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Contemporary outcomes of left thoraco-abdominal esophagectomy due to cancer in the esophagus or gastroesophageal junction, a multicenter cohort study. Dis Esophagus 2024:doae039. [PMID: 38678385 DOI: 10.1093/dote/doae039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 04/08/2024] [Accepted: 04/15/2024] [Indexed: 04/29/2024]
Abstract
Surgery for cancer of the esophagus or gastro-esophageal junction can be performed with a variety of minimally invasive and open approaches. The left thoracoabdominal esophagectomy (LTE) is an open technique that gives an opportunity to operate in the chest and abdomen with excellent exposure of the gastro-esophageal junction through a single incision, and there is currently no equivalent minimally invasive technique available. The aim of this multi-institutional review was to study a large contemporary international study cohort of patients treated with LTE. An international multicenter cohort study was performed including all patients treated with LTE at six high-volume centers for gastro-esophageal cancer surgery between 2012 and 2022. Patient data were prospectively collected in each participating centers' institutional database. Information about patient, tumor, and treatment details were collected. The study cohort included a total of 793 patients treated with LTE during the study period. The most frequently observed complications were pneumonia in 185/727 (25.5%) patients and atrial fibrillation in 91/727 (12.5%). Anastomotic leak occurred in 35/727 (4.8%) patients; no patient suffered from conduit necrosis. Thirty-day mortality occurred in 15/785 (1.9%) patients and 90-day mortality in 39/785 (5.0%) patients. Factors with statistically significant association with survival were American Society for Anesthesiologists-score, tumor location, tumor stage, and tumor free resection margins. Neoadjuvant therapy was not associated with increased survival compared to surgery alone but neoadjuvant chemoradiotherapy compared to neoadjuvant chemotherapy showed statistically significant improved survival with hazard ratio 0.60 (95% confidence intervals:0.44-0.80, P = 0.001) in a multivariable adjusted model. This study demonstrates that LTE can be applied in selected patients with results that are comparable to other large studies of open and minimally invasive surgery for esophageal or gastro-esophageal cancer at high-volume centers.
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Advancing health equity in prelicensure nursing curricula: Findings from a critical review. Nurs Inq 2024:e12629. [PMID: 38583134 DOI: 10.1111/nin.12629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 02/13/2024] [Accepted: 02/18/2024] [Indexed: 04/08/2024]
Abstract
Nurses play a crucial role in reducing health disparities and advancing health equity for individuals and communities. The future nursing workforce relies on their nursing education to prepare them to promote health equity. Nursing educators prepare students through a variety of andragogical learning strategies in the classroom and in clinical experiences and by intentionally updating and revising curricular content to address knowledge and competency gaps. This critical review aimed to determine the extent to which health equity concepts are explicitly present in prelicensure undergraduate nursing curricula globally. Of 434 articles screened, 22 articles describing 20 studies met inclusion criteria. Frequency and quantity of health equity content, concepts and topics, teaching strategies, evaluation strategies, and the overall extent of integration varied widely. Notably, only two articles described overall well-integrated explicit health equity content, and there was little attention to whether students transfer this learning into practice. A focus on individualism rather than population and community was noted, highlighting the presence of whiteness in nursing. Results from this review confirm that nursing education has room to improve with respect to health equity in the curricula.
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Early Initiation of Sacubitril/Valsartan in Patients With Acute Heart Failure and Renal Dysfunction: An Analysis of the TRANSITION Study. J Card Fail 2024; 30:425-435. [PMID: 37678704 DOI: 10.1016/j.cardfail.2023.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 08/22/2023] [Accepted: 08/22/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Treatment of patients with heart failure with reduced ejection fraction (HFrEF) and renal dysfunction (RD) is challenging owing to the risk of further deterioration in renal function, especially after acute decompensated HF (ADHF). METHODS AND RESULTS We assessed the effect of RD (estimated glomerular filtration rate of ≥30 to <60 mL/min/1.73 m2) on initiation, up-titration, and tolerability of sacubitril/valsartan in hemodynamically stabilized patients with HFrEF admitted for ADHF (RD, n = 476; non-RD, n = 483). At week 10, the target dose of sacubitril/valsartan (97/103 mg twice daily) was achieved by 42% patients in RD subgroup vs 54% in non-RD patients (P < .001). Sacubitril/valsartan was associated with greater estimated glomerular filtration rate improvements in RD subgroup than non-RD (change from baseline least squares mean 4.1 mL/min/1.73 m2, 95% confidence interval 2.2-6.1, P < .001). Cardiac biomarkers improved significantly in both subgroups; however, compared with the RD subgroup, the improvement was greater in those without RD (N-terminal pro-brain natriuretic peptide, -28.6% vs -44.8%, high-sensitivity troponin T -20.3% vs -33.9%) (P < .001). Patients in the RD subgroup compared with those without RD experienced higher rates of hyperkalemia (16.3% vs 6.5%, P < .001), investigator-reported cardiac failure (9.7% vs 5.6%, P = .029), and renal impairment (6.4% vs 2.1%, P = .002). CONCLUSIONS Most patients with HFrEF and concomitant RD hospitalized for ADHF tolerated early initiation of sacubitril/valsartan and showed significant improvements in estimated glomerular filtration rate and cardiac biomarkers. CLINICAL TRIAL REGISTRATION NCT02661217.
