Improved Prognostic Performance of Right Atrial Pressure-Corrected Cardiac Power Output in Pulmonary Hypertension and Heart Failure with Preserved Ejection Fraction

Cardiac power output (CPO) is a powerful predictor of adverse outcomes in heart failure (HF). However, the original formula of CPO included the difference between mean arterial pressure and right atrial pressure (RAP). The prognostic performance of RAP-corrected CPO (CPORAP) remains unknown in heart failure with preserved ejection fraction (HFpEF). We studied 101 HF patients with a left ventricular ejection fraction > 40% who had pulmonary hypertension due to left heart disease. CPORAP was significantly more discriminating than CPO in predicting outcomes (Delong test, P = 0.004). Twenty-five (24.8%) patients presented with dis-concordantly high CPORAP and low CPO when stratified by the identified CPORAP threshold of 0.547 W and the accepted CPO threshold of 0.803 W. These patients had the lowest RAP, and their cumulative incidence was comparable with those with concordantly high CPO and CPORAP (P = 0.313). CPORAP might identify patients with right ventricular involvement, thereby providing better prognostic performance than CPO in HFpEF.

Renal function modifies the association between hemoconcentration and outcomes in hospitalized heart failure patients

Evidence-based management of decongestion is lacking in hospitalized heart failure (HHF) patients, especially in patients with impaired renal function. Hemoconcentration is an objective measure of decongestion that portends a favorable prognosis and guides management in HHF patients with preserved renal function. We aim to investigate whether it remains a prognosticator in patients with renal impairment, and to refine the identification of subpopulations who will benefit from hemoconcentration-guided therapy. HHF patients admitted to Heart Failure Center of Fuwai Hospital were consecutively included from December 2006 to June 2018. Patient characteristics were depicted. Relationships between in-hospital hemoconcentration, worsening renal function (WRF), and one-year all-cause mortality were investigated in the total population and compared between renal function groups using survival analysis and cubic splines, with a special focus on renal function-based interactions. The association was further validated in sensitivity analyses. Clinically relevant cut-offs and subpopulations were identified by subpopulation treatment effect pattern plots (STEPP) and subgroup analysis. 3661 participants (30.4% with impaired renal function) were included. Hemoconcentration, reflected by an in-hospital increase in hemoglobin, hematocrit, or a relative reduction in estimated plasma volume from baseline to discharge, was predictive of decreased one-year mortality in the total cohort despite its correlation with higher WRF incidence. The prognostic value of hemoconcentration differed in patients with impaired and preserved renal function. Hemoconcentration was related to a favorable prognosis in patients with preserved renal function (HR, 0.69; 95% CI, 0.53-0.90; P = 0.007), especially in young male patients with New York Heart Association functional class III-IV, reduced ejection fraction, and baseline eGFR > 75 mL/min/1.73m2. Contrarily, impaired renal function patients experienced a higher incidence of WRF, and hemoconcentration was no longer related to outcome (HR, 0.90; 95% CI, 0.64-1.26; P = 0.545), with findings consistent in all clinically relevant subgroups. In HHF patients, the prognostic value of hemoconcentration differs by renal function, and the clinical utility of hemoconcentration is contingent on preserved renal function.

Effects of direct-fed microbial supplementation on performance and immune parameters of lactating dairy cows

We evaluated the effects of supplementing bacterial direct-fed microbial (DFM) on performance, apparent total-tract digestibility, rumen fermentation, and immune parameters of lactating dairy cows. One hundred fourteen multiparous Holstein cows (41 ± 7 DIM) were used in a randomized complete block design with an experiment comprising 14 d of a covariate (pre-experimental sample and data collection) and 91 d of an experimental period. Cows were blocked based on energy-corrected milk (ECM) yield during the covariate period and the following treatments were randomly assigned within each block: (1) control (CON), corn silage-based total mixed ration without DFM; (2) PRO-A, basal diet top-dressed with a mixture of Lactobacillus animalis and Propionibacterium freudenreichii at 3 × 109 cfu/d; and 3) PRO-B, basal diet top-dressed with a mixture of L. animalis, P. freudenreichii, Bacillus subtilis, and Bacillus licheniformis at 11.8 × 109 cfu/d. Milk yield, dry matter intake (DMI), and body weight were measured daily, while milk samples for component analysis were taken on 2 consecutive days of each week of data collection. Feces, urine, rumen, and blood samples were taken during the covariate period, wk 4, 7, 10, and 13 for estimation of digestibility, N-partitioning, rumen fermentation, plasma nutrient status and immune parameters. Treatments had no effect on DMI and milk yield. Fat-corrected milk (3.5% FCM) and milk fat yield were improved with PRO-B, while milk fat percent and feed efficiency (ECM/DMI) tended to increase with PRO-B compared with PRO-A and CON. Crude fat digestibility was greater with PRO-B compared with CON. Feeding CON and PRO-A resulted in higher total volatile fatty acid concentration relative to PRO-B. Percentage of neutrophils tended to be reduced with PRO-A compared with CON and PRO-B. The mean fluorescence intensity (MFI) of anti-CD44 antibody on granulocytes tended to be higher in PRO-B compared with CON. The MFI of anti-CD62L antibody on CD8+ T cells was lower in PRO-A than PRO-B, with PRO-A also showing a tendency to be lower than CON. This study indicates the potential of DFM to improve fat digestibility with consequential improvement in fat corrected milk yield, feed efficiency and milk fat yield by lactating dairy cows. The study findings also indicate that dietary supplementation with DFM may augment immune parameters or activation of immune cells, including granulocytes and T cells; however, the overall effects on immune parameters are inconclusive.

Obesity Paradox in Heart Failure Revisited: Etiology as Effect Modifier

The prognostic value of overweight/obesity in heart failure (HF) may vary according to HF etiologies. We aim to determine whether body mass index has differential impacts on survival among hospitalized HF patients with varying etiologies. Consecutive hospitalized HF patients between December 2006 and December 2017 were included. Multivariable analyses, including Cox proportional hazard models and restricted cubic splines, were used to investigate the impact of body mass index on mortality by HF etiology. Among the 3,836 patients included (mean age 57.1 years, 28.4% women), 1,475 (38.5%) were identified as having ischemic etiology. Of the remaining 2,361 patients with non-ischemic etiologies, dilated cardiomyopathy (DCM) accounted for 45.6% (n = 1,077). The rest of the patients were uniformly classified as having non-ischemic-non-DCM HF. The unadjusted data demonstrated an adiposity-related survival paradox in HF across all etiologies. However, the paradox holds only among non-ischemic-non-DCM HF patients after multivariate adjustment, wherein overweight patients exhibit the lowest mortality compared with their normal-weight counterparts (adjusted hazard ratio [aHR] 0.69, 95% confidence interval [CI] 0.52 to 0.91), with a nadir in mortality risk at 28.18 kg/m2. Similar survival benefits of overweight were not demonstrated in ischemic or DCM HF patients (ischemic etiology: aHR 1.07, 95% CI 0.84 to 1.36; DCM etiology: aHR 0.97, 95% CI 0.74 to 1.28). In conclusion, being overweight or obese does not confer better survival in HF patients of ischemic or DCM etiology, and the prognostic benefit of being overweight is maintained only in non-ischemic-non-DCM HF patients. Pathophysiologic interpretations are warranted, and whether patients of certain etiologies would benefit from weight reduction needs to be explored.

