Dynamic changes in echocardiographic parameters in acute decompensated heart failure: REALITY-ECHO.

BACKGROUND: Appropriate evaluation of hemodynamic status is vital in the management of acute heart failure (AHF). We aimed to investigate the changes in echocardiographic parameters during very acute phases of AHF and their association with clinical outcomes. METHODS: Patients who were admitted to four Japanese hospitals with AHF were prospectively enrolled. Comprehensive echocardiography and B-type natriuretic peptide (BNP) were assessed both on admission and the second day. RESULTS: A total of 271 patients (80 ±â€¯12 years old, 52 % male) was included. Overall, transmitral E velocity, E/A, tricuspid regurgitation pressure gradient (TRPG), and inferior vena cava diameter significantly decreased, and stroke volume and left ventricular ejection fraction showed a significant increase by the second day, whereas E/e' did not change. On the second day, BNP increased in 50 patients (18 %). Despite similar baseline characteristics, patients with increased BNP showed a significantly smaller improvement in transmitral flow parameters (E and A velocity, E/A, and flow patterns) and a smaller decrease in TRPG compared with patients with decreased BNP. Other echocardiographic parameter changes were not different between the groups. A combination of improvement in transmitral flow and TRPG was significantly associated with 90-day and 1-year composite events of all-cause death and heart failure hospitalization after adjustment by the Get With the Guidelines-Heart Failure risk score. CONCLUSIONS: Echocardiographic parameters show a dynamic change in the very acute phase of AHF. Several parameters, such as the transmitral flow and TRPG might be useful in monitoring favorable hemodynamic change.

Artificial intelligence-based point-of-care lung ultrasound for screening COVID-19 pneumoniae: Comparison with CT scans.

BACKGROUND: Although lung ultrasound has been reported to be a portable, cost-effective, and accurate method to detect pneumonia, it has not been widely used because of the difficulty in its interpretation. Here, we aimed to investigate the effectiveness of a novel artificial intelligence-based automated pneumonia detection method using point-of-care lung ultrasound (AI-POCUS) for the coronavirus disease 2019 (COVID-19). METHODS: We enrolled consecutive patients admitted with COVID-19 who underwent computed tomography (CT) in August and September 2021. A 12-zone AI-POCUS was performed by a novice observer using a pocket-size device within 24 h of the CT scan. Fifteen control subjects were also scanned. Additionally, the accuracy of the simplified 8-zone scan excluding the dorsal chest, was assessed. More than three B-lines detected in one lung zone were considered zone-level positive, and the presence of positive AI-POCUS in any lung zone was considered patient-level positive. The sample size calculation was not performed given the retrospective all-comer nature of the study. RESULTS: A total of 577 lung zones from 56 subjects (59.4 ± 14.8 years, 23% female) were evaluated using AI-POCUS. The mean number of days from disease onset was 9, and 14% of patients were under mechanical ventilation. The CT-validated pneumonia was seen in 71.4% of patients at total 577 lung zones (53.3%). The 12-zone AI-POCUS for detecting CT-validated pneumonia in the patient-level showed the accuracy of 94.5% (85.1%- 98.1%), sensitivity of 92.3% (79.7%- 97.3%), specificity of 100% (80.6%- 100%), positive predictive value of 95.0% (89.6% - 97.7%), and Kappa of 0.33 (0.27-0.40). When simplified with 8-zone scan, the accuracy, sensitivity, and sensitivity were 83.9% (72.2%- 91.3%), 77.5% (62.5%- 87.7%), and 100% (80.6%- 100%), respectively. The zone-level accuracy, sensitivity, and specificity of AI-POCUS were 65.3% (61.4%- 69.1%), 37.2% (32.0%- 42.7%), and 97.8% (95.2%- 99.0%), respectively. INTERPRETATION: AI-POCUS using the novel pocket-size ultrasound system showed excellent agreement with CT-validated COVID-19 pneumonia, even when used by a novice observer.

External Validation of the Kumamoto Criteria in Transthyretin Amyloid Cardiomyopathy Screening　- A Retrospective Cohort Study.