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RN Staffing Shortages in Nursing Homes: Nursing is Part of the Solution. J Gerontol Nurs 2024; 50:3-5. [PMID: 38015214 DOI: 10.3928/00989134-20231121-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
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RN Staffing Shortages in Nursing Homes: Nursing Is Part of the Solution. Res Gerontol Nurs 2024; 17:3-5. [PMID: 38261626 DOI: 10.3928/19404921-20231121-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
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Comparison of edoxaban and enoxaparin in a rat model of AlCl 3-induced thrombosis of the superior sagittal sinus. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2023; 396:3887-3892. [PMID: 37261475 PMCID: PMC10643418 DOI: 10.1007/s00210-023-02546-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 05/21/2023] [Indexed: 06/02/2023]
Abstract
Cerebral sinus venous thrombosis (CSVT) is an uncommon disease that is usually treated with anticoagulation (heparin, low-molecular heparin, or vitamin K-antagonists). We compared treatment with edoxaban, an oral factor Xa-antagonist, that has not been approved in patients with CSVT, with enoxaparin, a well-established therapy, in a rat model of CSVT. Fifty male Wistar rats were randomized into 5 groups (10 animals each) and subjected to aluminum chloride (AlCl3)-induced thrombosis of the superior sagittal sinus (SSS) or sham procedure. Animals with thrombosis of the SSS were treated with edoxaban, enoxaparin, or placebo. Diagnostic workup included neurological examination, MRI imaging, MR-flow measurements of the SSS, and immunohistochemical staining. Neurological examination revealed no differences between treatment groups. Seven days after initial thrombosis, flow in the SSS was lower in the active treatment group as compared to sham-operated animals (p < 0.05). Flow in the SSS in the active treatment groups (edoxaban 1 h prior to thrombosis: 0.16 cm/s ± 0.06 cm/s; edoxaban 6 h after thrombosis: 0.13 cm/s ± 0.05 cm/s; enoxaparin: 0.13 cm/s ± 0.04 cm/s; placebo: 0.07 cm/s ± 0.02 cm/s) was higher as compared to placebo (p < 0.05), but there were no differences between the active treatment groups (p > 0.05). Immunohistochemical staining showed no differences in the actively treated animals. Edoxaban proved to be similar to enoxaparin in a model of experimental AlCl3-induced CSVT.
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Planetary health in nursing curricula: How one school transformed nursing curricula as they integrated planetary health concepts with the 2021 AACN essentials. J Prof Nurs 2023; 49:52-56. [PMID: 38042562 DOI: 10.1016/j.profnurs.2023.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 08/11/2023] [Accepted: 08/24/2023] [Indexed: 12/04/2023]
Abstract
BACKGROUND Human health and the health of the planet are inextricably interconnected. The human impact on the environment and likewise the impact of the environment on human health is well documented across various areas of study. Climate change, air and water pollutants, land usage, vector borne illness, and other examples demonstrate this relationship. Nurse educators would be negligent if this knowledge was not integrated and aligned with AACN Essentials competencies to demonstrate acquisition of knowledge. METHODS The five domains of the Planetary Health Education Framework were mapped to the AACN Essentials competency based framework. RESULTS Crosswalks were developed for Level 1 and Level 2 Domains, Competencies, and Sub- Competencies with the Planetary Health Domains. Specific Planetary Health outcomes were identified with supporting resources. Exemplars demonstrate the application of the Planetary Health domains to classroom activities and learning objectives. CONCLUSIONS In order for graduates to be practice ready, practice to the full scope of their license, and practice from a holistic perspective, nursing education programs must address the reciprocal impacts of planetary health and human health as it is imperative for the health of all.
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A soluble LAG-3 protein (eftilagimod alpha) and an anti-PD-L1 antibody (avelumab) tested in a phase I trial: a new combination in immuno-oncology. ESMO Open 2023; 8:101623. [PMID: 37742484 PMCID: PMC10594027 DOI: 10.1016/j.esmoop.2023.101623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/28/2023] [Accepted: 07/31/2023] [Indexed: 09/26/2023] Open
Abstract
BACKGROUND Eftilagimod alpha (efti) is a major histocompatibility complex class II agonist activating antigen-presenting cells which leads to greater systemic type 1 T helper response and more cytotoxic CD8+ T-cell activation. This phase I trial evaluated the administration of efti, a soluble lymphocyte activation gene-3 (LAG-3) protein, combined with the anti-programmed death-ligand 1 (PD-L1) antibody avelumab in advanced solid tumors. PATIENTS AND METHODS Patients with heavily pretreated metastatic solid tumors received intravenous avelumab (800 mg) combined with subcutaneously administered efti (6 or 30 mg) for up to 12 cycles, followed by avelumab monotherapy. The primary endpoint was the assessment of the recommended phase II dose (RP2D) of efti in combination with avelumab. RESULTS Twelve patients with different tumor entities were enrolled (six patients in each cohort). During treatment, no dose-limiting toxicities occurred, and the severity of most adverse events was grade 1 or 2. In total, nine serious adverse events were documented, resulting in a fatal outcome in two cases, but none of them were assessed to be treatment related. Five patients (42%) achieved partial response. The median progression-free survival was 1.96 months and the median overall survival was not reached, with a 12-month survival rate of 75%. CONCLUSION Subcutaneously administered efti plus avelumab was well tolerated, and efti of 30 mg was determined to be RP2D. The activity is promising and warrants further investigation in future phase II trials.
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[Frequency and severity of sarcopenia in patients with inflammatory and noninflammatory musculoskeletal diseases : Results of a monocentric study in a tertiary care center]. Z Rheumatol 2023; 82:563-572. [PMID: 36877305 DOI: 10.1007/s00393-023-01332-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2023] [Indexed: 03/07/2023]
Abstract
INTRODUCTION Sarcopenia (SP) is defined as the pathological loss of muscle mass and function. This is a clinically relevant problem, especially in geriatric patients, because SP is associated with falls, frailty, loss of function, and increased mortality. People with inflammatory and degenerative rheumatic musculoskeletal disorders (RMD) are also at risk for developing SP; however, there is little research on the prevalence of this health disorder in this patient group using currently available SP criteria. OBJECTIVE To investigate the prevalence and severity of SP in patients with RMD. METHODS A total of 141 consecutive patients over 65 years of age with rheumatoid arthritis (RA), spondylarthritis (SpA), vasculitis, and noninflammatory musculoskeletal diseases were recruited in a cross-sectional study at a tertiary care center. The European Working Group on Sarcopenia in Older People (EWGSOP 1 and 2) definitions of presarcopenia, SP, and severe SP were used to determine the prevalence. Lean mass as a parameter of muscle mass and bone density were measured by dual X‑ray absorptiometry (DXA). Handgrip strength and the short physical performance battery (SPPB) were performed in a standardized manner. Furthermore, the frequency of falls and the presence of frailty were determined. Student's T-test and the χ2-test were used for statistics. RESULTS Of the patients included 73% were female, the mean age was 73 years and 80% had an inflammatory RMD. According to EWGSOP 2, 58.9% of participants probable had SP due to low muscle function. When muscle mass was added for confirmation, the prevalence of SP was 10.6%, 5.6% of whom had severe SP. The prevalence was numerically but not statistically different between inflammatory (11.5%) and noninflammatory RMD (7.1%). The prevalence of SP was highest in patients with RA (9.5%) and vasculitis (24%), and lowest in SpA (4%). Both osteoporosis (40% vs. 18.5%) and falls (15% vs. 8.6%) occurred more frequently in patients with SP than those without SP. DISCUSSION This study showed a relatively high prevalence of SP, especially in patients with RA and vasculitis. In patients at risk, measures to detect SP should routinely be performed in a standardized manner in the clinical practice. The high frequency of muscle function deficits in this study population supports the importance of measuring muscle mass in addition to bone density with DXA to confirm SP.