Estimated plasma volume status adds prognostic value to hemodynamic parameters in advanced heart failure

BACKGROUND

Estimated plasma volume status (ePVS) is a marker of intravascular congestion and has prognostic value in patients with heart failure (HF). The elevation of intracardiac filling pressures is defined as hemodynamic congestion and is also associated with poor prognosis. However, the relationship between intravascular congestion and hemodynamic congestion remains unclear. This study sought to explore the correlation between ePVS and hemodynamic parameters and determine the association between ePVS and clinical outcomes in patients with advanced HF.

METHODS

Patients with advanced HF underwent right heart catheterization (RHC) for hemodynamic profiles. The sum of right atrial pressure (RAP) and pulmonary arterial wedge pressure (PAWP) > 30 mmHg was considered to present with hemodynamic congestion. Blood tests were conducted within 24 h of RHC. We calculated ePVS using the Strauss-derived Duarte formula. The primary outcome was all-cause mortality.

RESULTS

A total of 195 patients were divided into two groups based on the cut-off value of ePVS (4.08 dL/g) calculated from receiver operating characteristic analysis. Patients with ePVS > 4.08 dL/g were more likely to present with wet rales (21.2% vs. 9.9%, P = 0.032) and had a higher risk of death (HR 4.748, 95% CI 2.385-9.453), regardless of whether RAP + PAWP was normal or elevated (all P < 0.05). Hemodynamic parameters and ePVS were not correlated (all P > 0.05). High ePVS significantly improved the predictive value beyond the clinical plus hemodynamic prognostic model (area under the curve of 0.844, Delong test, P = 0.024).

CONCLUSION

ePVS could additionally add prognostic value to hemodynamic parameters in advanced heart failure, although not correlated with hemodynamic parameters.

sST2 and Big ET-1 as Alternatives of Multi-Biomarkers Strategies for Prognosis Evaluation in Patients Hospitalized with Heart Failure

Objective

To identify biomarkers with independent prognostic value and investigate the prognostic value of multiple biomarkers in combination in patients hospitalized with heart failure.

Methods

A total of 884 consecutive patients hospitalized with heart failure from 2015 to 2017 were enrolled. Twelve biomarkers were measured on admission, and the relationships between biomarkers and outcomes were assessed.

Results

During the median follow-up of 913 days, 291 patients (32.9%) suffered from primary endpoint events. Soluble suppression of tumorigenicity-2 (sST2) (per log [unit] increase, adjusted HR [95% CI]: 1.39 [1.13,1.72], P = 0.002) and big endothelin-1 (big ET-1) (per log [unit] increase, adjusted HR [95% CI]: 1.56 [1.23,1.97], P < 0.001) remained independent predictors of primary endpoint event after adjusting for other predictors including N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin T (hs-cTnT). Both sST2 (C-statistic: 0.810 vs 0.801, P = 0.005, and 0.832 vs 0.826, P = 0.024, respectively) and big ET-1 (C-statistic: 0.829 vs 0.801, P = 0.001, and 0.843 vs 0.826, P < 0.001, respectively) significantly improved the predictive value for primary endpoint event at 1 year and 3 years. However, only big ET-1 (C-statistic: 0.852 vs 0.846, P = 0.014) significantly improved the predictive value at 3 months when added to clinical predictors and known biomarkers. According to the number of elevated biomarkers (including NT-proBNP, hs-cTnT, sST2, and big ET-1), patients with three or more elevated biomarkers had a higher risk of primary endpoint event compared to those with two elevated biomarkers (P = 0.001), as well as in patients with two elevated biomarkers compared to those with one elevated biomarker (P = 0.004). However, the risk of primary endpoint event was comparable between patients with one elevated biomarker and those with no elevated biomarker (P = 0.582).

Conclusion

Multiple biomarkers in combination could provide a better prognostic value than a single biomarker. sST2 and big ET-1 could act as alternatives of multi-biomarkers strategies for prognosis evaluation beyond NT-proBNP and hs-cTnT in patients hospitalized with heart failure.

Combined use of right ventricular coupling and pulmonary arterial elastance as a comprehensive stratification approach for right ventricular function

Right ventricular (RV)-pulmonary arterial uncoupling is the consequence of increased afterload and/or decreased RV contractility. However, the combination of arterial elastance (Ea) and end-systolic elastance (Ees)/Ea ratio to assess RV function is unclear. We hypothesized that the combination of both could comprehensively assess RV function and refine risk stratification. The median Ees/Ea ratio (0.80) and Ea (0.59 mmHg/mL) were used to classify 124 patients with advanced heart failure into four groups. RV systolic pressure differential was defined as end-systolic pressure (ESP) minus beginning-systolic pressure (BSP). Patients among different subsets showed dissimilar New York Heart Association functional class (V = 0.303, p = 0.010), distinct tricuspid annular plane systolic excursion/ pulmonary artery systolic pressure (mm/mmHg; 0.65 vs. 0.44 vs. 0.32 vs. 0.26, p < 0.001), and diverse prevalence of pulmonary hypertension (33.3% vs. 35% vs. 90% vs. 97.6%, p < 0.001). By multivariate analysis, Ees/Ea ratio (hazard ratio [HR] 0.225, p = 0.004) and Ea (HR 2.194, p = 0.003) were independently associated with event-free survival. Patients with Ees/Ea ratio greater than or equal to 0.80 and Ea less than 0.59 mmHg/mL had better outcomes (p < 0.05). In patients with Ees/Ea ratio greater than or equal to 0.80, those with Ea greater than or equal to 0.59 mmHg/mL had a higher adverse outcome risk (p < 0.05). Ees/Ea ratio less than or equal to 0.80 was associated with adverse outcomes, even when Ea was less than 0.59 mmHg/mL (p < 0.05). Approximately 86% of patients with ESP-BSP greater than 5 mmHg had an Ees/Ea ratio less than or equal to 0.80 and/or an Ea greater than or equal to 0.59 mmHg/mL (V = 0.336, p = 0.001). Combined use of Ees/Ea ratio and Ea could be a comprehensive approach to assessing RV function and predicting outcomes. An exploratory analysis demonstrated that Ees/Ea ratio and Ea might be roughly estimated based on RV systolic pressure differential.

Machine Learning for Mortality Prediction in Patients With Heart Failure With Mildly Reduced Ejection Fraction

Background Machine-learning-based prediction models (MLBPMs) have shown satisfactory performance in predicting clinical outcomes in patients with heart failure with reduced and preserved ejection fraction. However, their usefulness has yet to be fully elucidated in patients with heart failure with mildly reduced ejection fraction. This pilot study aims to evaluate the prediction performance of MLBPMs in a heart failure with mildly reduced ejection fraction cohort with long-term follow-up data. Methods and Results A total of 424 patients with heart failure with mildly reduced ejection fraction were enrolled in our study. The primary outcome was all-cause mortality. Two feature selection strategies were introduced for MLBPM development. The "All-in" (67 features) strategy was based on feature correlation, multicollinearity, and clinical significance. The other strategy was the CoxBoost algorithm with 10-fold cross-validation (17 features), which was based on the selection result of the "All-in" strategy. Six MLBPMs with 5-fold cross-validation based on the "All-in" and the CoxBoost algorithm with 10-fold cross-validation strategy were developed by the eXtreme Gradient Boosting, random forest, and support vector machine algorithms. The logistic regression model with 14 benchmark predictors was used as a reference model. During a median follow-up of 1008 (750, 1937) days, 121 patients met the primary outcome. Overall, MLBPMs outperformed the logistic model. The "All-in" eXtreme Gradient Boosting model had the best performance, with an accuracy of 85.4% and a precision of 70.3%. The area under the receiver-operating characteristic curve was 0.916 (95% CI, 0.887-0.945). The Brier score was 0.12. Conclusions The MLBPMs could significantly improve outcome prediction in patients with heart failure with mildly reduced ejection fraction, which would further optimize the management of these patients.

