Predicting 1-, 3-, 5-, and 8-year all-cause mortality in a community-dwelling older adult cohort: relevance for predictive, preventive, and personalized medicine

BACKGROUND

Population aging is a global public health issue involving increased prevalence of age-related diseases, and concomitant burden on medical resources and the economy. Ninety-two diseases have been identified as age-related, accounting for 51.3% of the global adult disease burden. The economic cost per capita for older people over 60 years is 10 times that of the younger population. From the aspects of predictive, preventive, and personalized medicine (PPPM), developing a risk-prediction model can help identify individuals at high risk for all-cause mortality and provide an opportunity for targeted prevention through personalized intervention at an early stage. However, there is still a lack of predictive models to help community-dwelling older adults do well in healthcare.

OBJECTIVES

This study aims to develop an accurate 1-, 3-, 5-, and 8-year all-cause mortality risk-prediction model by using clinical multidimensional variables, and investigate risk factors for 1-, 3-, 5-, and 8-year all-cause mortality in community-dwelling older adults to guide primary prevention.

METHODS

This is a two-center cohort study. Inclusion criteria: (1) community-dwelling adult, (2) resided in the districts of Chaonan or Haojiang for more than 6 months in the past 12 months, and (3) completed a health examination. Exclusion criteria: (1) age less than 60 years, (2) more than 30 incomplete variables, (3) no signed informed consent. The primary outcome of the study was all-cause mortality obtained from face-to-face interviews, telephone interviews, and the medical death database from 2012 to 2021. Finally, we enrolled 5085 community-dwelling adults, 60 years and older, who underwent routine health screening in the Chaonan and Haojiang districts, southern China, from 2012 to 2021. Of them, 3091 participants from Chaonan were recruited as the primary training and internal validation study cohort, while 1994 participants from Haojiang were recruited as the external validation cohort. A total of 95 clinical multidimensional variables, including demographics, lifestyle behaviors, symptoms, medical history, family history, physical examination, laboratory tests, and electrocardiogram (ECG) data were collected to identify candidate risk factors and characteristics. Risk factors were identified using least absolute shrinkage and selection operator (LASSO) models and multivariable Cox proportional hazards regression analysis. A nomogram predictive model for 1-, 3-, 5- and 8-year all-cause mortality was constructed. The accuracy and calibration of the nomogram prediction model were assessed using the concordance index (C-index), integrated Brier score (IBS), receiver operating characteristic (ROC), and calibration curves. The clinical validity of the model was assessed using decision curve analysis (DCA).

RESULTS

Nine independent risk factors for 1-, 3-, 5-, and 8-year all-cause mortality were identified, including increased age, male, alcohol status, higher daily liquor consumption, history of cancer, elevated fasting glucose, lower hemoglobin, higher heart rate, and the occurrence of heart block. The acquisition of risk factor criteria is low cost, easily obtained, convenient for clinical application, and provides new insights and targets for the development of personalized prevention and interventions for high-risk individuals. The areas under the curve (AUC) of the nomogram model were 0.767, 0.776, and 0.806, and the C-indexes were 0.765, 0.775, and 0.797, in the training, internal validation, and external validation sets, respectively. The IBS was less than 0.25, which indicates good calibration. Calibration and decision curves showed that the predicted probabilities were in good agreement with the actual probabilities and had good clinical predictive value for PPPM.

CONCLUSION

The personalized risk prediction model can identify individuals at high risk of all-cause mortality, help offer primary care to prevent all-cause mortality, and provide personalized medical treatment for these high-risk individuals from the PPPM perspective. Strict control of daily liquor consumption, lowering fasting glucose, raising hemoglobin, controlling heart rate, and treatment of heart block could be beneficial for improving survival in elderly populations.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s13167-023-00342-4.

Predictive Value of Septal Flash for Reduction of Left Ventricular Systolic Function as Reflected by Global Longitudinal Strain Using Echocardiography in Patients With Isolated Complete Left Bundle-Branch Block

BACKGROUND

Septal leftward motion followed by a counter motion during early systole is known as septal flash (SF) in patients with isolated complete left bundle-branch block (cLBBB). This study aimed to determine the predictive value of SF for reduction of left ventricular (LV) global systolic function using 2D speckle-tracking echocardiography (2D STE) in cLBBB patients.

METHODS AND RESULTS

The study group of 41 patients with isolated cLBBB and preserved LV ejection fraction and 41 age- and sex-matched control subjects were studied. The presence of SF and LV global longitudinal strain (GLS) were defined and measured using 2D STE. Multivariate logistic regression analysis identified the presence of SF as an independent factor predicting LV GLS >-20% in isolated cLBBB patients (odds ratio, 1.38; 95% confidence interval, 1.10-1.72; P=0.005). LV GLS in cLBBB patients with SF further decreased over time, whereas LV GLS did not decrease in patients without SF. The presence of SF was shown to be an independent factor predicting the reduction of LV global systolic function (relative reduction in LV GLS >15% from baseline to 2-year follow-up) (odds ratio, 1.27; 95% confidence interval, 1.06-1.50; P=0.008).

