) died, of whom 6 patients (5%) were in the treatment group and 22 patients (19%) in the control group. In univariate Cox-regression analysis, SGLT2i treatment was significantly associated with a lower mortality (HR 0.325, 95%CI 0.132-0.802, p=0.015). This association persisted after adjusting for age and sex (HR 0.347, 95%CI 0.139-0.867, p=0.023). However, when treatment initiation time was considered, the benefit did not remain statistically significant. No significant associations between SGLT2i treatment and worsening heart failure hospitalizations or cardiovascular death were observed. Conclusion In a prospective registry-based cohort of patients with ATTR-CM, SGLT2i therapy was associated with significantly better survival, with a potential treatment initiation time bias. These results suggest that SGLT2i may exert beneficial effects in patients with ATTR-CM and warrant a randomized controlled trial.

Myocardial parametric mapping in patients with suspected acute myocarditis: a prognosis study

Abstract Background T1 mapping and T2 mapping have become essential components of the 2018 Lake Louise criteria and obtained excellent results in diagnosing myocarditis. However, their prognostic value in acute myocarditis has not yet been well recognized or established. Purpose Our study aims to investigate the prognostic value of T1 mapping, T2 mapping, and extracellular volume fraction (ECV) in a large cohort of patients with suspected acute myocarditis. Materials Patients meeting the recommended clinical criteria for suspected acute myocarditis were consecutively enrolled. The primary endpoint is the composite of cardiac death, heart failure hospitalization, heart transplantation, sustained ventricular arrhythmia, and recurrent myocarditis, defined as major adverse cardiovascular events (MACE). All patients underwent CMR at 3.0 T scanner using a standardized, routine imaging protocol, and the three short-axis view slices (basal, mid-ventricular, and apical) were divided into 16 segments according to the American Heart Association 17-segment model (apex excluded). We also averaged the native T1 values, ECV, and T2 values of all 16 segments to get global T1 and ECV fraction values, respectively. Statistically significant parameters from univariate Cox analyses were put into multivariate Cox analysis. Results A total of 235 patients (150 men; 32±13 years) were enrolled in this study. During a mean follow-up of 43.0±3.6 months, MACE occurred in 37 patients (15.7%) and was univariably associated with heart failure presentation, left ventricular ejection fraction, left ventricular end-systolic volume index, left ventricular end-diastolic volume index, native T1 and ECV. Patients with MACE showed higher global native T1, ECV, and T2 values (1348±59 vs 1266±51, p=<0.001; 40.0±8.7 vs 32.8±5.9, p<0.001; 63.4±12.1 vs. 55.5±9.1, p=0.011), and were more likely to have tissue changes in the interventricular septum and anterior wall (Figure 1). In a series of nesting multivariable Cox regression models, the addition of native T1 (per 10-ms increase: HR, 1.128; 95% CI: 1.043, 1.220; p = 0.003; Harrell’s C-index = 0.833) or ECV (per 5% increase: HR, 1.382; 95% CI: 1.060, 1.802; p = 0.017; Harrell’s C-index = 0.847) improved prognostication compared with the model based on clinical variables, left ventricular ejection fraction, and septal late gadolinium enhancement (Harrell’s C-index = 0.762) (Figure 2). T2 in multivariate Cox regression analysis didn’t show predictive value, but his inclusion increased the C-index of the model to 0.814. Conclusions Myocardial parametric mapping not only holds substantial diagnostic value but also plays a critical role in the prognostic assessment and risk prediction of myocarditis. Their utilization in these contexts enhances the accuracy and effectiveness of clinical evaluations and decision-making processes.

Prediction of microvascular invasion in hepatocellular carcinoma with conventional ultrasound, Sonazoid-enhanced ultrasound, and biochemical indicator: a multicenter study