Afterload-related cardiac performance is a powerful hemodynamic predictor of mortality in patients with chronic heart failure

Background

Afterload-related cardiac performance (ACP), a diagnostic parameter for septic cardiomyopathy, integrates both cardiac performance and vascular effects and could predict prognosis in septic shock.

Objectives

We hypothesized that ACP would also correlate with clinical outcomes in patients with chronic heart failure (HF).

Design

A retrospective study.

Methods

We retrospectively studied consecutive patients with chronic HF who underwent right heart catheterization and established an expected cardiac output-systemic vascular resistance (CO-SVR) curve model in chronic HF for the first time. ACP was calculated as COmeasured/COpredicted × 100%. ACP > 80%, 60% < ACP ⩽ 80%, and ACP ⩽ 60% represented less impaired, mildly impaired, and severely impaired cardiovascular function, respectively. The primary outcome was all-cause mortality, and the secondary outcome was event-free survival.

Results

A total of 965 individual measurements from 290 eligible patients were used to establish the expected CO-SVR curve model (COpredicted = 53.468 × SVR -0.799). Patients with ACP ⩽ 60% had higher serum NT-proBNP levels (P < 0.001), lower left ventricular ejection fraction (P = 0.001), and required dopamine more frequently (P < 0.001). Complete follow-up data were available in 263 of 290 patients (90.7%). After multivariate adjustment, ACP remained associated with both primary outcome (hazard ratio (HR) 0.956, 95% confidence interval (CI) 0.927-0.987) and secondary outcome (HR 0.977, 95% CI 0.963-0.992). Patients with ACP ⩽ 60% had the worst prognosis (all P < 0.001). ACP was significantly more discriminating (area under the curve of 0.770) than other conventional hemodynamic parameters in predicting mortality (Delong test, all P < 0.05).

Conclusion

ACP is a powerful independent hemodynamic predictor of mortality in patients with chronic HF. ACP and the novel CO-SVR two-dimensional graph could be useful in assessing cardiovascular function and making clinical decisions.

Clinical trial registration

URL: https://www.clinicaltrials.gov. Unique identifier: NCT02664818.

Prevalence and prognostic importance of malnutrition, as assessed by four different scoring systems, in elder patients with heart failure

BACKGROUND AND AIMS

The lack of standard diagnostic criteria in elder patients with heart failure (HF) makes it challenging to diagnose and manage malnutrition. We aimed to explore the prevalence of malnutrition, its associations and prognostic significance among elder patients with HF using four different nutritional scoring systems.

METHODS AND RESULTS

Consecutively presenting patients aged ⩾65 years, diagnosed with HF, and admitted to HF care unit of Fuwai Hospital CAMS&PUMC (Beijing, China) were assessed for nutritional indices. In total, 1371 patients were enrolled (59.4% men; mean age 72 years; median NT-proBNP 2343 ng/L). Using scores for the prognostic nutritional index (PNI) ≤38, controlling nutritional status (CONUT) score >4, geriatric nutritional risk index (GNRI) ≤91, and triglycerides, total cholesterol, and body weight index (TCBI) ≤1109, 10.4%, 18.3%, 9.2%, and 50.0% of patients had moderate or severe malnutrition, respectively. There was a strong association between worse scores and lower body mass index, more severe symptoms, atrial fibrillation, and anemia. The mortality over a median follow-up of 962 days (interquartile range (IQR): 903-1029 days) was 28.3% (n = 388). For those with moderate or severe condition, 1-year mortality was 35.2% for PNI, 28.3% for CONUT, 28.0% for GNRI, and 19.1% for TCBI. Malnutrition, defined by any of the included indices, showed added prognostic value when incorporated into a model and included preexisting prognostic factors (C-statistic: 0.711). However, defining malnutrition by the CONUT score yielded the most significant improvement in the prognostic predictive value (C-statistic: 0.721; p < 0.001).

CONCLUSION

Malnutrition is prevalent among elder patients with HF and confers increased mortality risk. Among the nutritional scores studied, the CONUT score was most effective in predicting the mortality risk.

CLINICAL TRIAL REGISTRATION

URL: ClinicalTrials.gov; Unique Identifier: NCT02664818.

Inflammatory biomarkers in assessing severity and prognosis of immune checkpoint inhibitor-associated cardiotoxicity

AIMS

Inflammatory biomarkers, including CRP, the neutrophil-to-lymphocyte ratio (NLR), and the neutrophil-to-eosinophil ratio (NER), may predict outcomes in cancer. However, their value in immune checkpoint inhibitor (ICI) therapy-associated cardiotoxicity remains elusive. We aimed to characterize the relationship of inflammatory markers with severity of ICI-related cardiotoxicities (iRCs) and prognosis among patients with iRCs.

METHODS

Patients who were diagnosed with iRCs between January 2019 and December 2021 were retrospectively enrolled and were dichotomized based on iRC severity into low-grade (grade 1-2) vs. high-grade (grade 3-4) groups.

RESULTS

Forty-seven patients were included. The median time-to-event from first ICI infusion to onset of iRCs was 35 days (IQR: 19.0-65.5 days). When compared with respective baseline values, cardiac biomarkers and inflammatory markers were significantly elevated at onset of iRCs. Compared with low-grade iRCs, NER at iRC onset was significantly increased among patients with high-grade iRCs (Group × Time, P < 0.01). When grouped by the median NER (184.33) at iRC onset, NER ≥ 184.33 was associated with high-grade iRCs (OR: 10.77, P < 0.05) and had a 36.3% increased mortality compared to the lower NER group (HR: 2.67, P < 0.05).

CONCLUSIONS

In patients who develop iRCs, NER is significantly elevated at iRC onset, and higher NER correlates with greater iRC severity and higher mortality. Larger datasets are needed to validate these findings.

Hyponatremia and lower normal serum sodium levels are associated with an increased risk of all-cause death in heart failure patients

AIM

To explore the relationship between the serum sodium level on admission and all-cause mortality in HF patients.

DESIGN

A single-center retrospective cohort study.

METHODS

Patients hospitalized with HF at the Heart Failure Center, Fuwai Hospital, from November 2008 to November 2018 were enrolled.

RESULTS

A total of 3649 patients were included, and the mean sodium level was 137.19 ± 4.36 mmol/L, with a range from 115.6 to 160.9 mmol/L. During a median follow-up of 1101 days, mortality occurred in 1413 (38.7%) hospital survivors. After adjustment for age, sex, and other potential confounders, patients with sodium levels <135 mmol/L (hazard ratio [HR]: 1.67; 95% confidence interval [CI]: 1.29-2.16) and 135-137 mmol/L (HR: 1.34; 95% CI: 1.01-1.78) had an increased risk of all-cause mortality compared to those with sodium levels of 139-141 mmol/L.

A102 INTERDISCIPLINARY TELEHEALTH REFERRAL PATHWAY AND CONSULTATIONS TO IMPROVE OUTCOMES AMONG CANADIAN OLDER ADULTS WITH LIVER CIRRHOSIS

Background

Telehealth and telemedicine have become indispensable healthcare delivery tools during the COVID-19 pandemic. Older individuals with cirrhosis have complex medical needs that are currently unmet due to the growing disease burden and decreased access to care. Delivering timely specialist care virtually to older adults with cirrhosis will likely be beneficial and acceptable to such patients; however, this has not yet been prospectively evaluated.