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Nine-Year Experience with Treatment of Early Detectable Donor Specific Anti-HLA Antibodies in Pediatric Lung Transplant Recipients. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
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11MO Final data from a phase II study (TACTI-002) of eftilagimod alpha (soluble LAG-3) and pembrolizumab in 2nd-line metastatic NSCLC pts resistant to PD-1/PD-L1 inhibitors. J Thorac Oncol 2023. [DOI: 10.1016/s1556-0864(23)00265-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
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Policy Priorities for a Well-Prepared Nursing Home Workforce. THE PUBLIC POLICY AND AGING REPORT 2023; 33:S5-S10. [PMID: 36817185 PMCID: PMC9933699 DOI: 10.1093/ppar/prac029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
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2022 NASEM Quality of Nursing Home Report: Moving Recommendations to Action. J Am Geriatr Soc 2023; 71:318-321. [PMID: 36795630 DOI: 10.1111/jgs.18274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 01/25/2023] [Indexed: 02/17/2023]
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Nine-Year Experience with Treatment of Early Donor Specific Anti-HLA Antibodies in Pediatric Lung Transplant Recipients. Thorac Cardiovasc Surg 2023. [DOI: 10.1055/s-0043-1761791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2023]
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Production of tailored hydroxylated prodiginine showing combinatorial activity with rhamnolipids against plant-parasitic nematodes. Front Microbiol 2023; 14:1151882. [PMID: 37200918 PMCID: PMC10187637 DOI: 10.3389/fmicb.2023.1151882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 04/03/2023] [Indexed: 05/20/2023] Open
Abstract
Bacterial secondary metabolites exhibit diverse remarkable bioactivities and are thus the subject of study for different applications. Recently, the individual effectiveness of tripyrrolic prodiginines and rhamnolipids against the plant-parasitic nematode Heterodera schachtii, which causes tremendous losses in crop plants, was described. Notably, rhamnolipid production in engineered Pseudomonas putida strains has already reached industrial implementation. However, the non-natural hydroxyl-decorated prodiginines, which are of particular interest in this study due to a previously described particularly good plant compatibility and low toxicity, are not as readily accessible. In the present study, a new effective hybrid synthetic route was established. This included the engineering of a novel P. putida strain to provide enhanced levels of a bipyrrole precursor and an optimization of mutasynthesis, i.e., the conversion of chemically synthesized and supplemented monopyrroles to tripyrrolic compounds. Subsequent semisynthesis provided the hydroxylated prodiginine. The prodiginines caused reduced infectiousness of H. schachtii for Arabidopsis thaliana plants resulting from impaired motility and stylet thrusting, providing the first insights on the mode of action in this context. Furthermore, the combined application with rhamnolipids was assessed for the first time and found to be more effective against nematode parasitism than the individual compounds. To obtain, for instance, 50% nematode control, it was sufficient to apply 7.8 μM hydroxylated prodiginine together with 0.7 μg/ml (~ 1.1 μM) di-rhamnolipids, which corresponded to ca. ¼ of the individual EC50 values. In summary, a hybrid synthetic route toward a hydroxylated prodiginine was established and its effects and combinatorial activity with rhamnolipids on plant-parasitic nematode H. schachtii are presented, demonstrating potential application as antinematodal agents. Graphical Abstract.
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Open left thoracoabdominal esophagectomy a viable option in the era of minimally invasive esophagectomy. Dis Esophagus 2022; 36:6576314. [PMID: 35511475 DOI: 10.1093/dote/doac024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/27/2022] [Indexed: 01/11/2023]
Abstract
Minimally invasive surgical technique has become standard at many institutions in esophageal cancer surgery. In some situations, however other surgical approaches are required. Left thoracoabdominal esophagectomy (LTE) facilitates complete resection of esophageal cancer particularly for bulky distal esophageal tumors, but there are concerns that this approach is associated with significant morbidity. Prospectively entered esophagectomy databases from three high-volume centers were reviewed for patients undergoing LTE or MIE 2009-2019. Patient demographics, tumor characteristics, operative outcomes, postoperative outcomes, and pathologic surrogates of oncologic efficacy (R0 resection rate, and number of resected lymph nodes) were compared. In total 915 patients were included in the study, LTE was applied in 684 (74.8%) patients, and MIE in 231 (25.2%) patients. LTE patients had more locally advanced tumor stage and received more neoadjuvant treatment. Patients treated with MIE had more comorbidities. The results showed no difference in overall postoperative complications (LTE = 61.7%, MIE = 65.7%, P = 0.289), severe complications (Clavien-Dindo ≥IIIa (LTE = 25.9%, MIE 26.8%, P = 0.806)), pneumonia (LTE = 29.0%, MIE = 24.7%, P = 0.211), anastomotic leak (LTE = 7.8%, MIE = 11.3%, P = 0.101), or in-hospital mortality (LTE = 2.6%, MIE = 3.5%, P = 0.511). Median number of resected lymph nodes was 24 for LTE and 25 for MIE (P = 0.491). LTE was used for more advanced tumors in patients that were more likely to have received neoadjuvant treatment compared with MIE, however postoperative morbidity, mortality, and oncologic outcomes were equivalent to that of MIE in this cohort. In conclusion open resection with left thoracoabdominal approach is a valid option in selected patients when performed at high-volume esophagectomy centers.
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EXPOSING THE REALITIES OF THE WORKFORCE IN NURSING HOMES. Innov Aging 2022. [PMCID: PMC9766657 DOI: 10.1093/geroni/igac059.229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
For decades, staffing in nursing homes has been highlighted as being inadequate and directly affecting the quality of care received by residents. The COVID-19 pandemic, occurring during the committee’s deliberations, further highlighted and exacerbated the multiple workforce challenges in nursing homes. The committee’s recommendations related to the nursing home workforce will be presented. Dr. Christine Mueller, a professor at University of Minnesota and with expertise in staffing and quality of care, will discuss strengthening the workforce to meet complex and varied resident needs that align with the committee’s recommendations.