Background: The Kumamoto criteria have been proposed as a non-invasive screen for transthyretin amyloid cardiomyopathy. This study assessed the validity of the Kumamoto criteria externally. Methods and Results: The study included 138 patients (median age 73 years; 65% male) who underwent 99 mTc-pyrophosphate (PYP) scintigraphy. Patients were divided into 4 groups according to total scores on the Kumamoto criteria (i.e., 0-3) for the following 3 factors: high-sensitivity cardiac troponin T ≥0.0308 ng/mL, wide (≥120 ms) QRS, and left ventricular posterior wall thickness ≥13.6 mm. The diagnostic performance and positive predictive value (PPV) of the Kumamoto criteria for positive 99 mTc-PYP scintigraphy were validated. Eighteen (13%) patients were positive on 99 mTc-PYP scintigraphy. The Kumamoto criteria had a favorable diagnostic performance (area under the curve 0.808). The PPV for groups with scores of 0, 1, 2, and 3 was 0% (n=0/42), 11% (n=6/57), 21% (n=7/33), and 83% (n=5/6), respectively, which is lower, particularly for those with a score of 2, than in the original Kumamoto cohort. However, the PPV increased after combining the Kumamoto criteria with a history of orthopedic diseases (spinal canal stenosis and/or carpal tunnel syndrome). Conclusions: This study suggests that the Kumamoto criteria have a favorable diagnostic performance; however, the PPV may decrease depending on the study population. Combining the Kumamoto criteria with the presence of orthopedic disease may improve the PPV.

The prognostic impact of the uric acid level in patients who require cardiovascular intensive care - is serum uric acid a surrogate biomarker for critical patients in the non-surgical intensive care unit?

BACKGROUND: The prognostic impact of hyperuricemia and the factors that induce hyperuricemia in cardiovascular intensive care patients remain unclear. METHODS AND RESULTS: A total of 3257 emergency department patients were screened, and data for 2435 patients who were admitted to an intensive care unit were analyzed. The serum uric acid level was measured within 15 min of admission. The patients were assigned to a low-uric acid group (uric acid ⩽7.0 mg/dl, n=1595) or a high-uric acid group (uric acid >7.0 mg/dl, n=840) according to their uric acid level on admission. Thereafter, the patients were divided into four groups according to the quartiles of their serum uric acid level (Q1, Q2, Q3 and Q4), and uric acid levels and Acute Physiology and Chronic Health Evaluation II (APACHE II) score. A Kaplan-Meier curve showed a significantly lower 365-day survival rate in a high-uric acid group than in a low-uric acid group, and in Q3 than in Q1 or Q2 and in Q4 than in the other groups. The multivariate logistic regression model for 30-day mortality identified Q4 (odds ratio: 1.856, 95% confidence interval (CI) 1.140-3.022; p=0.013) as an independent predictor of 30-day mortality. The area under the receiver-operating characteristic curve values of the serum uric acid level and APACHE II score for the prediction of 30-day mortality were 0.648 and 0.800, respectively. The category-free net reclassification improvement and integrated discrimination improvement showed that the calculated risk shifted to the correct direction by adding the serum uric acid level to the APACHE II score (0.204, 95% CI 0.065-0.344; p=0.004, and 0.015, 95% CI 0.005-0.025; p=0.004, respectively). The prognosis, including the 365-day mortality, among patients with a high uric acid level and a high APACHE II score was significantly poorer in comparison with other patients. CONCLUSION: The serum uric acid level, which might be elevated by the various critical stimuli on admission, was an independent predictor in patients who were emergently hospitalized in the intensive care unit. The serum uric acid level is therefore useful as a surrogate biomarker for critical patients in the intensive care unit.

Hyperuricemia complicated with acute kidney injury is associated with adverse outcomes in patients with severely decompensated acute heart failure.