Purpose

The primary goal is to pilot the delivery of dual specialist care from a hepatologist and geriatrician, delivered virtually, for older adults living with liver cirrhosis who are at high risk of geriatric syndromes (age >/= 65 with frailty, undifferentiated cognitive impairment from dementia or hepatic encephalopathy, recurrent falls, risk factors for polypharmacy and moderate to severe malnutrition). Care is delivered using a dedicated hepatology-geriatric referral pathway. Primary objectives include evaluating the impact of this approach on emergency care and inpatient utilization, along with patient attitude and satisfaction to the virtual interdisciplinary care delivery model.

Method

This pilot quality improvement study was conducted in Halifax, Nova Scotia. Ethics approval was obtained from the Nova Scotia Health Research Ethics Board and the University of Alberta Research Ethics Board. Fifty to one hundred participants (age 65 years or older with at least one geriatric syndrome; diagnosis of liver cirrhosis by liver elastography or liver biopsy, or Fibrosis-4 Index for Liver Fibrosis greater than three and having radiological features of cirrhosis and/or portal hypertension) were recruited between September 2022 to December 2022 at the time of their hepatology consultation. After consent and screening, each patient underwent a telehealth appointment by zoom with a geriatrician within four weeks of their initial hepatology assessment. Follow-up by telephone using a standardized survey regarding ease of access and quality of their telehealth experience then occurred at 3-4 weeks, 3 months and 6 months for emergency room visits and hospital admission status.

Result(s)

Pending

Conclusion(s)

Pending

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Other

Please indicate your source of funding;

Pfizer Canada

Disclosure of Interest

J. Zhu Grant / Research support from: Pfizer Canada, F. Carr Grant / Research support from: Pfizer Canada, P. Tian: None Declared, M. McLeod: None Declared, M. MacFarlane: None Declared, S. De Coutere: None Declared, M. Sun: None Declared, K. Peltekian: None Declared

Big Endothelin-1 as a Predictor of Reverse Remodeling and Prognosis in Dilated Cardiomyopathy

This study aimed to investigate the predictive value of Big endothelin-1(ET-1) for left ventricular reverse remodeling (LVRR) and prognosis in patients with dilated cardiomyopathy (DCM). Patients with DCM and a left ventricular ejection fraction (LVEF) ≤ 50% from 2008 to 2017 were included. LVRR was defined as the LVEF increased by at least 10% or follow-up LVEF increased to at least 50% with a minimum improvement of 5%; meanwhile, the index of left ventricular end-diastolic diameter (LVEDDi) decreased by at least 10% or LVEDDi decreased to ≤33 mm/m². The composite outcome for prognostic analysis consisted of death and heart transplantations. Of the 375 patients included (median age 47 years, 21.1% female), 135 patients (36%) had LVRR after a median of 14 months of treatment. An independent association was found between Big ET-1 at baseline and LVRR in the multivariate model (OR 0.70, 95% CI 0.55-0.89, p = 0.003, per log increase). Big ET-1, body mass index, systolic blood pressure, diagnosis of type 2 diabetes mellitus (T2DM) and treatment with ACEI/ARB were significant predictors for LVRR after stepwise selection. Adding Big ET-1 to the model improved the discrimination (∆AUC = 0.037, p = 0.042 and reclassification (IDI, 3.29%; p = 0.002; NRI, 35%; p = 0.002) for identifying patients with LVRR. During a median follow-up of 39 (27-68) months, Big ET-1 was also independently associated with the composite outcome of death and heart transplantations (HR 1.45, 95% CI 1.13-1.85, p = 0.003, per log increase). In conclusion, Big ET-1 was an independent predictor for LVRR and had prognostic implications, which might help to improve the risk stratification of patients with DCM.

Predictive value of remnant cholesterol level for all-cause mortality in heart failure patients

Background

Lower cholesterol levels are associated with increased mortality in heart failure (HF) patients. Remnant cholesterol corresponds to all cholesterol not found in high-density lipoprotein (HDL) and low-density lipoprotein (LDL). The prognostic role of remnant cholesterol in HF remains unknown.

Objective

To reveal the relationship between the baseline remnant cholesterol level and all-cause mortality in HF patients.

Methods

This study enrolled 2,823 patients hospitalized for HF. Kaplan-Meier analysis, Cox regression, C-statistic, net reclassification improvement (NRI), and integrated discrimination improvement (IDI) were used to evaluate the prognostic value of remnant cholesterol for all-cause mortality in HF.

Results

The mortality rate was lowest in the fourth quartile of remnant cholesterol, which had an adjusted hazard ratio (HR) for death of 0.56 [HR: 0.39, 95% confidence interval (CI): 0.46-0.68, p < 0.001] relative to the first quartile. After adjustment, a one-unit increase in the level of remnant cholesterol was associated with a 41% decrease in the risk of all-cause mortality (HR: 0.59, 95% CI: 0.47-0.73, p < 0.001). A refinement in risk prediction was observed after adding remnant cholesterol quartile to the original model (ΔC-statistic = 0.010, 95% CI: 0.003-0.017; NRI = 0.036, 95% CI: 0.003-0.070; IDI = 0.025, 95% CI: 0.018-0.033; all p < 0.05).

Conclusion

Low remnant cholesterol levels are associated with increased all-cause mortality in HF patients. The addition of the remnant cholesterol quartile improved the predictive value over traditional risk factors.

Clinical Trial Registration

ClinicalTrials.gov, Unique Identifier: NCT02664818.

Clinical Profile, Treatment, and Prognosis of Left Ventricular Thrombus in Dilated Cardiomyopathy

Despite the emerging prevalence of left ventricular (LV) thrombus in dilated cardiomyopathy (DCM), clinical characteristics, management, and disease prognosis are poorly studied. We aim to assess the efficacy/safety profile of direct oral anticoagulants (DOACs) compared to warfarin by evaluating thrombus evolution, risk for stroke and systemic embolism (SSE), heart failure (HF) rehospitalization, all-cause mortality, and major adverse cardiovascular events (MACEs), and determine the impact of thrombus evolution on adverse events. We performed a historical cohort study of patients with a primary diagnosis of DCM and LV thrombus. Relationships between anticoagulants and thrombus resolution were analyzed with the Kaplan-Meier method and Cox regression. Associations between longitudinal thrombus evolution and adverse event hazard were measured with joint modeling. Among 122 patients included, 58.0% were prescribed warfarin, and 42.0% DOACs. Complete thrombus resolution at 90-day-after-index and 180-day-after-index was observed in 93 and 111 patients, with no difference in cumulative resolution between DOACs and warfarin. During a median follow-up of 12.5 months, MACE, all-cause death, SSE, and HF rehospitalization occurred in 42.6%, 27.9%, 4.1%, and 13.9% of patients, comparable in warfarin and DOACs groups. Thrombus persistence was associated with a higher risk of HF rehospitalization. Thrombus progression was associated with poor prognosis, with per unit increment in square-root-transformed thrombus-area resulting in a 1.0691-fold increase in MACE risk and a 1.0546-fold increase in death risk. This study suggests that in DCM patients with LV thrombus, DOACs were comparable to warfarin in thrombus resolution and safety profile. Thrombus persistence or progression was associated with an increased risk of HF rehospitalization, MACE, and mortality.