CONCLUSIONS

Assessment of SF by 2D STE may be an easy and effective method of predicting the reduction in LV global systolic function in isolated cLBBB patients.

Restoration of ventricular septal hypoperfusion by cardiac resynchronization therapy in patients with permanent right ventricular pacing

BACKGROUND

Pacing from the right ventricular apex (RVA) is associated with cardiac dysfunction and shows electrophysiological features similar to left bundle branch block in which left ventricular (LV) mechanical dyssynchrony impairs septal coronary artery perfusion.

METHODS

A total of 62 non-ischemic patients with an implanted pacemaker at the RVA with a pacing rate of >95% were studied. LV septal coronary perfusion as indicated by the LV septal perfusion index was measured by electrocardiography (ECG)-gated single-photon emission computed tomography for all patients at baseline and for patients who were upgraded to CRT at 6months after CRT. Relationships among LV septal perfusion index, QRS duration, and LV ejection fraction were analyzed.

RESULTS

Among the patients with permanent RVA pacing, 28 of 62 (45%) had impaired septal perfusion (i.e., septal perfusion index <0.9). The LV septal perfusion index was significantly correlated with both QRS duration (r=-0.763, p<0.001) and LV ejection fraction (r=0.462, p=0.001). Eleven patients were upgraded to CRT. CRT significantly improved the LV septal perfusion index from 0.63 (SD=0.13) to 0.89 (SD=0.19) (p<0.001)and cardiac function: LV end-systolic volume from 102.3mL (SD=70.0) to 179.7mL (SD=118.4) (p=0.002) and LV ejection fraction from 22.5 (SD=8.9%) to 38.4% (SD=13.9%) (p=0.001).

CONCLUSIONS

Nearly half of the non-ischemic patients with permanent RVA pacing presenting with prolonged QRS duration and LV dysfunction developed LV septal hypoperfusion. Both septal perfusion and LV function improved in patients who were upgraded to CRT.

Left Bundle Branch Block in Acute Cardiac Events: Insights From a 23-Year Registry

Between 1991 and 2013, we evaluated the demographics, presentations, and final diagnosis of patients hospitalized with acute cardiac events and left bundle branch block (LBBB). Of 50 992 patients, 768 (1.5%) had LBBB. Compared with non-LBBB patients, patients with LBBB were mostly older, female, diabetic, and had hypertension and chronic kidney failure (CKF; P < .001 for all). Dyspnea (P < .001) and dizziness (P = .037) were more frequent in patients with LBBB. The most frequent cause of admission with LBBB was congestive heart failure (CHF; 54.2%), followed by ST-elevation myocardial infarction (STEMI; 13.3%), valvular heart disease (9.4%), unstable angina (8.3%) and Non-STEMI (7.7%). On multivariate analysis, CKF (odds ratio [OR]: 2.02, 95% confidence interval [CI]: 1.09-3.70) and LBBB (OR: 2.96, 95% CI: 2.01-4.42) were predictors of in-hospital mortality in the entire study population. Further analysis of patients with LBBB showed that CKF (OR: 2.93, 95% CI: 1.40-6.12) was the only predictor of in-hospital mortality. Regardless the presenting symptoms, CHF was the final diagnosis in most cases with LBBB.

Radiofrequency Ablation Versus Antiarrhythmic Medication for Treatment of Ventricular Premature Beats From the Right Ventricular Outflow Tract

Background—

The purpose of this study was to compare the efficacy of radiofrequency catheter ablation (RFCA) versus antiarrhythmic drugs (AADs) for treatment of patients with frequent ventricular premature beats (VPBs) originating from the right ventricular outflow tract (RVOT).

Methods and Results—

A total of 330 eligible patients were included in the study and were randomly assigned to RFCA or AADs group. The absolute number and the burden of VPBs on 12-lead Holter monitors were measured at baseline and at 1st, 3rd, 6th, and 12th months after randomization. Left ventricular eject fraction was evaluated by transthoracic echocardiogram at baseline and at 3 and 6 months after randomization. During the 1-year follow-up period, VPB recurrence was significantly lower in patients randomized to RFCA group (32 patients, 19.4%) versus AADs group (146 patients, 88.6%; P <0.001, log-rank test). In a Poisson generalized estimating equations (GEE) regression model, RFCA was associated with a greater decrease in the burden of VPBs (incidence rate ratio 0.105; 95% confidence intervals [0.104–0.105]; P <0.001) compared with AADs. In a liner GEE model, the left ventricular eject fraction had a tendency to increase after the treatment in both groups (coefficient, 0.584; 95% confidence intervals [0.467–0.702]; P <0.001). In a Cox proportional model, the QS morphology in lead I was the only predictor of VPB recurrence free for catheter ablation (hazards ratio, 0.154; 95% confidence intervals [0.044–0.543]; P =0.004).

Conclusions—

Catheter ablation is more efficacious than AADs for preventing VPB recurrence in patients with frequent VPBs originating from the RVOT. QS morphology in lead I was associated with better outcome after ablation.