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Transatlantic Collaborations: Baccalaureate Nursing Students' Experiences of Participating in a Semester-Long Study Abroad Program. Nurs Educ Perspect 2022; 43:357-362. [PMID: 35861596 PMCID: PMC9586825 DOI: 10.1097/01.nep.0000000000001000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
AIM The aim of this study was to describe students' experiences during a 15-week semester involving clinical placement in an Irish university. BACKGROUND Internationalization is promoted and facilitated through study abroad initiatives within nurse education. Collaborations were developed between one university in the United States, an Irish university, and service partners. This study abroad initiative involved planning logistics, curriculum learning opportunities, and negotiating clinical placement in meeting state professional requirements. METHOD A qualitative descriptive approach was used. Following ethical approval, 19 fourth-year students participated in focus group and individual semistructured interviews. Data analysis followed a thematic approach. RESULTS Connecting our worlds details a process of acclimatizing, navigating learning, and using person-centered practices, illustrating meaningful learning in a journey of personal and professional development. CONCLUSION Moving beyond the rhetoric of globalization is critical in future proofing initiatives in developing nursing practitioners while balancing potential safety risks in a post-COVID-19 era.
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Clinical risk scores versus simple integrated clinical judgment in patients with suspected acute coronary syndromes. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
The clinical utility of clinical risk scores in patients presenting with suspected acute coronary syndromes to the emergency department (ED) is uncertain.
Purpose
We aimed to directly compare the performance of three established clinical risk scores to simple integrated clinical judgment (ICJ) of the treating ED physician.
Methods
Thirty day major adverse cardiac events (MACE) including all-cause death, life-threatening arrhythmia, cardiogenic shock, acute myocardial infarction (AMI, including the index event), and unstable angina requiring urgent coronary revascularization were centrally adjudicated by two independent cardiologists in patients presenting to the emergency department (ED) with acute chest discomfort in an international multicenter study (12 centres in 5 European countries). ICJ for the likelihood that an ACS is the cause of acute chest discomfort was quantified by the treating ED physician using a visual analogue scale at 90 minutes after patient's presentation to the ED. At this time, the ED physician had obtained the patient history, physical examination including vital signs, the 12-lead electrocardiogram at presentation, and the first local (hs)-cTn measurement. We directly compared the prognostic performance of the HEART-score, the GRACE-score, and the T-MACS decision aid to simple integrated clinical judgment (ICJ) of the treating ED physician. We also assessed the safety for rule-out of MACE at 30-days.
Results
Among 4551 eligible patients, 1110/4551 patients (24.4%) had at least one MACE within 30 days. Prognostic accuracy as quantified by the area under the receiver-operating characteristics curve was 0.85 (95% CI, 0.84–0.87) for the HEART-score, 0.85 (95% CI, 0.84–0.87) for the GRACE-score, 0.79 (95% CI, 0.77–0.80) for the TIMI decision aid, and 0.87 (95% CI, 0.85–0.88) for ICJ (Figure). The HEART-score identified 1893/4551 (41.6%) patients as low-risk with an NPV of 96.0% (95% CI, 95.0–96.8), the GRACE score identified 1542/4551 (33.9%) patients as low-risk with an NPV of 97.0% (95% CI, 96.0–97.7), the TIMI score identified 2157/4551 (47.4%) patients as low-risk with an NPV of 93.1% (95% CI, 91.9–94.1), and simple ICJ identified 1743/4551 (38.3%) patients as low-risk with an NPV of 95.6% (95% CI, 94.5–96.5).
Conclusion
The simple ICJ of the treating physician performed well for the prediction of 30-day MACE and might be an alternative to the well-validated HEART-score, GRACE-score, and T-MACS decision aid.
Funding Acknowledgement
Type of funding sources: Other. Main funding source(s): The study was supported by research grants from the the Swiss Heart Foundation and the University of Basel.
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Differences in circulating cardiac troponin I and T in acute and chronic cardiac disease. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Clinical practice and guidelines assume that cardiac troponin I (cTnI) and cTnT are interchangeable, reflecting identical pathophysiological processes. However, it is unknown if cTnI and cTnT really are equivalent measures in different pathophysiological settings.
Purpose
To highlight potential differences in the release of cTnI and cTnT.
Methods
Large pooled cohort analysis including extensively characterized individuals, stratified into three groups: no cardiac disease (normal aging), chronic cardiac disease, and acute cardiac disease. Circulating cTnI and cTnT concentrations were measured blinded to clinical data using high-sensitivity assays (hs-cTnI-Architect, hs-cTnT-Elecsys) and their ratio calculated. Findings were validated using a second hs-cTnI assay (hs-cTnI-Clarity).
Results
Among 8719 individuals, 29% female, 10% had no known cardiac disease, 71% chronic cardiac disease, and 20% acute cardiac disease. Baseline characteristics including renal function were comparable between individuals with chronic and acute cardiac disease. Normal aging (without cardiac disease) was associated with a disproportional increase in cTnT versus cTnI (low cTnI/cTnT ratio, median 0.50, IQR 0.38–0.68). Although older, patients with chronic cardiac disease had a slightly higher cTnI/cTnT ratio (median 0.53, IQR 0.37–0.79, p<0.05). In contrast, in patients with acute cardiac disease, cTnI concentrations were disproportionally elevated compared to cTnT concentrations, resulting in a cTnI/cTnT ratio of 1.96 (IQR 0.93–4.73, p<0.001). Internal validation using a second hs-cTnI assay confirmed these findings.
Conclusion
These findings suggest relevant differences in the release of cTnI and cTnT with a greater release of cTnT versus cTnI in normal aging and a disproportional increase in cTnI versus cTnT in acute cardiac disease.
Funding Acknowledgement
Type of funding sources: Foundation. Main funding source(s): Swiss National Science Foundation
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Acute heart failure after non-cardiac surgery: incidence, phenotypes, determinants and outcomes. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Background
Primary acute heart failure (AHF) is an established and common cause of hospitalization. AHF may also develop secondarily, e.g. postoperatively (pAHF). Little is known about pAHF.
Purpose
To assess the incidence, phenotypes, determinants and outcomes of pAHF following non-cardiac surgery.
Methods
We prospectively included 9,164 consecutive patients at high cardiovascular risk undergoing 11,262 non-cardiac surgeries. The incidence, phenotypes, determinants and outcome of pAHF, centrally adjudicated by independent cardiologists, was determined. Logistic regression models identified the risk factors for pAHF. Cox regression analysis compared mortality and AHF readmission within 1 year in patients with and without pAHF. External validation was performed using a prospective cohort multicenter study of 1250 patients.