BACKGROUND: The relationship between the serum level of uric acid (UA) and the acute kidney injury on admission in patients with acute heart failure (AHF) remain unclear. METHODS AND RESULTS: A total of 1326 AHF patients were screened, and data for 1047 patients who were admitted to the intensive-care unit were analyzed. The patients were assigned to a low-UA group (UA ≤ 7.0 mg/dl, n = 569) or a high-UA group (UA > 7.0 mg/dl, n = 478) according to their UA level at admission. Acute kidney injury (AKI) at admission was defined based on the ratio of the serum creatinine value recorded on admission to the baseline creatinine value: no-AKI (n = 736) or AKI (n = 311). The patients were therefore assigned to four groups: low-UA/no-AKI (n = 428), high-UA/no-AKI (n = 308), low-UA/AKI (n = 141) and high-UA/AKI (n = 170). The high-UA patients were significantly more frequent in the AKI group than in the non-AKI group among all patients and the non-chronic kidney injury (CKD) cohort. A Kaplan-Meier curve showed a significantly lower 365-day survival rate in the high-UA/AKI group than in the other groups. The multivariate Cox regression model identified only high-UA/AKI as an independent predictor of 365-day mortality (hazard ratio [HR]: 2.511, 95% confidence interval [CI] 1.671-3.772 in all AHF patients, HR: 1.884, 95% CI 1.022-3.473 in non-CKD patients and HR: 3.546, 95% CI 2.136-5.884 in CKD patients). CONCLUSION: An elevated serum UA level complicated with AKI was an independent predictor of mortality in patients with severely decompensated AHF.

Gender Differences in the Social Determinants of the Long-term Prognosis for Severely Decompensated Acute Heart Failure in Patients over 75 Years of Age.

Objective The aim of present study was to elucidate the gender differences in social determinants among patients with acute heart failure (AHF). Methods A total of 1,048 AHF patients were enrolled, and the 508 AHF patients who were ≥75 years old and the 540 patients who were <75 years old were evaluated as the elderly and non-elderly cohorts, respectively. Participants who met one of the three marital status-, offspring-, and living status-related criteria were considered socially vulnerable, and subjects were thus classified into socially vulnerable and non-socially vulnerable groups by gender in both the non-elderly and elderly cohorts. Social vulnerability was significantly more common in the elderly cohort (n=246, 48.4%) than in the non-elderly cohort (n=197, 36.5%) and significantly more common in the elderly women (n=157, 69.4%) than in the elderly men (n=89, 31.5%). Kaplan-Meier curves showed that the survival rate of the socially vulnerable group was significantly poorer than that of the non-socially vulnerable group in the elderly male cohort (p=0.010). Social vulnerability was an independent predictor of the 1,000-day mortality in the elderly male cohort (hazard ratio: 1.942, 95% confidence interval: 1.102-3.422) but not in the elderly female cohort according to a multivariate analysis. Conclusion Social vulnerability was shown to be more common in elderly female AHF patients than in elderly men, although it was associated with a poor prognosis in elderly men. Reinforcing the social structure of elderly male AHF patients might help improve their prognosis.

Comparison of Coronary Culprit Lesion Morphology Determined by Optical Coherence Tomography and Relation to Outcomes in Patients Diagnosed with Acute Coronary Syndrome During Winter -vs- Other Seasons.

Patients diagnosed with acute coronary syndrome (ACS) during winter have worse outcomes; however, mechanisms driving this trend are unclear. We examined coronary culprit lesion morphologies using optical coherence tomography (OCT). Features and outcomes were retrospectively compared between patients admitted with ACS in winter (W-ACS; n = 390) and in other seasons (O-ACS; n = 1,027). Angiography and OCT results were analyzed in patients who underwent OCT examination (173 patients in W-ACS and 450 in O-ACS). On initial angiography, minimum lumen diameter was smaller (median; 0.12 mm vs 0.25 mm, p = 0.021) and Thrombolysis in myocardial infarction flow grade was worse (Thrombolysis in myocardial infarction 0/1; 57% vs 44%, p = 0.005) in W-ACS. OCT performed before coronary interventions or just after intracoronary thrombectomy showed that plaque rupture (56% vs 46%) and calcified nodules (8% vs 5%) were more prevalent, and plaque erosion (37% vs 49%) was less prevalent in W-ACS (p = 0.039 for all 3 variables). At 2-year follow-up for all admitted ACS patients, Kaplan-Meier estimates showed higher cardiac mortality in W-ACS (11.8% vs 8.3%, p = 0.043). Multivariate Cox proportional hazard analysis showed that patients in W-ACS group had a 1.5-fold increased risk of cardiac death within 2 years after adjusting for traditional cardiovascular risk factors (hazard ratio, 1.54 [95% confidence interval, 1.06 to 2.23]; p = 0.024). In conclusion, patients diagnosed with ACS during winter had worse angiographic results and OCT revealed less plaque erosion (more plaque rupture or calcified nodules) at the culprit lesions, which may be partly associated with worse cardiac mortality within 2 years.