PurposeTo develop and validate a preoperative prediction model based on multimodal ultrasound and biochemical indicator for identifying microvascular invasion (MVI) in patients with a single hepatocellular carcinoma (HCC) ≤ 5 cm.MethodsFrom May 2022 to November 2023, a total of 318 patients with pathologically confirmed single HCC ≤ 5 cm from three institutions were enrolled. All of them underwent preoperative biochemical, conventional ultrasound (US), and contrast-enhanced ultrasound (CEUS) (Sonazoid, 0.6 mL, bolus injection) examinations. Univariate and multivariate logistic regression analyses on clinical information, biochemical indicator, and US imaging features were performed in the training set to seek independent predictors for MVI-positive. The models were constructed and evaluated using the area under the receiver operating characteristic curve (AUC), calibration curve, and decision curve analysis in both validation and test sets. Subgroup analyses in patients with different liver background and tumor sizes were conducted to further investigate the model’s performance.ResultsLogistic regression analyses showed that obscure tumor boundary in B-mode US, intra-tumoral artery in pulsed-wave Doppler US, complete Kupffer-phase agent clearance in Sonazoid-CEUS, and biomedical indicator PIVKA-II were independently correlated with MVI-positive. The combined model comprising all predictors showed the highest AUC, which were 0.937 and 0.893 in the validation and test sets. Good calibration and prominent net benefit were achieved in both sets. No significant difference was found in subgroup analyses.ConclusionsThe combination of biochemical indicator, conventional US, and Sonazoid-CEUS features could help preoperative MVI prediction in patients with a single HCC ≤ 5 cm.Critical relevance statementInvestigation of imaging features in conventional US, Sonazoid-CEUS, and biochemical indicators showed a significant relation with MVI-positivity in patients with a single HCC ≤ 5 cm, allowing the construction of a model for preoperative prediction of MVI status to help treatment decision making.Key PointsMVI status is important for patients with a single HCC ≤ 5 cm.The model based on conventional US, Sonazoid-CEUS and PIVKA-II performs best for MVI prediction.The combined model has potential for preoperative prediction of MVI status.Graphical

National survey to estimate seroprevalence for toxoplasmosis among pregnant women in France, 2021

Abstract Background Toxoplasmosis during pregnancy can result in congenital malformations and fetal death. In France, universal antenatal screening and monthly re-testing of seronegative pregnant women has been established since the 1970s. However, decreasing Toxoplasma gondii seroprevalence among pregnant women and lower incidence of congenital toxoplasmosis may challenge the cost-effectiveness of such programs. The aim of this study was to estimate the current seroprevalence among pregnant women participating in the 2021 national perinatal survey (ENP). Methods All adult women giving birth in France between 15-21 March 2021 were invited to participate in the ENP. Data collected included demographic information, nationality, socio-economic status, education level and Toxoplasma gondii serology. We classified a woman as seropositive if she had IgG antibodies prior to pregnancy or seroconverted during it. Univariable and multivariable regression analyses using Poisson model were conducted to estimate prevalence ratios (PRs) and identify significant factors associated with seropositivity. Results Among the 15,605 participating women, 0.22% seroconverted during pregnancy. The overall seroprevalence was 25.95%. Seropositivity was higher with increasing age (∼5% per 5 years), among residents of French overseas territories Guadeloupe/Saint Martin (PRs:1.07; 95%-CI: 1.03-1.10), La Réunion (PRs:1.10; 95%-CI: 1.08-1.13) and Mayotte (PRs:1.27; 95%-CI: 1.23-1.31), with lower education (PRs:1.22; 95%-CI: 1.04-1.42) and African nationality (PRs:1.11; 95%-CI: 1.02-1.20). Conclusions High seroprevalence for Toxoplasma gondii was found in older women, which may reflect their higher risk of past exposure. The observed geographical differences in seroprevalence may mirror dietary and environmental diversity. Declining seroprevalence among pregnant women in France can affect screening effectiveness and warrants a comprehensive review to determine appropriate future prevention strategies. Key messages • Older women and residents of French overseas territories show higher toxoplasmosis seroprevalence, possibly due to past exposure risks and diverse diets/environments. • Declining toxoplasmosis seroprevalence among pregnant women in France can affect screening effectiveness and warrants a comprehensive review to determine appropriate future prevention strategies.