Results
The incidence of pAHF was 2.5% (95% confidence interval [CI] 2.2–2.8%). pAHF most often occurred on postoperative day 2 (median day 4). About half of pAHF (51%) occurred in patients without known HF (de novo pAHF), and 49% in patients with chronic HF. Preserved left ventricular ejection fraction (LVEF) was the dominant phenotype among de novo pAHF (72%), while reduced LVEF was dominant among pAHF in chronic HF (43%). Age, coronary artery disease, peripheral artery disease, diabetes, urgent/emergent surgery, chronic HF, atrial fibrillation, chronic obstructive pulmonary disease, anemia, and chronic myocardial injury were independent predictors of pAHF. Patients with pAHF had significantly higher all-cause mortality (44% vs. 11%, p<0.001) and AHF readmission (15% vs. 2%, p<0.001) within 1 year than patients without pAHF. pAHF was an independent predictor of all-cause mortality (adjusted hazard ratio [aHR] 1.7 [95% CI 1.3–2.2]; P<0.001) and AHF readmission (aHR 2.7 [95% CI 1.7–4.2]; P<0.001) within 1 year. Findings were confirmed in an external validation cohort of 1250 patients, e.g. incidence of pAHF 2.4% (95% CI, 1.6–3.3%).
Conclusions
pAHF frequent developed following non-cardiac surgery, being de novo in about half of cases, and associated with an unacceptable high mortality. Strategies focusing on early detection and treatment of pAHF seem warranted.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Swiss National Science FoundationSwiss Heart Foundation
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Risk stratification of perioperative myocardial infarction/injury following noncardiac surgery in high risk patients. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Perioperative myocardial infarction/injury (PMI) screening is increasingly recommended by current guidelines. PMI is often caused by type 2 myocardial infarction, and risk stratification tools for these patients are lacking.
Purpose
To derive and internally validate a risk prognostication model for PMI of likely type 2 infarction (lT2MI)
Methods
We included consecutive high-risk patients undergoing noncardiac surgery into this prospective multicenter study. Patients received a systematic routine PMI screening with pre- and postoperative measurement of cardiac troponin (cTn). PMI was prospectively defined as an absolute increase of cTn above the preoperative value. PMI etiology was centrally adjudicated and hierarchically classified by 2 independent physicians based on all clinical information obtained during index hospitalization and selected those with lT2MI for further analyses. To identify risk factors and allow risk stratification in lT2MI, we prespecified that only perioperative variables should be included into the model. We constructed a logistic binary regression model for major adverse cardiac events (MACE) within 120 days, including variables available at time of clinical evaluation: additional symptoms or ECG-criteria required according to the Universal Definition of Myocardial Infarction, absolute increase in cTn (categorized according to level of absolute increase 1–<2 times the 99th percentile, ≥2 to <4 times, and ≥4 times), urgency of procedure, perioperative bleeding (drop in haemoglobin >30g/L or deemed relevant for PMI by adjudicator), and ESC/ESA surgery risk (low, medium, high risk of cardiac events). Variables were omitted from the final model if the p-value was >0.05. Variable levels with similar odds ratios were grouped for simplification of the prognostic model. We constructed a calibration plot and calculated the area under the receiver-operating characteristics curve (AUC) and Brier Score. For internal validation we calculated the predicted probabilities and classified patients into low-risk (predicted event rate <10%), intermediate range (10–20%), and high-risk (>20%), and compared the predicted with the observed event rate.
Results
PMI occurred in 1016/7754 patients (13.1%) of which 750/1016 (73.8%) were adjudicated as lT2MI. MACE within 120 days occurred in 118/750 (15.7%) patients. The initial and final logistic prognostic model for 120-day MACE or death is shown in the table. Internal validation found a good fit of predicted and observed event rate following bootstrapping of 1000 iterations (Figure 1), a good AUC of 0.71 and a Brier score of 0.12.
Conclusion
The derived risk prognostication model for PMI of lT2MI can aid in the stratification of patients and support clinical decision making following noncardiac surgery.
Funding Acknowledgement
Type of funding sources: Foundation. Main funding source(s): Swiss National Science FoundationSwiss Heart Foundation
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Detrimental effects of intense vasodilation in women with acute heart failure: novel insights from a prospective randomized controlled trial. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Guidelines recommend evaluating the risk/benefit ratio of novel therapies individually in women and men, as the pathophysiology and the response to treatment may differ according to sex. Among patients with acute heart failure (AHF), a strategy of intensive vasodilation, compared with usual care, overall did provide comparable outcomes. However, sex-specific differences in heart failure pathophysiology and the effect of the strategy in women with AHF remained unclear.
Purpose
To characterize sex-specific differences in heart failure pathophysiology and to evaluate the effect of a strategy that emphasized early intensive and sustained vasodilation in women with AHF.
Methods
In a randomized, open-label blinded-end-point trial patients hospitalized for AHF were enrolled in 10 hospitals in Switzerland, Bulgaria, Germany, Brazil, and Spain. Inclusion criteria were AHF expressed by acute dyspnea and increased plasma concentrations of natriuretic peptides, systolic blood pressure ≥100 mmHg, and a plan for treatment in a general ward. Patients were randomized 1:1 to a strategy of early intensive and sustained vasodilation throughout the hospitalization or usual care. The primary end point was a composite of all-cause mortality or rehospitalization for AHF at 180 days. The subgroup analysis according to sex was predefined.
Results
Among 781 patients who completed the trial, 288 (36.9%) were women. Women were significantly older, had a higher systolic blood pressure at presentation and a more common history of diastolic dysfunction (all ps<0.05), whereas men had a significantly higher body surface area, a more common history of ischemic heart disease and a significant lower left ventricular ejection fraction (all ps<0.05). The primary end point, a composite of all-cause mortality or rehospitalization for AHF at 180 days, occurred in 53 female patients (37.9%) in the intervention group (including 28 deaths [20.0%]) and in 35 female patients (23.6%) in the usual care group (including 22 deaths [14.9%]) (absolute difference for the primary end point, 14.3%; adjusted hazard ratio, 1.62 [95% CI, 1.05–2.50]; P=0.03).
Conclusion
Among women with AHF, a strategy of early intensive and sustained vasodilation, compared with usual care, had a detrimental effect on a composite outcome of all-cause mortality and AHF rehospitalization at 180 days.