Worsening renal failure in patients with acute heart failure: the importance of cardiac biomarkers.

AIMS: The importance of true worsening renal failure (WRF), which is associated with a poor prognosis, had been suggested in patients with acute heart failure (AHF). The aim of the present study was to establish the biomarker strategy for the prediction of true WRF in AHF. METHODS AND RESULTS: Two hundred eighty-one patients with AHF were analysed. Their biomarkers were measured within 30 min of admission. Patients were assigned to the non-WRF (n = 168), pseudo-WRF (n = 56), or true-WRF (n = 57) groups using the criteria of both acute kidney injury on admission and increasing serum creatinine value during the first 7 days. A Kaplan-Meier curve showed that the survival and heart failure event rate of the true-WRF group within 1000 days was significantly lower than that of the non-WRF and pseudo-WRF groups (P ≤ 0.001). The multivariate Cox regression model also indicated that true WRF was an independent predictor of 1000 day mortality and heart failure events [hazard ratio: 4.315, 95% confidence interval (CI): 2.466-7.550, P ≤ 0.001, and hazard ratio: 2.834, 95% CI: 1.893-4.243, P ≤ 0.001, respectively]. The serum heart-type fatty acid-binding protein (s-HFABP) levels were significantly higher in the true-WRF group than in the non-WRF and pseudo-WRF groups (P ≤ 0.001). The multivariate logistic regression model indicated that the predictive biomarker for the true-WRF group was the s-HFABP level (odds ratio: 5.472, 95% CI: 2.729-10.972, P ≤ 0.001). The sensitivity and specificity for indicating the presence of true WRF were 73.7% and 76.8% (area under the curve = 0.831) for s-HFABP in whole patients, respectively, and 94.7% and 72.7% (area under the curve = 0.904) in non-chronic kidney disease (CKD) patients, respectively. CONCLUSIONS: Cardiac biomarkers, especially the s-HFABP, might predict the development of true WRF in AHF patients. Furthermore, the predictive value was higher in AHF patients without CKD than in those with CKD.

Plasma xanthine oxidoreductase activity in patients with decompensated acute heart failure requiring intensive care.

AIMS: Plasma xanthine oxidoreductase (XOR) activity during the acute phase of acute heart failure (AHF) requires further elucidation. METHODS AND RESULTS: One hundred eighteen AHF patients and 231 control patients who attended a cardiovascular outpatient clinic were prospectively analysed. Blood samples were collected within 15 min of admission from AHF patients (AHF group) and control patients who visited a daily cardiovascular outpatient clinic (control group). Plasma XOR activity was compared between the two groups, and factors independently associated with extremely elevated XOR activity were identified using a multivariate logistic regression model. Plasma XOR activity in the AHF group (median, 104.0 pmol/h/mL; range, 25.9-423.5 pmol/h/mL) was significantly higher than that in the control group (median, 45.2 pmol/h/mL; range, 19.3-98.8 pmol/h/mL). The multivariate logistic regression model showed that serum uric acid (per 1.0 mg/dL increase, odds ratio: 1.280; 95% confidence interval: 1.066-1.536; P = 0.008) and lactate levels (per 1.0 mmol/L increase, odds ratio: 1.239; 95% confidence interval: 1.040-1.475; P = 0.016) were independently associated with high plasma XOR activity (>300 pg/h/mL) during the acute phase of AHF. CONCLUSIONS: Plasma XOR activity was extremely high in patients with severely decompensated AHF. This would be associated with a high lactate value and would eventually lead to hyperuricaemia in patients with AHF.

Clinical Features of Acute Heart Failure During Sleep　- Prognostic Impact of a Prodrome in Patients With Severely Decompensated Acute Heart Failure Admitted at Midnight or Early Morning.