Cardiac risk confrontation in primary care as a teachable moment towards improved health outcomes

Abstract Background Urgent life events, such as acute coronary events, can evoke a teachable moment (TM) for lifestyle change. This study aims to investigate whether less urgent events, such as being confronted with an increased risk of cardiovascular disease, can evoke a TM, what psychosocial factors are associated with it, and whether experiencing such a TM predicts improved health outcomes. Methods The study included 114 patients who were informed about their elevated cardiovascular risk during a primary care visit. Participants completed a survey assessing whether they experienced a TM and several psychosocial factors linked to experiencing it: perceived risk, affective impact, changed self-concept. Participants monitored their weight and blood pressure for six months using an at-home self-monitoring device. Univariate and multivariate regression analyses were conducted to examine the associations between the psychosocial factors and the lifestyle change intentions with changes in blood pressure and weight. Results Of the participants, 55.3% experienced increased lifestyle change intentions. Lower risk perception ((B = -0.27; CI = -0.39-(-0.15)) and higher change in self-concept (B = 0.34; CI = 0.23-0.44) were associated with higher intention to change lifestyle. Higher risk perception (B = 0.23; CI = 0.06-0.42) and higher change in self-concept (B = 0.54; CI = 0.37-0.72) predicted a lower weight reduction at six months. A higher change in self-concept predicted a higher blood pressure reduction (B = -3.32; CI = -6.55-(0.09)). Lastly, a higher lifestyle change intention predicted bigger reductions blood pressure (B = -5.04; CI = -9.08-(-0.29)). Conclusions Results suggest that less urgent cardiac events, such as a confrontation with an increased cardiac risk, can be experienced as a TM that urges lifestyle change intentions and affects health outcomes. Risk confrontations in primary care therefore offer a unique opportunity to provide lifestyle counseling at the right moment. Key messages • A confrontation with an increased cardiac risk in primary care can be experienced as a teachable moment. • Experiencing a teachable moment after a cardiac risk confrontation in primary care affects health outcomes.

Effect of left atrial function on cardiovascular outcome in non-dilated left ventricular cardiomyopathy

Abstract Background This study aimed to determine whether atrial function and strains can provide the greatest or joint incremental prognostic value in patients with non-dilated left ventricular cardiomyopathy (NDLVC) over a long follow-up period. Methods One hundred sixty-four NDLVC patients were included retrospectively. Comprehensive clinical evaluation and echocardiographic investigations were obtained, including measurements of strain derived left atrial (LA) reservoir, conduit, booster strain. All patients were followed up for adverse cardiac events (MACE) including all-cause mortality, hospitalization due to heart failure aggravation. The predictors of MACE were examined with univariable and multivariable Cox regression analysis. Subsequently, nested Cox regression models were built to evaluate the incremental prognostic value of strain parameters. Patient survival was illustrated by Kaplan–Meier curves and differences were evaluated by log-rank test. Results During a median follow-up of 3.8 years, MACEs were identified in 34 (21%) patients. Cox regression models showed that the predictive value of LA conduit strain was independent from and incremental to LAVi and baseline variables. Age, E/e', RASP and LA reservoir and conduit strain were univariably associated with the outcome (all P < 0.05). LA conduit strain was a stronger predictor of outcome compared with reservoir strain. LA conduit strain, age, RASP remained associated in the multivariable model (LA conduit strain HR: 2.14 [95% CI: 1.37-3.87; P < 0.007]; age HR: 1.05 [95% CI: 1.01-1.10; P = 0.020]; and RASP HR: 1.07 [95% CI: 1.01-1.14; P = 0.021]), whereas LVEF, LAVi were not. Adding LA conduit strain to other independent predictors (age and LAVi) improved the prediction of MACEs. (p < 0.05). Also, when a Kaplan Meier graph was obtained for the occurrence of MACE based on LA conduit strain 17%, a significant difference was shown between the two groups. Conclusion LA conduit strain provided the good prognostic value and added incremental value to conventional clinical predictors for patients with NDLVC.Incremental value of LA strainKM according to LA strain 17%

Leveraging ML for profiling lipidomic alterations in breast cancer tissues: a methodological perspective

In this study, a comprehensive methodology combining machine learning and statistical analysis was employed to investigate alterations in the metabolite profiles, including lipids, of breast cancer tissues and their subtypes. By integrating biological and machine learning feature selection techniques, along with univariate and multivariate analyses, a notable lipid signature was identified in breast cancer tissues. The results revealed elevated levels of saturated and monounsaturated phospholipids in breast cancer tissues, consistent with external validation findings. Additionally, lipidomics analysis in both the original and validation datasets indicated lower levels of most triacylglycerols compared to non-cancerous tissues, suggesting potential alterations in lipid storage and metabolism within cancer cells. Analysis of cancer subtypes revealed that levels of PC 30:0 were relatively reduced in HER2(−) samples that were ER(+) and PR(+) compared to those that were ER(−) and PR(−). Conversely, HER2(+) tumors, which were ER(−) and PR(−), exhibited increased concentrations of PC 30:0. This increase could potentially be linked to the role of Stearoyl-CoA-Desaturase 1 in breast cancer. Comprehensive metabolomic analyses of breast cancer can offer crucial insights into cancer development, aiding in early detection and treatment evaluation of this devastating disease.