Clinical characteristics of patients with heart failure and intracardiac thrombus

Background

Heart failure (HF) patients are in a hypercoagulable state that predisposes them to an intracardiac thrombus. We aim to assess the clinical features of patients with HF and intracardiac thrombus.

Methods

Patients diagnosed with HF with intracardiac thrombus were enrolled in this study. Patients' demographics, clinical comorbidities, laboratory tests, and cardiac imaging parameters are recorded. Baseline characteristics are described; the relationship between intracardiac thrombus location and cardiac underlying diseases, New York Heart Association (NYHA) class, and left ventricular ejection fraction (LVEF) are analyzed; and the anticoagulation rate is summarized.

Results

A total of 1,248 patients were included in the study. Most patients were men (72.2%) with a mean age of 54 years. The left ventricle is the most frequently involved (66.8%), and the prevalence of left ventricular thrombus is more in patients complicated with coronary artery diseases, ventricular noncompaction cardiomyopathy, and dilated cardiomyopathy (86.3%, 86.4%, and 78.2%, respectively). When combined with atrial fibrillation, atrial flutter, hypertrophic cardiomyopathy, restrictive cardiomyopathy, or valvular cardiomyopathy, the intracardiac thrombus is mostly likely to occur in the left atrium. The incidence rate of left cardiac thrombosis increased with the decline of LVEF, an increase of NYHA class, and enlargement of a cardiac chamber. Overall, the anticoagulation rate was 56.8%, with warfarin still the mainstay drug (45.1%), while the prescription of non-vitamin K antagonist oral anticoagulants rose year by year. As for imaging modalities for thrombus detection and diagnosis, transthoracic echocardiography was the most widely performed (75.1%).

Conclusion

This study summarizes the underlying disease constitution, thrombus location and related factors, imaging modalities, and antithrombotic profile in HF patients with intracardiac thrombus comprehensively.

Prognostic utility of the prognostic nutritional index combined with serum sodium level in patients with heart failure

BACKGROUND AND AIMS

Both malnutrition and hyponatremia (serum sodium <135 mmol/L) can be induced by the impaired absorption function of the edematous intestinal wall caused by heart failure (HF) and are prognostic factors of mortality in HF. However, little is known about the interrelationship of nutritional status and hyponatremia in mortality risk prediction in HF.

METHODS AND RESULTS

This study enrolled 2882 HF patients admitted to the HF care unit of Fuwai Hospital, Beijing, China from 2008 to 2018; 71.3% were male and the mean age was 56.64 ± 15.96 years. Nutritional status was assessed by prognostic nutritional index (PNI), calculated as serum albumin (g/L) + 5 × total lymphocyte count (10⁹/L). Lower PNI indicates worse nutritional status. Patients were divided into 8 groups based on baseline PNI quartiles (Q1: <43.6, Q2: 43.6-48.55, Q3: 48.55-63.25, Q4: >63.25) and sodium level (normal sodium and hyponatremia). After adjustment, patients in the PNI Q1 associated with hyponatremia had a 2.12-fold higher risk of all-cause death (95% confidence interval [CI]: 1.67-2.70) compared with those in the PNI Q4 with normal sodium. A refinement in risk prediction was observed after adding PNI quartile and serum sodium category to the original model (ΔC-statistic = 0.018, 95% CI: 0.007-0.025; net re-classification index = 0.459, 95% CI: 0.371-0.548; integrated discrimination improvement = 0.025, 95% CI: 0.018-0.032).

CONCLUSION

HF patients with both the lowest PNI quartile and hyponatremia are at higher risk of all-cause mortality. The combination of PNI and serum sodium level enhanced the predictive value for all-cause mortality in hospitalized HF patients.

CLINICAL TRIAL REGISTRATION

URL: ClinicalTrials.gov; Unique Identifier: NCT02664818.

Prognostic value of high-sensitivity cardiac troponin I in patients with non-ischaemic heart failure: insights from China

AIMS

Evidence of the prognostic value of high-sensitivity troponin in patients with non-ischaemic heart failure (NIHF) is scarce. This study aimed to assess the predictive value of high-sensitivity cardiac troponin I (hs-cTnI) in NIHF patients.

METHODS

Hs-cTnI was measured at baseline in 650 NIHF patients admitted to the Heart Failure Center. The prognostic value of hs-cTnI was assessed based on a well-established model (including age, sex, New York Heart Association class, left ventricular ejection fraction, haemoglobin, sodium, estimated glomerular filtration rate, diabetes mellitus, treatment with angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, treatment with β-blockers, and NT-proBNP).

RESULTS

During a median follow-up of 1036 days, 163 patients died of various causes. In total, 46.92% of patients had high hs-cTnI (hs-cTnI >0.011 ng/ml). Over a 3-year follow-up, patients with high hs-cTnI (>0.011 ng/ml) had a 1.54 [95% confidence interval (95% CI) 1.11-2.15] fold higher all-cause mortality risk than those without. Increasing concertation of hs-cTnI was also associated with a 23.0% (95% CI 13-33%, per log₂ increase) increment risk of all-cause mortality. The inclusion of hs-cTnI significantly improved the risk prediction and stratification of all-cause mortality (integrated discrimination improvement 1.58%, 95% CI 0.38-2.79%, absolute net reclassification improvement 23.41% 95% CI 4.52-44.49%, additive net reclassification improvement 27.8%, 95% CI 9.29-46.3%) of the well-established model.

CONCLUSIONS

Hs-cTnI provides significant prognostic value and could further remarkably improve risk stratification and prediction capabilities in NIHF patients.

Prognostic value of RDW alone and in combination with NT-proBNP in patients with heart failure

BACKGROUND

Red blood cell distribution width (RDW) and N-terminal pro brain natriuretic peptide (NT-proBNP) may predict the prognosis of heart failure (HF). However, the impact of combined RDW and NT-proBNP levels as a prognostic marker of HF remains unclear and the significance of this combination at various time-points has not been sufficiently studied.

HYPOTHESIS

RDW can predict prognosis in HF at various time-points and combination with NT-proBNP improves the prognostic value.

METHODS

Patients admitted to HF care unit of Fuwai Hospital CAMS&PUMC (Beijing, China) with a diagnosis of HF from November 2008 to November 2018 were analyzed retrospectively.

RESULTS

In total, 3231 patients with available RDW data at admission were evaluated (median age 58 years, 71.9% males, 39.7% coronary heart disease, 68.6% New York Heart Association [NYHA] III or IV). Median RDW and NT-proBNP at admission were 13.4% (interquartile range [IQR]: 12.7%-14.5%), and 1723.00 pg/ml (IQR: 754.00-4006.25 pg/ml), respectively. During 2.9-year median follow-up, all-cause death occurred in 1075 (33.27%) patients. Kaplan-Meier survival curve and Cox proportional-hazard models, showed patients in the top quarter RDW had a 32.0% increased mortality compared to the bottom quarter (hazard ratio: 4.39, 95% confidence interval: 3.59-5.38; p <.001). The top quarter RDW retained independent prognostic value across HF with reduced ejection fraction [HFrEF], HF with mid-range ejection fraction [HFmrEF], and HF with preserved ejection fraction [HFpEF] subgroups. Patients were subsequently divided into four groups by median RDW and NT-proBNP. Comparison of Kaplan-Meier survival curves for various groups showed good risk stratification (p < .001).