Background: The features of sleep-associated acute heart failure (AHF) patients admitted at midnight or early morning (M/E) are unclear. Methods and Results: Of 1,268 AHF patients screened, 932 were analyzed, and divided into 2 groups by admission time (M/E group, 23:00-06:59, n=399; daytime group, 07:00-22:59, n=533). Those in the M/E group were further divided by the presence of a prodrome: with (n=176; prodrome group) or without (n=223; sudden onset group). The median time from symptom onset to hospitalization was significantly shorter in the M/E group (98 min; range, 65-170 min) than in the daytime group (123 min; range, 68-246 min). The 365-day HF event rate in the M/E group was significantly lower than that of the daytime group. On multivariate logistic regression modeling the M/E group was independently associated with a better outcome than the daytime group (OR, 0.673; 95% CI: 0.500-0.905). In the M/E group, the 365-day HF event rate was significantly lower in the prodrome group than in the sudden onset group. On multivariate logistic regression modeling, inclusion in the prodrome group was independently associated with a better outcome (OR, 0.544; 95% CI: 0.338-0.877). Conclusions: AHF patients admitted during sleeping hours were not sicker than those admitted during the daytime. The absence of a prodrome, however, might be associated with future repeated HF events.

Prognostic benefit of acute heart failure associated with atherosclerosis: the importance of prehospital medication in patients with severely decompensated acute heart failure.

Atherosclerotic diseases sometimes contribute to acute heart failure (AHF). The aim of the present study is to elucidate the prognostic impact of AHF with atherosclerosis. A total of 1226 AHF patients admitted to the intensive care unit were analyzed. AHF associated with atherosclerosis was defined by the etiology: atherosclerosis-AHF group (n = 708) (patients whose etiologies were ischemic heart disease or hypertensive heart disease) or AHF not associated with atherosclerosis (non-atherosclerosis-AHF) group (n = 518). Kaplan-Meier curves showed that the survival rate of the atherosclerosis-AHF group was significantly better than that of the non-atherosclerosis-AHF group within 730 days of follow-up. Regarding pre-hospital medications, atherosclerosis-AHF patients were more likely to be administered nitroglycerin (20.3 vs. 13.7%, p = 0.003), nicorandil (18.8 vs. 7.5%, p < 0.001), angiotensin-converting enzyme inhibitor (ACE-I) or angiotensin II receptor blocker (ARB) (46.5 vs. 38.6%, p = 0.006), ß-blocker (33.2 vs. 26.6%, p = 0.014) and statin (30.1 vs. 22.4%, p = 0.003) because of a previous coronary event or atherosclerotic diseases. In sub-group analysis of medication including administered ≥ 3 drugs within 5 medications and ACE-I/ARB, atherosclerosis-AHF significantly decreased the rate of all-cause death within 180 days (hazard ratio (HR) 0.215, 95% CI 0.078-0.593 and HR 0.395, 95% CI 0.244-0.641, respectively) with a significant interaction (p value for interaction 0.022 and 0.005, respectively). Kaplan-Meier curves showed that the 180-days survival rate of the atherosclerosis-AHF group with ACE-I/ARB and ≥ 3 drugs were significantly better than other groups. The AHF patients associated with atherosclerosis lead to be a good long-term outcome. A relationship may exist between efficient treatment including ACE-Is before admission and a good outcome in mid-term.

Social determinants are crucial factors in the long-term prognosis of severely decompensated acute heart failure in patients over 75 years of age.

BACKGROUND: The association between social factors and the long-term prognosis of acute heart failure (AHF) remains unclear. METHODS AND RESULTS: One thousand fifty-one AHF patients were screened, and 915 were enrolled. Four hundred forty-two AHF patients ≥75 years of age (the elderly cohort) were also included in a sub-analysis. Participants who fulfilled one of the three marital status-, offspring-, and living status-related criteria were considered socially vulnerable. On this basis they were classified into the socially vulnerable (n=396) and non-socially vulnerable (n=519) groups in the overall cohort, and the socially vulnerable (n=219) and non-socially vulnerable (n=223) groups in the elderly cohort. Kaplan-Meier curves showed that the survival rate of the socially vulnerable group was significantly poorer than that of the non-socially vulnerable group in the overall (p=0.049) and elderly (p=0.004) cohorts. A multivariate Cox regression model revealed that social vulnerability was an independent predictor of 1000-day mortality in the overall [hazard ratio (HR): 1.340, 95% confidence interval (CI): 1.003-1.043, p=0.048] and elderly cohort (HR: 1.531, 95% CI: 1.027-2.280, p=0.036). Regarding the components of social vulnerability, the marital status was an independent factor in the elderly cohort (HR: 1.500, 95% CI 1.043-2.157, p=0.029). CONCLUSION: Social vulnerability was independently associated with long-term outcomes in AHF patients, especially in the elderly cohort. Organization of the social structure of AHF patients might be able to improve their prognosis.