Prognostic utility of heart-type fatty acid binding protein in patients with cardiac amyloidosis

Abstract Background Heart-type fatty acid binding protein (H-FABP) is a biomarker that has been shown to provide long-term prognostic information in patients with heart failure (HF), yet its role in patients with cardiac amyloidosis (CA) is unknown. Purpose We aim to investigate the association of H-FABP levels with prognosis in patients with CA. Methods Consecutive patients diagnosed with cardiac amyloidosis from October 2015 to May 2022 at Heart Failure Center, of our hospital were enrolled. Patients were categorized into 2 categories based on H-FABP levels measured in the baseline blood sample: < or = 7 ng/ml (low H-FABP), >7 ng/ml (high H-FABP). Univariate and multivariate Cox models were used to identify predictors of survival. Kaplan-Meier analysis was performed to compare survival between patients with low or high H-FABP. Results Overall, ninety-five patients were included. H-FABP was elevated (>7 ng/ml) in 37 patients (39%). Patients with high H-FABP were more likely to present with higher levels of high-sensitivity troponin-T (hs-TNT)(0.17ng/mL vs. 0.11ng/mL, p =0.01) and higher levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP) (18098.76pg/mL vs. 6211.69pg/mL, p<0.001). Patients were followed for an average follow-up period of 440 days, in which 53 (56%) patients died. Univariate and multivariate analysis demonstrated that H-FABP levels (HR 1.48, 95% CI 1.03-2.13, per 1-SD greater) was independently associated with prognosis, even after adjusting for NT-proBNP, hs-TNT and renal function. Conclusions Elevation of H-FABP is associated with an increased risk of death in patients with cardiac amyloidosis. H-FABP can serve as a novel biomarker independent of other established predictors for prognosis in cardiac amyloidosis.Kaplan-Meier curves for overall survival

Long-term prognosis in patients undergoing atrial fibrillation ablation

Abstract Aims The aim of the analysis was to assess the risk of atrial fibrillation (AF) recurrence in the long-term observation of contemporary patients undergoing pulmonary vein isolation (PVI), who did not have recurrence during the first year after catheter ablation. Methods Retrospective analysis has been performed. Inclusion criteria: (1) the patients undergoing their first PVI in years 2017–2022, (2) the electroanatomical system, contact force catheters and lesion indexes (Ablation Index or Lesion Size Index) were used, (3) no recurrences were observed during the first 12 months of follow-up, and (4) follow-up longer than 12 months was available. Demographic, clinical and echocardiographic data were collected. Follow-up was based on ambulatory visits with ECG/holter monitoring or implanted device interrogation, when available. Results A total of 247 patients were included. The median follow-up was 22 months (interquartile range, 16–31 months). After 24 months, ablation efficacy was 84%, and after 36 months, it was 72%. In the univariate Cox regression analysis, age, previous electrical cardioversion, glomerular filtration rate (eGFR) and the presence of coronary artery disease were linked to AF-free survival. Interestingly, nonparoxysmal AF, left atrial (LA) dimension, heart failure, hypertension or diabetes were not linked to the risk of long-term recurrences. In multivariate Cox regression analysis, presence of coronary artery disease and previous electrical cardioversion were independently linked to the risk of long-term recurrence. In 127 (51.4%) patients, information about the presence of low voltage areas (LVA) was available, and in 21 (16.5%) patients in this group, the presence of LVA was found. Survival of patients with LVA was strikingly worse than that of those without (Figure 1), log-rank test p <0.0001. Conclusions Patients who had no recurrences within one year after PVI, still have substantial risk of recurrence in the next 2 years. That concerns specially the patients who had LVA in the electroanatomical mapping.