CONCLUSIONS

RDW is an independent predictor of mortality among patients with HF in the short-, medium-, and long-term. Combination of RDW and NT-proBNP improves the prognostic value. This is true across all clinical subtypes of heart failure (HFrEF, HFmrEF, HFpEF), and among most subgroups of patients with various comorbidities (infection, diabetes, hypertension).

D-dimer and outcomes in hospitalized heart failure patients across the ejection fraction phenotypes

AIMS

The prognostic significance of D-dimer in hospitalized heart failure (HF) patients is incompletely characterized. We aimed to assess the association of D-dimer levels on admission with adverse events at follow-up in patients hospitalized with HF across all ejection fraction (EF) phenotypes.

METHODS AND RESULTS

Consecutive patients hospitalized from December 2006 to December 2017 for HF with D-dimer and EF values available (n = 1795) were enrolled. Associations between D-dimer and all-cause death were examined at 1-year follow-up. Median age was 57 years, 73.4% were male, and the majority (72.1%) were in New York Heart Association Classes III-IV. EF was reduced in 53.3% (HFrEF), mildly reduced in 16.3% (HFmrEF), and preserved in 30.4% (HFpEF). Median (interquartile range) D-dimer on admission was 0.56 (0.27-1.295) μg/mL FEU (fibrinogen-equivalent unit) in the whole cohort, 0.64 (0.28-1.48) μg/mL FEU in HFrEF, 0.50 (0.27-1.03) μg/mL FEU in HFmrEF, and 0.495 (0.25-1.10) μg/mL FEU in HFpEF (P = 0.001). At 1-year follow-up, higher D-dimer (D-dimer ≥0.56 μg/mL FEU) independently predicted all-cause death in total cohort [hazard ratio (HR) 1.55; 95% confidence interval (CI), 1.15-2.1], in HFrEF (HR, 1.49; P = 0.039), and in HFpEF (HR, 2.06; P = 0.033). However, no relationship was found for HFrEF or HFmrEF when D-dimer was treated as quartiles. In sensitivity analysis, quantitatively similar but more pronounced association between D-dimer and all-cause death was observed in total cohort and HFpEF cohort.

CONCLUSIONS

In hospitalized HF patients, higher D-dimer concentration was a significant and independent predictor of 1-year all-cause mortality. Across all HF phenotypes, this effect was most evident in HFpEF patients.

Outcome and prognostic value of N-terminal pro-brain natriuretic peptide and high-sensitivity C-reactive protein in mildly dilated cardiomyopathy vs. dilated cardiomyopathy

AIMS

Mildly dilated cardiomyopathy (MDCM) was characterized as a subset of dilated cardiomyopathy (DCM) with systolic dysfunction and modest ventricular dilatation, of which the prognostic studies were limited. We aimed to compare the prognostic value of the N-terminal pro-brain natriuretic peptide (NT-proBNP) and high-sensitivity C-reactive protein (hs-CRP) between MDCM and DCM.

METHODS AND RESULTS

We retrospectively included hospitalized patients diagnosed with DCM and a left ventricular ejection fraction ≤ 50% at Fuwai Hospital from 2006 to 2017. MDCM was defined as left ventricular end-diastolic diameter index (LVEDDi) ≤ 33 mm/m² in males and ≤34 mm/m² in females. A total of 640 patients (median age 49 years, 24.8% female) were included in this study. At baseline, 110 cases (17%) were categorized as MDCM and 529 cases (83%) as DCM. Of 282 patients who had follow-up echocardiograms ≥ 6 months, 7 MDCM patients (11.1%) evolved to DCM and 70 DCM patients (32.0%) recovered to MDCM by the change of LVEDDi. Compared with DCM, patients with baseline MDCM had lower composite risks of all-cause mortality, heart transplantation, and heart failure rehospitalization [adjusted hazard ratio (HR) 0.63, 95% confidence interval (CI) 0.43-0.93, P = 0.019]. Both hs-CRP and NT-proBNP were independently associated with the composite endpoint in the overall cohort (hs-CRP: adjusted HR 1.07, 95% CI 1.00-1.15, P = 0.036; NT-proBNP: adjusted HR 1.11, 95% CI 1.02-1.22, P = 0.019). After a propensity-score matching between MDCM and DCM, higher NT-proBNP (above the median) was significantly associated with the outcome in DCM patients (HR 1.83, 95% CI 1.05-3.20, P = 0.034), but not in MDCM patients (HR 1.54, 95% CI 0.76-3.11, P = 0.227). On the contrary, higher hs-CRP (above the median) showed prognostic value for adverse events in MDCM patients (HR 3.19, 95% CI 1.52-6.66, P = 0.002), but not in DCM patients (HR 1.04, 95% CI 0.61-1.79, P = 0.88).

CONCLUSIONS

In patients with MDCM, although no evidence suggested the prognostic role of NT-proBNP, higher level of hs-CRP was associated with outcome, supporting the use of hs-CRP in risk stratification for patients with MDCM.

Development of a Self-reported Olfactory Dysfunction Questionnaire (SODQ) to screen olfactory disorders in China

BACKGROUND

The diagnosis of olfactory dysfunction is challenging given the negligence during routine physical examination, inconvenience of diagnosis in clinical practice, and the inattention to cross-cultural adaptability. The study aimed to develop and validate a simple and effective self-reported olfactory dysfunction questionnaire (SODQ) for the initial screening of clinical olfactory disorders in China.

METHODS

A total of 121 subjects participated in the study; of these, 96 subjects completed the T&T olfactometer test and 12-item questionnaire, and 25 participants were retested using the SODQ after one week. The T&T olfactometer test examined the olfactory function and the questionnaire measured the ability to perceive common odors in daily life. We evaluated the factor structure, reliability, validity, and discriminative ability of the SODQ.

RESULTS

The final version of the SODQ consisted of 10 items with one factor. Test-retest and internal consistency were excellent. Convergent validity of the questionnaire with the T&T olfactory test was high. Furthermore, the discrimination ability was high for the questionnaire with an area under the curve of 0.95 and a cut-off point of 22.

CONCLUSIONS

The SODQ is a brief, valid, and repeatable tool that has the potential to effectively screen for clinical olfactory disorders from a subjective perspective.

Elevated urinary albumin concentration predicts worse clinical outcomes in hospitalized acute decompensated heart failure patients

Objective

To investigate the prognostic value of elevated urinary albumin concentration (UAC) in hospitalized acute decompensated heart failure (ADHF) patients.

Methods

We measured UAC at baseline in 1818 hospitalized ADHF patients who were admitted to our Heart Failure Center. All patients were followed up for a median period of 937.5 days. The primary endpoint was a composite of all‐cause death or heart transplantation (HTx) or left ventricular assist device (LVAD) implantation.

Results

In total, 41.5% of ADHF patients had albuminuria (UAC ≥ 20 mg/L). The median value of UAC was 15.5 mg/L. A total of 679 patients died or underwent HTx/LVAD during follow‐up. The median UAC was significantly lower in non‐HTx/LVAD survivors (14.3 mg/L) than in those who died or underwent HTx/LVAD (18.0 mg/L, P < 0.001). Compared with patients without albuminuria (reference, n = 1064), those with albuminuria had a 1.47‐fold higher risk of all‐cause death or HTx/LVAD (95% confidence interval [CI]:1.26–1.71, P < 0.001), with hazard ratios (HRs) of 1.42 (95% CI: 1.21–1.66) and 1.74 (95% CI: 1.33–2.26) in patients with microalbuminuria (20 mg/L ≤ UAC < 200 mg/L, n = 617) and macroalbuminuria (UAC ≥ 200 mg/L, n = 137), respectively (both P < 0.001). After adjustment for significant clinical risk factors, the albuminuria group had a higher risk of primary adverse events than the non‐albuminuria group (HR = 1.28, 95% CI: 1.09–1.50, P = 0.003), with HRs of 1.27 [95% CI: 1.07–1.49] and 1.36 [95% CI: 1.01–1.84] in patients with microalbuminuria and macroalbuminuria, respectively (P = 0.006 and P = 0.041). The adjusted risk of primary adverse events also increased with the degree of albuminuria in the test for trend (HR = 1.21, 95% CI: 1.06–1.37, P for trend = 0.004). In the subgroup analysis, albuminuria had a significantly greater prognostic value for patients with left ventricular ejection fraction ≥ 40%, eGFR ≥ 60 mL/min/1.73 m², BUN/creatinine ratio ≥ 20 or NT‐proBNP < 2098 pg/mL.