Decreased blood glucose at admission has a prognostic impact in patients with severely decompensated acute heart failure complicated with diabetes mellitus.

The prognostic impact of a decreased blood glucose level in acute heart failure (AHF) has not been sufficiently clarified. The data from 1234 AHF patients were examined in the present study. The blood glucose (BG) levels were evaluated at admission. The patients were divided into groups based on the following: with or without diabetes mellitus (DM), and BG level ≥ 200 mg/dl (elevated BG) or < 200 mg/dl (decreased BG). The elevated and decreased BG patients were further divided into another three groups: 200 mg/ml ≤ BG < 300 mg/dl (mild-elevated), 300 mg/ml ≤ BG < 400 mg/dl (moderate-elevated) and BG ≥ 400 mg/ml (severe-elevated); and 150 mg/ml ≤ BG < 200 mg/dl (mild-decreased), 100 mg/ml ≤ BG < 150 mg/dl (moderate-decreased) and BG < 100 mg/ml (severe-decreased), respectively. The DM patients had a significantly poorer mortality than the non-DM patients. The prognosis was different between patients with elevated or decreased BG. In DM patients with elevated BG, the severe-elevated patients had a significantly poorer prognosis than moderate- and mild-elevated patients. In the DM patients with decreased BG, the severe-decreased patients had a significantly poorer prognosis than those moderate- and mild-decreased patients. The multivariate Cox regression model showed that a severe-decreased [hazard ratio (HR) 3.245, 95% confidence interval (CI) 1.271-8.282] and severe-elevated (HR 2.300, 95% CI 1.143-4.628) status were independent predictors of 365-day mortality in AHF patients with DM. The mortality was high among AHF patients with DM. Furthermore, both severe hyperglycemia and hypoglycemia were independent predictors of the mortality in patients with AHF complicated with DM.

sjTREC quantification using SYBR quantitative PCR for age estimation of bloodstains in a Japanese population.

Individual age is a phenotypic trait that provides useful information in forensic investigations. Levels of signal joint T-cell receptor rearrangement excision circle (sjTREC) in human peripheral blood are known to decline with increasing age. The advantages of sjTREC quantification are the simple procedures and highly accurate age estimation results. Whereas TaqMan quantification PCR (qPCR) is widely used for sjTREC quantification, SYBR qPCR assay is not routinely used for evaluating ethnic data. Therefore, we focused on the advantages of the SYBR qPCR assay, which is cheaper and simpler to set up than the TaqMan probe assay. In this study, we developed a SYBR qPCR assay for sjTREC quantification from bloodstains from a Japanese population and evaluated the strength of correlation between sjTREC levels and actual age. The results were obtained from 194 individuals ranging from 18 to 81 years old, and showed a negative correlation between sjTREC level and individual age (r =  -0.786). The equation for age estimation was Age =  -6.27 dCt (CtTBP - CtsjTREC) - 25.841 with standard error ±8.0 years. Furthermore, this formula for the SYBR assay can be applied to not only fresh bloodstains, but also whole blood and bloodstains up to 1 month old. These results indicate that SYBR qPCR is an effective method for age estimation from bloodstains, and its practicality and affordability make it an attractive sjTREC quantification technique.

Worsening renal function definition is insufficient for evaluating acute renal failure in acute heart failure.