International cooperation in cardiogenic shock is key to improving outcomes: Cardiogenic Shock Working Group impacts a single-center in a developing country

Abstract Background Management of cardiogenic shock (CS) poses a formidable challenge in healthcare, necessitating innovative approaches and collaborative efforts, not only local, to improve outcomes. Purpose To demonstrate that CSWG international cooperation and research in CS can lower mortality, change practices, and improve outcomes. Methods From our institutional registry 28,054 patients, we selected 9,430 with CS in SCAI CWSG-score B-E 2022-23 CSWG incorporation (n=1112) against previous years (05-21, n=8318). The primary outcome was in-hospital mortality. Univariate and multivariate analyses were performed, and with PAC use as a a priori subgroup. Adjusted analysis was carried out with age, sex, DM, HTN, previous MI, PCI, CABG, or stroke; CKD, CS etiology, PAC, hemodialysis, number of vasoactives; the presence of MCS, use of mechanical ventilation, and SCAI-CSWG stage. Also, propensity score matching was used to explore differences using the a priori selected variables using K-nearest neighbors (K=2), radius of 1:2, caliper 0.2, and exact SCAI stage matching without replacement (Pre-CSWG n=2198, CSWG era n=1106). Results In the CSWG era, there's a increase in mean age (P=0.049) and a higher proportion of men (72.2 vs. 68%, p=0.005). Clinical risk factors show changes, including increased weight (P=0.037), higher smoking (53.3 vs. 48.6%, P=0.003), diabetes (40.1 vs. 34.8%, P=0.001), and hypertension (46.8 vs. 50%, p=0.043). Prior MI and CABG decreased significantly in the CSWG era. Therapeutic shifts are evident, with increased use of PAC (7.9 vs. 4.2%, P<0.001) and significant changes in mechanical circulatory support (p<0.001). Mortality substantially decreases in the CSWG era (15.3 vs. 22.3%, P<0.001). The unadjusted Cox Pre-CSWG era, the HR 1.41 (1.2-1.65, P< 0.001) a restricted mean survival time (RSMT) of 1.73 days (0.92-2.54, P<0.001). In PAC subgroup, the relationship between PAC use and outcomes appears to be consistent across the levels of the interacting variable (Pint=0.918), with a HR Pre-CSWG era 0.51 (0.44-0.59, P <0.001) and CSWG era HR 0.48 (0.33-0.71,P <0.001)(Fig1C) The adjusted analysis, the Pre-CSWG era had a HR 1.21 (1.03-1.42, P=0.019). PAC outcomes were consistent across eras (Pint= 0.923). In the Pre-CSWG era HR 0.71 (0.59-0.84,P<0.001), and similarly in the CSWG era 0.54 (0.34-0.87,P=0.01). (Fig1D) The PS-cohort had a Pre-CSWG era HR 1.21 (1.01-1.45, P=0.034) of the Pre-CSWG era vs CSWG era and a RSMT at 30 days of 1.07 (0.14-2.01 P=0.025). (Fig2) Conclusion Shifts in patient demographics, clinical risk factors, hemodynamic parameters, and therapeutic strategies were observed. Notably, mortality significantly decreased with the CSWG incorporation, with consistent benefits of PAC use in both eras. The PS cohort underscored the impact of CSWG incorporation on outcomes. Overall, these findings highlight the transformative influence of CSWG on CS management, as international cooperation is key to improving outcomes.Figure 1.Mortality through erasFgure 2.Propensity score cohort

Role of inflammation and cholesterol efflux in myocardial infarction patients without standard modifiable risk factors