Conclusion

The presence of albuminuria evaluated by UAC predicts adverse clinical outcomes in hospitalized ADHF patients.

Development and validation of novel diagnostic nomogram for tuberculous pleurisy based on TB-IGRA results

OBJECTIVE: To establish the diagnostic nomogram for tuberculous pleurisy (TP) based on TB-interferon-gamma release assays (TB-IGRA), as well as clinical and peripheral blood characteristics.MATERIAL AND METHODS: Patients who underwent TB-IGRA tests during hospitalisation and were finally diagnosed, were retrospectively and continuously enrolled. TP was divided into confirmed TP (cTP) and presumptive TP (pTP), and corresponding diagnostic nomograms were established.RESULTS: A total of 1283 patients were enrolled (median age 49 years, range 14-96; males: 63.1%). The area under the curve (AUC) of TB-IGRA was 0.81 (95%CI 0.77-0.84) for cTP (n = 272) and 0.74 (95%CI 0.71-0.78) for pTP (n = 644). The false-positive and negative rates of TB-IGRA among non-TP and cTP were respectively 32.4% and 16.8%. Based on LASSO analysis, we then selected respectively 12 and 10 predictors from clinical and peripheral blood characteristics to establish cTP and pTP nomograms (TB-IGRA was selected). The cTP and pTP nomograms had an AUC of 0.93 (95%CI 0.90-0.95) and 0.92 (95%CI 0.90-0.94) in the training group, and 0.91 (95%CI 0.87-0.96) and 0.93 (95%CI 0.89-0.96) in the validation group, respectively, which were superior to TB-IGRA test alone.CONCLUSION: Novel predictive nomograms with less invasiveness were provided based on TB-IGRA test to assist differential diagnosis of TP and non-TP patients.

Correlation of lipid peroxidation and ATP enzyme on erythrocyte membrane with fetal distress in the uterus in patients with intrahepatic cholestasis of pregnancy

OBJECTIVE

This paper aims to investigate the correlation of lipid peroxide in erythrocytes and ATP (Adenosine Triphosphate) enzyme activity of erythrocyte membrane with fetal distress in patients with intrahepatic cholestasis of pregnancy (ICP).

PATIENTS AND METHODS

Forty-three patients with ICP treated at Jining No. 1 People's Hospital were enrolled as a study group, and another forty healthy parturient women in the same period were enrolled as a control group, to extract their elbow venous blood and fetal umbilical cord blood. Thiobarbituric acid (TBA) was used to detect superoxide dismutase (SOD) activity of erythrocytes, malondialdehyde (MDA) activity in plasma, Na+-K+-ATP enzyme activity and Ca2+-Mg2+-ATP enzyme activity of erythrocytes, which were compared between the study and control groups. The correlation of MDA, Na+-K+-ATP enzyme and Ca2+-Mg2+-ATP enzyme activities with fetal distress in the study group was analyzed, and the correlation of MDA with Na+-K+-ATP enzyme activity was investigated.

RESULTS

SOD and MDA activities of erythrocytes in maternal blood of the study group were significantly higher than those in the control group (p<0.05, p<0.001, respectively), but MDA activity in umbilical cord blood of the study group was markedly higher than that in the control group (p<0.001). Na+-K+-ATP enzyme and Ca2+-Mg2+-ATP enzyme activities of maternal and fetal erythrocytes of the study group were remarkably lower than those of the control group (p<0.001). MDA in the fetal distress group was significantly higher than that in the no fetal distress group in the study group (p<0.001). Na+-K+-ATP enzyme activity was negatively correlated with MDA concentration in maternal and fetal erythrocytes of patients with ICP (both p<0.001).

CONCLUSIONS

Lipid peroxidation in patients with ICP will affect ATP enzyme activity of erythrocyte membrane, and the down-regulation of ATP enzyme activity in umbilical cord blood of patients with ICP may cause fetal distress in the uterus.

Engineering CRISPR interference system to enhance the production of pyrroloquinoline quinone in Klebsiella pneumonia

Pyrroloquinoline quinone (PQQ) is a cofactor of glucose dehydrogenase (GDH) and thus participates in glucose utilization. In Klebsiella pneumoniae, glucose utilization involves PQQ-dependent direct oxidation pathway (DOP) and phosphoenolpyruvate-dependent transport system (PTS). It is challenging to overproduce PQQ, as its biosynthesis remains unclear. Here, we report that PQQ production can be enhanced by stimulating the metabolic demand for it. First, we developed CRISPR interference (CRISPRi) system to block PTS and thereby intensify DOP. In shake-flask cultivation, the strain with CRISPRi system (simultaneously inhibiting four PTS-related genes) produced 225·65 nmol l^-1 PQQ, which was 2·14 times that of wild type. In parallel, an exogenous soluble glucose dehydrogenase (sGDH) was overexpressed in K. pneumoniae. In the shake-flask cultivation, this sGDH-overexpressing strain accumulated 140·05 nmol l^-1 PQQ, which was 1·33 times that of wild type. To combine the above two strategies, we engineered a strain harbouring both CRISPRi vector and sGDH-overexpressing vector. In the shake-flask cultivation, this two-plasmid strain generated 287·01 nmol l^-1 PQQ, which was 2·72 times that of wild type. In bioreactor cultivation, this two-plasmid strain produced 2206·1 nmol l^-1 PQQ in 57 h, which was 7·69 times that in shake-flask cultivation. These results indicate that PQQ production can be enhanced by intensifying DOP, as the apo-enzyme GDH is intrinsically coupled with cofactor PQQ. This study provides a strategy for the production of cofactors whose biosynthesis mechanisms remain ambiguous. SIGNIFICANCE AND IMPACT OF THE STUDY: Pyrroloquinoline quinone (PQQ) is an economically important chemical, which typically serves as a cofactor of glucose dehydrogenase (GDH) and thus participates in glucose metabolism. Klebsiella pneumoniae can naturally synthesize PQQ, but current yield constrains its commercialization. In this study, the PQQ level was improved by stimulating metabolic demand for PQQ, instead of overexpressing PQQ synthetic genes, as the synthetic mechanism remains ambiguous.

Prognostic value of sleep apnea and nocturnal hypoxemia in patients with decompensated heart failure

Background

Nocturnal hypoxemia is an important factor underlying the impact of sleep apnea on heart failure. It remains unclear whether nocturnal hypoxemia has a greater prognostic value in acute decompensated heart failure (ADHF) compared with the frequency of sleep apnea.

Hypothesis

Nocturnal hypoxemia might be better than the frequency of sleep apnea in predicting the outcomes in ADHF.