AIMS: Whether or not the definition of a worsening renal function (WRF) is adequate for the evaluation of acute renal failure in patients with acute heart failure is unclear. METHODS AND RESULTS: One thousand and eighty-three patients with acute heart failure were analysed. A WRF, indicated by a change in serum creatinine ≥0.3 mg/mL during the first 5 days, occurred in 360 patients while no-WRF, indicated by a change <0.3 mg/dL, in 723 patients. Acute kidney injury (AKI) upon admission was defined based on the ratio of the serum creatinine value recorded on admission to the baseline creatinine value and placed into groups based on the degree of AKI: no-AKI (n = 751), Class R (risk; n = 193), Class I (injury; n = 41), or Class F (failure; n = 98). The patients were assigned to another set of four groups: no-WRF/no-AKI (n = 512), no-WRF/AKI (n = 211), WRF/no-AKI (n = 239), and WRF/AKI (n = 121). A multivariate logistic regression model found that no-WRF/AKI and WRF/AKI were independently associated with 365 day mortality (hazard ratio: 1.916; 95% confidence interval: 1.234-2.974 and hazard ratio: 3.622; 95% confidence interval: 2.332-5.624). Kaplan-Meier survival curves showed that the rate of any-cause death during 1 year was significantly poorer in the no-WRF/AKI and WRF/AKI groups than in the WRF/no-AKI and no-WRF/no-AKI groups and in Class I and Class F than in Class R and the no-AKI group. CONCLUSIONS: The presence of AKI on admission, especially Class I and Class F status, is associated with a poor prognosis despite the lack of a WRF within the first 5 days. The prognostic ability of AKI on admission may be superior to WRF within the first 5 days.

Features and Outcomes of Patients with Calcified Nodules at Culprit Lesions of Acute Coronary Syndrome: An Optical Coherence Tomography Study.

OBJECTIVES: We sought to clarify clinical features and outcomes related to calcified nodules (CN) compared with plaque rupture (PR) and plaque erosion (PE) detected by optical coherence tomography (OCT) at the culprit lesions in patients with acute coronary syndrome (ACS). METHODS: Based on OCT findings for culprit lesion plaque morphologies, ACS patients with analyzable OCT images (n = 362) were classified as CN, PR, PE, and other. RESULTS: The prevalence of CN, PR, and PE was 6% (n = 21), 45% (n = 163), and 41% (n = 149), respectively. Patients with CN were older (median 71 vs. 65 years, p = 0.03) and more diabetic (71 vs. 35%, p = 0.002) than those without CN. In OCT findings, the distal reference lumen cross-sectional area (median 4.2 vs. 5.2 mm2, p = 0.048) and the postintervention minimum lumen cross-sectional area (median 4.5 vs. 5.3 mm2, p = 0.04) were smaller in lesions with CN than in those without. Kaplan-Meier estimate survival curves showed that the 500-day survival without target lesion revascularization (TLR) was lower (p = 0.011) for patients with CN (72.9%) than for those with PR (89.3%) or PE (94.8%). CONCLUSIONS: ACS patients with CN at the culprit lesion had more TLR compared to those with PR or PE.

Prognostic benefit of maintaining the hemoglobin level during the acute phase in patients with severely decompensated acute heart failure.

The optimum method of managing anemia during the acute phase of acute heart failure (AHF) remains to be elucidated. The data from 1109 AHF patients were enrolled in present study. The hemoglobin (Hb) levels were evaluated in all patients at admission (day 1) and 3 days after admission (day 3), and in survival discharge patients (n = 998) before discharge (pre-discharge). The serum hemoglobin levels were significantly lower on day 3 (11.2 (9.6-12.9) g/dl) than on day 1 (12.4 (10.4-14.2) g/dl) and at pre-discharge (11.6 (10.1-13.2) g/dl). A multivariate Cox regression model showed that mild anemia (11.0 ≤ Hb ≤ 12.9 g/dl, n = 316) and severe anemia (Hb ≤ 10.9 g/dl, n = 517) on day 3 were independent predictors of HF event (hazard ratio (HR) 1.542, 95% confidence interval (CI)1.070-2.221, HR 2.026, 95% CI 1.439-2.853), and severe anemia on day 3 were independent predictors of 365-day mortality (HR 2.247, 95% CI 1.376-3.670). The prognosis, including all-cause death and HF events, in patients with non-anemia on day 1 was significantly poorer in severe new-anemia patients on day 3 (n = 44) than in mild new-anemia patients on day 3 (n = 153) and non-anemia patients on day 3 (n = 252). In patients with anemia on day 1, the prognosis was significantly poorer in patients with severe anemia on day 3 (n = 190) than in those with non-anemia or mild anemia on day 3 (n = 482). The hemoglobin level after the initial treatment might be easily influenced by clinical decongestion. Successfully treated decongestion can help maintain the hemoglobin levels. It, therefore, leads to a prognostic benefit in patients with AHF. These findings might underscore the importance of hemoglobin management of the acute phase of AHF.