Abstract Background A substantial proportion of ST-segment elevation myocardial infarction (STEMI) patients has no standard modifiable cardiovascular risk factors (SMuRF) at admission. Knowledge on pathogenesis and risk markers of mortality in these patients remain limited. Aims We described the characteristics and prognosis of SMuRF-less patients admitted for a first STEMI in the light of recent prognostic biomarkers. Methods Baseline characteristics including interleukin (IL)-1β, hs-CRP and serum cholesterol efflux capacity were compared between patients with and without SMuRF. Determinants of 1-year all-cause mortality were assessed using univariable and multivariable Cox regression analyses. Results Among the 1604 patients included, 178 (11.1%) were SMuRF-less. SMuRF-less patients were older (66.9 ± 15.3 vs 61.9 ± 13.9, p<0.001), less often men (66.9 vs 75.9%, p<0.001) and had lower body mass index (24.2 ± 3.9 vs 26.0 ± 4.4, p<0.001) compared to patients with ≥1 SMuRFs. SMuRF-less patients presented higher rates of altered LVEF<45% and killip≥2 at admission (31.8% vs 22.8%, p=0.014 and 19 vs 12.9%, respectively, p=0.027) without differences in proportions of late STEMI presenters (symptoms-to-balloon time >360 min) did not differ between groups. SMuRF-less patients had lower rates of revascularization (82 vs 92.3%, p<0.001) and received less guidelines recommended medications (statins, β-blockers or angiotensin-converting enzyme (ACE) inhibitors) at discharge; p<0.001 for all. Compared to patients with SMuRF, SMuRF-less patients had lower serum cholesterol efflux capacity (0.79 ± 0.16 vs 0.83 ± 0.16, respectively, p<0.001), were more often in the highest tertile of IL-1β (28.7% vs 18.9%, respectively, p=0.002) with a trend towards more patients within the highest hs-CRP level tertile (24.7% vs 19.1%, respectively, p=0.077). Crude rates of mortality were more than doubled in the SMuRF-less group (18.5% vs 7.7%, respectively, p<0.001). After multivariable adjustment SMuRF-less status was associated with a higher rate of mortality at one year aHR 1.87 [1.05-2.38], p=0.029) as well as inflammation biomarkers IL-1β (HR 1.81 [1.23-2.66], p=0.003) and high tertiles of hs-CRP (HR 1.87 [1.31-2.66], p<0.001) whereas having a high serum cholesterol efflux capacity was associated with a lower mortality (HR 0.27 [0.09-0.87], p=0.0208). Conclusion In STEMI patients, SMuRF-less patients have higher levels of inflammatory biomarkers and more frequent defective serum cholesterol efflux capacity, are undertreated, and have higher rate of mortality than patients with standard modifiable cardiovascular risk factors. Optimized management of such patients is needed.

Prognostic preoperative factors for recurrence of tricuspid regurgitation following annuloplasty: examining the influence of 3d echocardiography

Abstract Introduction The increasing worry revolves around the reappearance of tricuspid regurgitation (TR) following tricuspid annuloplasty (TA) among individuals dealing with functional tricuspid regurgitation (FTR). Despite TA's efficacy as a treatment, a complete understanding of the echocardiographic elements influencing the recurrence of TR is pivotal. This knowledge holds the potential to guide the development of more robust preventive strategies, aiming to ease the incidence of recurrent TR after TA. Aim The aim of this study was to examine the prognostic value of tricuspid valve (TV) and echocardiographic parameters related to both right ventricular (RV) geometry and function. Specifically, our focus is on understanding these relationships in the context of recurrent TR following TA. Methods This prospective observational cohort study aimed to investigate determinants of recurrent TR post-surgical TV repair. The focus was on patients with moderate or severe functional TR related to left heart valvular disease, primarily severe mitral regurgitation, excluding those with ischemic heart disease. The study involved 66 participants, assessed preoperatively with 2D and 3D echocardiography, examining RV and right atrial (RA) geometry, functional, and TV parameters. TR severity followed ESC guidelines. Two groups were formed: effective TA group (50 patients) and recurrent TR group (16 patients), defined by mild to moderate TR and significant moderate-severe TR one year post-surgery, respectively. Statistical analysis employed SPSS software, with adjusted univariate logistic regression considering age and gender. Results Of the patients, 54% were male, with a mean age of 68±9 years. Echocardiography parameters in Table 1 showed no significant differences in gender, left ventricular, atrial geometrical, functional parameters, or preoperative effective regurgitant TV orifice area between groups (recurrent TR vs. effective TA: 38 [33] mm2 vs. 29 [15] mm2, p=0.117). Univariate logistic regression analysis highlighted RV and RA geometry, along with TV diameter, as predictors for recurrent TR. Notably, 3D TV geometrical parameters had prognostic significance, as confirmed by univariate adjusted logistic regression analysis. Functional RV parameters did not exhibit statistical significance in this analysis. Conclusion In conclusion, the recurrence of moderate-severe functional tricuspid regurgitation following tricuspid annuloplasty is linked to the tricuspid annulus size, as well as the geometry of the right atrium and right ventricle before surgery. Notably, no correlation was identified between the recurrence of TR and alterations in RV function.