Methods

Sleep studies were prospectively performed during an ADHF hospitalization from January 2015 to December 2017. Sleep apnea was defined as the apnea‐hypopnea index (AHI) ≥15/h. The severity of nocturnal hypoxemia was determined by the percentage of time with saturation below 90% (T90%). The endpoint was the first event of all‐cause death, heart transplantation, implantation of left ventricular assist device, unplanned hospitalization for worsening heart failure, acute coronary syndrome, significant arrhythmias, or stroke.

Results

Of 382 patients, 189 (49.5%) had sleep apnea. The endpoint incidence did not differ between AHI categories (≥15/h vs <15/h: 52.4% vs 44.6%, log rank P = .353), but did between T90% categories (≥3.6% vs <3.6%: 54.5% vs 42.4%, log rank P = .023). Multivariate Cox regression analysis showed that T90% was independently associated with the endpoint (hazard ratio [HR] 1.008, 95% confidence interval [CI] 1.001‐1.016, P = .033), whereas AHI was not; the risk of the endpoint increased by 40.8% in patients with T90% ≥3.6% (HR 1.408, 95%CI 1.030‐1.925, P = .032).

Conclusion

Nocturnal hypoxemia had a greater prognostic value in ADHF than the frequency of sleep apnea.

[The value of (18)F-fluorodeoxyglucose positron emission tomography-computed tomography ((18)F-FDG PET-CT) in evaluating the stability of atherosclerotic plaques]

Objective: Positron emission tomography-computed tomography (PET-CT) has been used to quantify inflammatory response in the body. The aim of the present study was to explore the possibility of using this method to evaluate the stability of atherosclerotic plaques and the efficacy of atorvastatin in stabilizing atherosclerotic plaques. Methods: Twenty New Zealand male white rabbits were included and divided into the atorvastatin intervention group and the control group, with 10 rabbits in each group. Rabbits in both groups were fed with a high fat diet for 20 weeks, and treated with thoracoabdominal aortic balloon-pulling to establish atherosclerosis model at the end of the 2nd week. Rabbits in atorvastatin intervention group was given atorvastatin intragastrically once a day. At the 8th week, thoracoabdominal aortic ultrasound was used to detect plaques in all rabbits. Blood was drawn at the 3rd and the 20th week, respectively, to measure blood lipids, high-sensitive C-reactive protein (hs-CRP) and matrix metalloproteinase-9 (MMP-9). At the end of experiment, survival animals were scanned by (18)F-FDG PET-CT, and the average and maximum standard uptake values (SUVmean, SUVmax) of aortic segments were measured. Thereafter, the animals were sacrificed and aortic specimens of rabbits were taken and examined by immunohistochemistry. The pathological indexes were measured and compared. Results: At the end of experiment, the total cholesterol (TC), triglyceride (TG), low-density lipoprotein cholesterol (LDL-C), hs-CRP [ (4.58±0.51) ng/ml vs.(5.87±0.66) ng/ml, P<0.01], MMP-9[ (43.93±2.16) ng/ml vs. (50.77±2.32) ng/ml, P<0.01], SUVmean (0.59±0.15 vs. 0.68±0.20, P<0.05) , SUVmax (0.68±0.20 vs. 0.81±0.27, P<0.05) , plaque area [ (0.36±0.24) mm(2) vs. (0.50±0.34) mm(2), P<0.05) ] and density of macrophage[ (4.34±1.54) % vs. (5.65±1.89) %, P<0.01] in the atorvastatin intervention group were significantly lower than those in the control group. In contrast, fiber cap thickness of the plaque[ (4.12±0.66) μm vs. (2.96±0.37) μm, P<0.01] in the atorvastatin intervention group was higher than that of the control group, and the difference was statistically significant. The arterial plaque areas were positively correlated with SUVmean (r=0.27, P<0.05) and SUVmax (r=0.43, P<0.01) . Fiber cap thickness was negatively correlated with SUVmean (r=-0.38, P<0.05) and SUVmax (r=-0.47, P<0.01) . The density of macrophage were positively correlated with SUVmean (r=0.52, P<0.01) and SUVmax (r=0.51, P<0.01) . Conclusion: (18)F-FDG PET/CT can be used to evaluate the efficacy of atorvastatin by the stability of atherosclerotic plaques.

Outcomes of standard dose EC-MPS with low exposure to CsA in DCD renal transplantation recipients with DGF

AIMS

The lower limit of exposure to cyclosporine A (CsA) has not yet been established in donation after cardiac death (DCD) renal transplantation recipients with delayed graft function (DGF) receiving enteric-coated mycophenolate sodium (EC-MPS) therapy. Stable and adequate mycophenolic acid (MPA) dosing may facilitate lower CsA exposure after DCD renal transplantation in recipients with DGF without compromising safety.

METHODS

A 12-month, single-centre open-label prospective trial was performed in our centre. According to their DGF risk index using the previous DGF prediction models, we divided up the patients on oral CsA into either a DGF group (n = 26) and no DGF group (n = 48). All of the patients initially received the standard EC-MPS dosing (1440 mg/day). The initial dose of CsA in the low risk of DGF group was 4.5 mg/kg/day and in the high risk of DGF group was 2.5 mg/kg/day. Efficacy parameters, safety and tolerability were assessed over a 12-month study period.

RESULTS

The incidence of DGF was 18.5% in the 162 DCD recipients. Between the DGF group and the no DGF group, the 1-year patient survival and graft survival were not significantly different. The incidence of BPAR was higher in the DGF group (26.9% vs. 8.3%, p = 0.032). Most patients in the DGF group had recovery of renal function after 1 month. The adverse events between the two groups were not significantly different. The daily EC-MPS doses of the DGF group were significantly higher than the no DGF group before the 6-month follow-up period. There were no significant differences between the two groups regarding the mean AUC levels during the follow-up period.

CONCLUSIONS

These results show that low expose CsA with standard dosing of EC-MPS and thymoglobulin was efficacious, safe and well-tolerated in DCD renal transplant recipients with DGF in China. Furthermore, stable and adequate MPA exposure helped to reduce the dose of and exposure to CsA. Thus, this may lead to less-induced nephrotoxicity and better renal function recovery.

Phylogenetic analysis of Elymus (Poaceae) in western China

Elymus L. is often planted in temperate and subtropical regions as forage. Species in the genus have 5 allopolyploid genomes that are found in the grass tribe Triticeae. To determine the phylogenetic relationships in Elymus species from western China, we estimated phylogenetic trees using sequences from the nuclear ribosomal internal transcribed spacer and non-coding chloroplast DNA sequences from 56 accessions (871 samples) of 9 polyploid Elymus species and 42 accessions from GenBank. Tetraploid and hexaploid Elymus species from western China had independent origins, and Elymus species from the same area or neighboring geographic regions were the most closely related. Based on the phylogenetic tree topology, the St- and Y-genomes were not derived from the same donor and Y-genome likely originated from the H-genome of Hordeum species, or they shared the same origin or underwent introgression. The maternal genome of tetraploid and hexaploid Elymus species originated from species of Hordeum or Pseudoroegneria. Additionally, Elymus species in western China began diverging 17-8.5 million years ago, during a period of increased aridification as a consequence of the Messinian salinity crisis. Elymus species adapted to drought and high salinity may have developed based on the environmental conditions during this period. Elymus evolution in western China may have been affected by the uplift of the Qinghai-Tibetan Plateau (5 million years ago), when Elymus seeds were dispersed by gravity or wind into a newly heterogeneous habitat, resulting in isolation.