Funding Acknowledgement
Type of funding sources: Public hospital(s). Main funding source(s): University Hospital Basel
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VEGF beta is a candidate biomarker for cardiovascular risk stratification. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
The blood-based transcriptome changes in relation to body weight but longitudinal data on specific transcripts are rare. Monocytes play a crucial role in the development of atherosclerosis and coronary artery disease. Monitoring monocytic gene expression patterns could aid to identify biomarkers for improved cardiovascular risk stratification. BMI and diabetes mellitus (T2DM) are associated with coronary artery disease (CAD). There are mRNAs associated with the development of atherosclerosis and CAD, which can be detected in circulating cells. The exact pathways and direct targets have not been explored.
Objective
To apply transcriptome screening and validation analysis to identify novel biomarker candidates associated with longitudinal changes of BMI as cardiovascular risk factors and test association with clinical endpoints.
Methods
Transcriptome-wide monocytic gene expression changes were screened in relation to changes in BMI over a time period of 5 years in 1,092 participants of the Gutenberg Health Study with available transcriptomics data at baseline investigation and at 5-years follow-up. Functional enrichment of BMI-related genes (FDR <0.01) was tested based on pathway databases and selected gene sets. Serum VEGFB levels were quantified and validated in serum from n=1,895 individuals from an independent cohort study (FinRisk). In-vitro, THP1 cells were stimulated with recombinant VEGFB.
Results
143 transcripts showed a significant association with change in BMI over 5 years. Decreased VEGFB mRNA levels strongly associated with increased BMI (p=2.8x10–9). Lower levels of VEGFB mRNA were associated with increased mortality (HRperSD=0.757, 95% CI: 0.647–0.885, p=0.0005) following adjustment for age and sex and incident diabetes (p=0.01). Circulating VEGFB levels inversely correlated with VEGFB mRNA (r=−0.2, p=0.0024) and positively correlated with an increase in BMI (beta=0.226, p=8.4x10–6), type 2 diabetes mellitus risk (HRperSD=1.279, 95% CI: 1.148–1.425, p=7.8x10–6) and all-cause mortality (HRperSD=1.184, 95% CI: 1.045–1.342, p=0.008). Further exploration in n=1,895 individuals from FinRisk revealed an association of increased VEGFB levels with increased risk for heart failure (HRperSD=1.373, 95% CI: 1.210–1.560, p=1.0x10–6) and coronary artery disease (HR=1.018, 95% CI: 1.003–1.034, p=0.019), even after adjustment for BMI. In THP-1 culture, stimulation with VEGFB resulted in downregulation of VEGFB mRNA levels.
Conclusion
Decreased monocytic gene expression of VEGFB is related to increased BMI, increased risk of T2DM and all-cause mortality. Vice versa,circulating VEGFB levels associates positively with BMI, diabetes, mortality as well as heart failure and coronary heart disease. We hypothesize that monocytes regulate VEGFB expression by a negative feed-back mechanism based. Circulating VEGFB is a potential novel biomarker candidate for weight-related diabetes risk and cardiovascular risk evaluation.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): DZHK
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Machine learning to optimise use of cardiac troponin in the diagnosis of acute myocardial infarction. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Guidelines recommend fixed cardiac troponin thresholds for the assessment of patients with suspected acute coronary syndrome, however, performance varies in important patient groups as concentrations are influenced by age, sex and comorbidities. This limitation can be addressed using machine learning algorithms.
Methods
Machine learning algorithms were developed that integrate cardiac troponin concentrations at presentation or on serial testing with age, sex and clinical features in 10,038 consecutive emergency patients with suspected acute coronary syndrome. The primary outcome was an adjudicated diagnosis of type 1, type 4b or type 4c myocardial infarction. The best performing algorithm was selected for the CoDE-ACS (Collaboration for the Diagnosis and Evaluation of Acute Coronary Syndrome) decision-support tool, and performance was externally validated in 3,035 patients pooled from three prospective studies.
Findings
CoDE-ACS had excellent discrimination and calibration using cardiac troponin at presentation (area under curve [AUC] 0.959, 95% confidence interval 0.948–0.971, Brier score 0.040), in the pooled external validation cohort. At presentation, the rule-out score identified 62.1% (1,885/3,035) of all patients as low-probability of myocardial infarction with a 99.5% (99.1–99.7%) negative predictive value and 97.0% (96.3–97.6%) sensitivity. The rule-in score identified 8.3% (252/3,035) of patients as high-probability with an 83.7% (82.4–85.0%) positive predictive value and 98.5% (98.0–98.9%) specificity. Performance of the rule-out and rule-in scores was consistent across patient subgroups (Figure 1 and Figure 2). CoDE-ACS incorporating a second cardiac troponin measurement also had excellent discrimination and calibration (AUC 0.971 [0.962–0.980], Brier score 0.039) and refined the individualised probabilities in the 29.5% (898/3,035) of patients neither ruled-out or ruled-in at presentation to guide further investigation.
Conclusions
We developed and externally validated the CoDE-ACS decision-support tool using machine learning to aid in the diagnosis of myocardial infarction. CoDE-ACS had excellent diagnostic performance to rule-out and rule-in myocardial infarction at presentation, performed consistently across patient subgroups, and provided individualised probabilities to guide further care in those who require serial troponin measurements.
Conclusions
We developed and externally validated the CoDE-ACS decision-support tool using machine learning to aid in the diagnosis of myocardial infarction. CoDE-ACS had excellent diagnostic performance to rule-out and rule-in myocardial infarction at presentation, performed consistently across patient subgroups, and provided individualised probabilities to guide further care in those who require serial troponin measurements.
Funding Acknowledgement
Type of funding sources: Public Institution(s). Main funding source(s): National Institute for Health ResearchBritish Heart Foundation
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Performance of high-sensitivity cardiac troponin T versus I for the early diagnosis of myocardial infarction. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Clinical practice guidelines assume that both cardiac troponin (cTn) T and cTnI concentrations reflect identical pathophysiological processes and are equally effective in the detection of myocardial injury. However, there are differences between cTnT and cTnI that have been reported.
Purpose
The aim of this study was to directly compare the diagnostic performance of high-sensitivity cardiac troponin (hs-cTn) T versus hs-cTnI for the early diagnosis of acute myocardial infarction (MI).