Association between surgery treatment delays and survival outcomes in patients with esophageal cancer in Hebei, China

IntroductionThe delays in cancer therapies have the potential to impact disease progression by allowing the unchecked growth and spread of cancer cells. However, the understanding of the association between treatment waiting time and survival outcomes in patients with esophageal cancer (EC) is limited. This study aims to assess the impact of waiting time on survival outcomes among EC patients in Hebei province, which is recognized as one of the high-risk areas for EC in China.MethodsA total of 9,977 non-metastatic EC patients who underwent surgical treatment were identified between 2000 and 2020. The survival outcomes of overall survival (OS) and cancer-specific survival (CSS) were determined using the Kaplan-Meier methodology. Univariate and multivariate Cox regression analysis was employed to evaluate the impact of treatment delays on OS and CSS.ResultsThe average delay time for initiating EC surgical treatment after diagnosis was 1.31 months (95%CI=1.29–1.34). Patients with a long delay (≥ 3 months) in treatment, comprising 9977 EC patients, exhibited significantly lower rates of 3-, 5-, and 10-year OS and CSS compared to those without any delay in treatment initiation. A long delay in EC treatment independently associated with an elevated risk of all-cause and cancer-cause mortality among various patient subgroups, including males, older individuals, single individuals, low-income patients, residents of nonmetropolitan counties, as well as those diagnosed with poorly differentiated and stage IV EC.DiscussionThe long delay of treatment initiation impacts the outcomes of OS and CSS in EC patients. Optimizing treatment timing may enhance life expectancy for individuals diagnosed with EC.

Combination therapy using low-dose anlotinib and immune checkpoint inhibitors for extensive-stage small cell lung cancer.

This study evaluated the efficacy and safety of low-dose anlotinib combined with immune checkpoint inhibitors as second-line or later treatment for extensive-stage small cell lung cancer (ES-SCLC). The study included 42 patients with ES-SCLC who were treated with low-dose anlotinib combined with programmed cell death protein 1/programmed cell death-ligand 1 inhibitors at Henan Cancer Hospital between March 2019 and August 2022. We retrospectively analyzed the efficacy and safety data for these patients. Indicators assessed included progression-free survival (PFS), overall survival (OS), the overall response rate (ORR), the disease control rate (DCR), and adverse events (AEs). Prognostic factors were identified in univariate and multivariate analyses. Median PFS was 11.0 months (95% CI: 7.868-14.132) and median OS was 17.3 months (95% CI: 11.517-23.083). The ORR was 28.5% and the DCR was 95.2%. Treatment-related AEs were noted in 27 patients (64.3%), the most common of which was thyroid dysfunction (26.2%). Grade 3/4 treatment-related AEs were observed in two patients (4.8%). A combination of low-dose anlotinib and immune checkpoint inhibitors as second-line or later treatment for ES-SCLC may achieve longer PFS and OS and have manageable AEs.

Evolution and prognostic impact of left ventricular myocardial work indices after transcatheter aortic valve replacement in patients with severe aortic stenosis