The prognostic impact of malnutrition in patients with severely decompensated acute heart failure, as assessed using the Prognostic Nutritional Index (PNI) and Controlling Nutritional Status (CONUT) score.

Patients with heart failure (HF) are sometimes classified as malnourished, but the prognostic value of nutritional status in acute HF (AHF) remains largely unstudied. 1214 patients who were admitted to the intensive care unit between January 2000 and June 2016 were screened based on their serum albumin, lymphocyte count, and total cholesterol measures. A total of 458 HF patients were enrolled in this study. The Prognostic Nutritional Index (PNI) is calculated as 10 × serum albumin (g/dL) + 0.005 × lymphocyte count (per mm3) (lower = worse). The Controlling Nutritional Status (CONUT) score is points based, and is calculated using serum albumin, total cholesterol, and lymphocyte count (range 0-12, higher = worse). Patients were divided into three groups according to PNI: high-PNI (PNI < 35, n = 331), middle-PNI (35 ≤ PNI < 38, n = 50), and low-PNI (PNI ≥ 38, n = 77). They were also divided into four groups according to CONUT score: normal-CONUT (0-1, n = 128), mild-CONUT (2-4, n = 179), moderate-CONUT (5-8, n = 127), and severe-CONUT (≥9, n = 24). The PNI, which exhibited a good balance between sensitivity and specificity for predicting in-hospital mortality [66.1 and 68.4%, respectively; area under the curve (AUC) 0.716; 95% confidence interval (CI) 0.638-0.793), was 39.7 overall, while the CONUT score was 5 overall (61.4 and 68.4%, respectively; AUC 0.697; 95% CI 0.618-0.775). A Kaplan-Meier curve indicated that the prognosis, including all-cause death, was significantly (p < 0.001) poorer in low-PNI patients than in high-PNI groups and was also significantly poorer in severe-CONUT patients than in normal-CONUT and mild-CONUT groups. A multivariate Cox regression model showed that the low-PNI and severe-CONUT categories were independent predictors of 365-day mortality [hazard ratio (HR) 2.060, 95% CI 1.302-3.259 and HR 2.238, 95% CI 1.050-4.772, respectively). Malnutrition, as assessed using both the PNI and the CONUT score, has a prognostic impact in patients with severely decompensated AHF.

Impact of Accumulated Serum Uric Acid on Coronary Culprit Lesion Morphology Determined by Optical Coherence Tomography and Cardiac Outcomes in Patients with Acute Coronary Syndrome.

OBJECTIVES: We aimed to examine the relations of very high levels of serum uric acid (sUA) with features of culprit lesion plaque morphology determined by optical coherence tomography (OCT) and adverse clinical outcomes in patients with acute coronary syndrome (ACS). METHODS: We retrospectively compared ACS patients according to sUA levels of > 8.0 mg/dL (n = 169), 7.1-8.0 mg/dL (n = 163), 6.1-7.0 mg/dL (n = 259), and ≤6.0 mg/dL (n = 717). Angiography and OCT findings were analyzed in patients with preintervention OCT and the 4 sUA groups (> 8.0 mg/dL, n = 61; 7.1-8.0 mg/dL, n = 72; 6.1-7.0 mg/dL, n = 131; and ≤6.0 mg/dL, n = 348) were compared. RESULTS: Cardiogenic shock was more prevalent in ACS patients with sUA > 8.0 mg/dL (22% vs. 19% vs. 10% vs. 6%, p < 0.001). Plaque rupture was observed more prevalently by OCT in patients with sUA > 8.0 mg/dL (67% vs. 47% vs. 56% vs. 45%, p = 0.027). At the 2-year follow-up, Kaplan-Meier estimates showed higher cardiac mortality in patients with sUA > 8.0 mg/dL (25% vs. 12% vs. 5% vs. 5%, p < 0.001). After adjusting for traditional cardiovascular risk factors and creatinine levels, patients with sUA > 8.0 mg/dL showed a 4.5-fold increased risk in 2-year cardiac death by multivariate Cox proportional hazard analysis (hazard ratio 4.54, 95% confidence interval 2.98-6.91; p < 0.001). CONCLUSIONS: Very high sUA levels like > 8.0 mg/dL are the primary predictor of 2-year cardiac mortality and could partly be caused by adverse effects of accumulated sUA on plaque morphology in patients with ACS.