Methods
In a prospective multicentre study, diagnostic and prognostic accuracies of hs-cTnT and I were analyzed in consecutive patients presenting to the emergency department with acute chest pain. The final diagnosis was adjudicated by two independent cardiologists using all information pertaining to the individual patient according to the fourth universal definition of MI. Adjudication of the final diagnoses was performed twice: once using serial measurements of hs-cTnT and once using hs-cTnI. Furthermore, the clinical performance of hs-cTnT/I when embedded in the European Society of Cardiology (ESC) 0/1h-algorithm was assessed.
Results
Among 5087 consecutive patients (median [Interquartile range, IQR] age 61 [49.0, 74.0] years, 33.2% female), 951 (18.7%) and 901 patients (17.7%) had an adjudicated final diagnosis of non-ST-segment elevation myocardial infarction (NSTEMI) when using serial measurements of hs-cTnT and hs-cTnI for adjudication, respectively. Diagnostic accuracy was very high for both hs-cTnT and hs-cTnI and comparable when using hs-cTnT for adjudication (hs-cTnT: area under the curve [AUC] 0.93 [95% CI 0.92–0.94] versus hs-cTnI AUC 0.93 [95% CI 0.92–0.94]; p=0.891). However, when using serial measurements of hs-cTnI for adjudication, diagnostic accuracy was significantly higher for hs-cTnI (AUC 0.93 [95% CI 0.92–0.94] versus AUC 0.94 [95% CI 0.94–0.95], p<0.001; Figure 1). This was confirmed in subgroup analyses including early presenter (≤3h), patients with renal failure, known coronary artery disease and elderly (≥70 years). However, both assays performed excellent with very high safety for rule-out and high accuracy for rule-in MI when embedded in the ESC 0/1h-algorithm. Prognostic accuracies for 730-day all-cause mortality and cardiovascular death were significantly higher for hs-cTnT compared to hs-cTnI (Figure 2).
Conclusions
While there seem to be differences between hs-cTnT and hs-cTnI in their diagnostic and prognostic performance, clinical relevance needs to be further evaluated since both assays performed excellent when embedded in their respective early triage algorithms.
Funding Acknowledgement
Type of funding sources: Foundation. Main funding source(s): Swiss National Foundation, Swiss Heart Foundation
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Association of accompanying dyspnea with diagnoses and outcome of patients presenting with suspected acute coronary syndromes. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
The presence of accompanying dyspnea is routinely assessed and common in chest pain patients with suspected acute coronary syndromes (ACS), but its impact on differential diagnoses, diagnostic work-up and outcome is incompletely understood.
Purpose
To determine the association of accompanying dyspnea with diagnoses, diagnostic work-up, and outcome of patients presenting with suspected ACS to the emergency department (ED).
Methods
We prospectively enrolled unselected patients presenting to the ED with chest pain as the main symptom suggestive of ACS in an international multicenter study. Final diagnoses were adjudicated by two independent cardiologists using all information including cardiac imaging. Patients were stratified by the presence or absence of self-reported dyspnea. The primary diagnostic endpoint was the differential diagnosis. The secondary diagnostic endpoint was the performance of high-sensitivity cardiac troponin (hs-cTn) and the European Society of Cardiology (ESC) 0/1h-algorithms for the diagnosis of myocardial infarction (MI). The primary prognostic endpoint was all-cause mortality at two years.
Results
Among 6045 patients, 2892/6045 (48%) had accompanying dyspnea. Final diagnoses in patients with versus without dyspnea were different (overall p<0.001), but prevalence of ACS was comparable (MI 22.4% vs. 21.9%, p=0.602, unstable angina 8.7% vs. 7.9%, p=0.291). In contrast, patients with dyspnea more often had cardiac, non-coronary disease (15.3% vs. 10.2%, p<0.001). Diagnostic accuracy of high-sensitivity cardiac troponin (hs-cTn)T/I concentrations at presentation for the diagnosis of MI was high and not affected by the presence of dyspnea (area under the curve 0.89–0.91 in both groups). The ESC 0/1h-algorithms performed excellent in both groups with negative predictive values >99.4%. The presence of dyspnea was associated with all-cause death at two years (hazard ratio [HR] 2.487 [95% CI, 2.001–3.091, p<0.001) and remained an independent predictor after adjustment for covariates at baseline (HR 1.813 [95% CI, 1.453–2.261, p=0.001]). Overall mortality rates were higher in patients with dyspnea at two years (9.0% vs. 3.7%, p<0.001).
Conclusion
Accompanying dyspnea was not associated with a higher prevalence of ACS but with cardiac, non-coronary disease such as heart failure. While the safety of the diagnostic work-up was not affected, accompanying dyspnea was associated with and an independent predictor for two-year all-cause mortality.
Funding Acknowledgement
Type of funding sources: Other. Main funding source(s): Swiss Heart Foundation, University of Basel.
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Combining qualitative and quantitative ECG criteria with the ESC 0/1h-hs-cTn-algorithm in the early diagnosis of non-ST-elevation myocardial infarction. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
The electrocardiogram (ECG) is one of the three main diagnostic tools for the assessment of patients with suspected non-ST-elevation myocardial infarction (NSTEMI). However, it is unknown how established qualitative or novel quantitative ECG criteria can best be combined with high-sensitivity cardiac troponin (hs-cTn)-based diagnostic algorithms, such as the ESC 0/1h-algorithm, for the early diagnosis of NSTEMI.
Methods
ST-segment depression, T-wave inversion, and a novel modified ST-segment deviation score (1), defined as the sum of ST-segment elevation in aVR plus absolute, unsigned ST-segment depressions in the remaining leads, were assessed blinded to all clinical data among unselected patients presenting with acute chest discomfort to the emergency department in an international multicentre prospective diagnostic study. Final diagnoses were centrally adjudicated by two independent cardiologists based on complete cardiac work-up, cardiac imaging and serial hs-cTn. Direct rule-in thresholds for the modified ST-segment deviation score, achieving a positive predictive value (PPV) of >70% justifying early monitorization and management, were derived, validated and compared to ST-segment depression and T-wave inversion and applied 1) alone and 2) in combination with the ESC 0/1h-hs-cTnT/I-algorithms.