Abstract Introduction Left ventricular myocardial work (LVMW) is an echocardiographic-based technique to evaluate LV function using pressure-strain loops and therefore correcting for the left ventricular (LV) afterload. LVMW indices have been shown to be of prognostic importance in patients with aortic stenosis (AS) before transcatheter aortic valve replacement (TAVR), but no data is available on the evolution and the prognostic value of these parameters after TAVR. Purpose To measure LVMW indices before and after TAVR in patients with severe AS and explore the association with outcome. Methods As previously validated, LV global longitudinal strain (GLS) and LV systolic pressure (as the sum of the brachial arterial blood pressure and mean aortic valve gradient before TAVR and as brachial arterial blood pressure after TAVR) were incorporated to build pressure-strain loops and to calculate the following LVMW indices: global work index (LV GWI), global constructive work (LV GCW), global wasted work (LV GWW) and global work efficiency (LV GWE). The endpoint was all-cause mortality. Results A total of 255 patients were included with a median age of 82 years (IQR 77-85); 51% were men and 67% presented with NYHA class III/IV. After TAVR, LVEF and LV GLS remained in average unchanged (from 56 to 55%, p=0.470 and from 13.6 to 13.2%, p=0.068). While LV GWW remained unchanged after TAVR (from 247 to 258mmHg%, p=0.080), LV GWI, LV GCW and LV GWE significantly decreased (from 1882 to 1291mmHg%, p <0.001, from 2248 to 1671mmHg%, p <0.001 and from 89 to 85%, p <0.001 respectively). During a median follow-up of 59 months (IQR 40-72), 129 patients died. Univariable Cox regression analysis identified an association between all-cause mortality and male sex, diabetes mellitus, chronic obstructive pulmonary disease (COPD), renal function, atrial fibrillation, Charlson comorbidity index, pacemaker implantation, and post-TAVR LV GLS, LV GWI and LV GCW. These clinical parameters were used as a basal multivariable Cox regression model of which on top either post-TAVR LV GLS, LV GWI or LV GCW were added. All these parameters of post-TAVR LV systolic function showed an independent association with all-cause mortality, but LV GWI demonstrated the highest increase in model predictivity (Figure 1). Given the prognostic relevance of post-TAVR LV GWI, the population was divided into LV GWI tertiles. The group with the lowest LV GWI tertile showed a significantly higher proportion of male patients, higher prevalence of atrial fibrillation and also worse pre-TAVR LVEF, LV GLS, LV GWI, LV GCW and LV GWE. Kaplan Meier survival analysis confirmed the worse survival in the group with the lowest LV GWI compared to the highest tertile (log-rank ꭓ2: 8,224, p 0.016, Figure 2). Conclusion LVMW indices change after TAVR and post-TAVR LV GLS, LV GWI, LV GCW are independently associated with all-cause mortality. Among these parameters, LV GWI yielded the highest prognostic value.

Increased serum level of IL-6 predicts poor prognosis in anti-MDA5-positive dermatomyositis with rapidly progressive interstitial lung disease

BackgroudAnti-melanoma differentiation-associated protein 5 antibody-positive dermatomyositis (anti-MDA5-positvie DM) is a subtype of dermatomyositis with a poor prognosis, characterized by rapidly progressive interstitial lung disease (RP-ILD). The study aims to investigate the significance of serum cytokines profiles and peripheral lymphocytes in predicting prognoses of anti-MDA5-positvie DM with RP-ILD. Furthermore, it seeks to analyze longitudinal data of lymphocytes during hospitalization to identify distinct trajectories and cluster patients accordingly.MethodsA total of 168 patients with anti-MDA5-positive DM were enrolled in this retrospective study from two cohorts. Univariate and multivariate Cox regression analyses were conducted to determine the predictors of 6-month all-cause mortality and RP-ILD. Group-based trajectory modeling (GBTM) was employed to model the trajectories of longitudinal peripheral lymphocytes.ResultsIn the multivariate Cox regression analysis, IL-6 ≥ 13.41pg/mL, lymphocytes < 0.5 × 109 /L, lymphocytes from 0.5 to 1.0 × 109 /L, older age, and elevated LDH were identified as independent predictors of 6-month all-cause mortality. Furthermore, IL-6 ≥ 13.41pg/mL, lymphocytes < 0.5 × 109 /L, and lymphocytes from 0.5 to 1.0 × 109 /L were found to be independent predictors of RP-ILD. Additionally, three trajectory groups of lymphocytes within the first week after admission were established based on GBTM. These groups included: Group 1, with low-level of lymphocytes that declined; Group 2, with medium-level of lymphocytes that slightly rose; and Group 3, with high-level of lymphocytes that rose. Notably, group 1 showed the highest mortality (90.7%) and all experiencing RP-ILD. Increased expression of IL-6 in lung tissues was observed in two cases with RP-ILD compared to two cases without RP-ILD. We also found the increased infiltration of CD4 + and CD8 + T cells, particularly CD8 + T cells, in lung tissues from patients with RP-ILD.ConclusionsOur study demonstrated that increased level of serum IL-6 (≥ 13.41pg/mL) and severe lymphopenia were promising predictors of 6-month all-cause mortality and the occurrence of RP-ILD in anti-MDA5-positive DM patients. Furthermore, tracking distinct trajectories of lymphocytes during hospitalization can be utilized to cluster patients.