Results
Among 3299 eligible patients, NSTEMI was present in 581 (17.6%) patients. ST-segment depression identified 243/3299 patients (7.4%) with a specificity of 96.5% (95% CI 95.7–97.1) and a PPV of 60.5% (95% CI 54.2–66.4) for the rule-in of NSTEMI, while T-wave inversion had a low PPV (38.0%; 95% CI 33.1–43.1). A modified ST-segment deviation score ≥6mm triaged 108/3299 patients (3.3%) towards direct rule-in upon ED arrival, resulting in a PPV of 71.3% (95% CI 62.1–79.0) and a specificity of 98.9% (95% CI 98.4–99.2), Figure 1. Bootstrap internal validation confirmed the robustness of these findings. Most patients ruled-in by ST-segment depression or a modified ST-segment deviation score ≥6mm would have been also ruled-in by the ESC 0/1h-hs-cTnT/I-algorithm, albeit 1–2h later. Combining ST-segment depression or a modified ST-segment deviation score ≥6mm with the ESC 0/1h-hs-cTnT-algorithm (Figure 2) accelerated the rule-in in those identified already by the ECG-criteria, and resulted in a modest number of reclassifications from rule-out or observe to rule-in. These results were confirmed in a secondary analysis assessing the combination of these ECG signatures with two ESC 0/1h-hs-cTnI-algorithms (Architect and Centaur).
Conclusion
Combining either ST-segment depression or a modified ST-segment deviation Score ≥6mm with the ESC 0/1h-hs-cTnT/I-algorithms accelerated and improved the early diagnosis of NSTEMI.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Swiss Heart Foundation (SHF) and Swiss National Science Foundation (SNSF)
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Prognostic value of a disease-specific health-related quality score in acute heart failure. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Despite the striking therapeutic progress made in the treatment of heart failure (HF), rehospitalization rate and mortality remain a major and often unpredictable problem. Previous studies have shown the prognostic value of Kansas City Cardiomyopathy Questionnaire (KCCQ), a score assessing disease-specific health-related quality of life in stable chronic HF patients. Recently, a large study including 4898 patients with acute HF (AHF) enrolled in China reported the incremental predictive ability of KCCQ for a composite outcome of death and rehospitalization. However, these findings were not yet confirmed. In order to address this unmet need, the aim of this study was to examine the prognostic value of KCCQ in another AHF cohort.
Purpose
To validate the prognostic value of the KCCQ in AHF.
Methods
Goal-directed AfterLoad Reduction in Acute Congestive Cardiac Decompensation Study (GALACTIC) was a prospective, multicenter (n=10), randomized, interventional controlled trial enrolling adult patients presenting with AHF. KCCQ was assessed shortly after admission. We focused on the prognostic value of the short version KCCQ-12, explored the association with the composite of all-cause mortality and AHF rehospitalization within 30- and 180-day follow-up and compared it to the original score. Patients were grouped into quartiles according their KCCQ: high-risk (0–<25), moderate- to high-risk (25–<50), low- to moderate-risk (50–<75) and low-risk group (75–100). Cumulative incidence of assessed endpoints was displayed in Kaplan-Meier curves. Covariate adjustments were made using Cox regression. Prognostic accuracy over N-terminal pro-B-type natriuretic peptide (NT-proBNP) was evaluated by time-dependent area under the curve.
Results
Among 781 patients, 419 (median age 78, 35% female, 32% new onset of HF) had a complete set of variables to calculate KCCQ. Follow-up was available in all patients up to 180 days. 29 (7%) and 122 (29%) patients died or were rehospitalized for AHF within 30- and 180-days, respectively. Median KCCQ-12 was 37.5 with 25% of patients attaining the high- and 8% the low-risk group. After adjustment, each 10-point decrease in the KCCQ was associated with a 10% increase in 180-day risk regardless of new onset or acute decompensated chronic HF, age, sex, comorbidities, systolic blood pressure, creatinine, NT-proBNP and sodium levels. The prognostic ability for a 30-day risk was not significant. Using the same adjustments, a 10-point decrease in the original KCCQ was significant for a 20% and a 11% increase in risk for the short- and long-term composite outcome. The prognostic accuracy of KCCQ was comparable to NT-proBNP.
Conclusions
Health status, measured by the KCCQ-12 among patients with AHF, is significantly associated with a long-term composite outcome of all-cause mortality and AHF rehospitalization. The original KCCQ overall score is an independent predictor for both, the 30- and 180-day composite outcome.
Funding Acknowledgement
Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Union, the Swiss National Science Foundation
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Renal failure: a non-cardiac source of high sensitivity cardiac troponin T. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Circulating high sensitivity cardiac troponin T (hs-cTnT) levels are frequently elevated in patients with end-stage renal disease (ESRD). The underlying pathophysiology is largely unknown. Currently, accumulation of hs-cTnT due to impaired renal clearance, as well as increased production caused by chronic cardiomyocyte injury is being discussed.
Purpose
The aim of this study was to assess the relative contribution of impaired renal clearance as a non-cardiac source of elevated hs-cTnT concentrations, using renal transplantation as an in vivo model of rapidly improved renal function and on a short-term basis rather unchanged cardiac pathology.
Methods
This single-centre study was a secondary analysis within a prospective active surveillance study program for perioperative myocardial infarction/injury (PMI). 42 consecutive high-risk patients undergoing renal transplantation without evidence of PMI were included. Serial creatinine and hs-cTnT (Elecsys, Roche) measurements were performed pre-transplant (baseline) and post-transplant on day (d) 1, between d2 and d5, and between d14 and d180. The effect of time and creatinine on hs-cTnT was estimated with a log-level non-linear mixed-effects model, where time and creatinine were treated as the fixed effects and subject as the random effect. Natural cubic splines were used to account for nonlinearity in the fixed effects.
Results
Baseline median serum creatinine concentration was 616 umol/L [interquartile range (IQR) 477–825], and significantly fell to 425 umol/L (IQR 313–619) on d1, 285 umol/L (IQR 194–509) on day2–5, and 116 umol/L (IQR 100–166) on d14–180 (p<0.001, p<0.001, and p=0.043, respectively; Figure 1A).
Pre-transplant hs-cTnT concentrations were above the 99th percentile (14ng/L) in all patients, median hs-cTnT concentration was 50 ng/L (IQR 35–70). In parallel to the fall in serum creatinine from baseline to d1, hs-cTnT concentrations significantly fell to 28 ng/L (IQR 15–40) on d1 (p<0.001), and then remained constant on d2–5 (27 ng/L (IQR 18–35)), and on d14–180 (24 ng/L (IQR 19–28); Figure 1B).
The mixed-effect model showed a significant decrease of hs-cTnT between baseline and d1 (p<0.001), whereas no significant change between d1 and d2 (p=0.82) occurred (Figure 2).
Conclusion
In contrast to the continuously falling serum creatinine levels, hs-cTnT concentrations reduced by about 50% only within the first 24 hours with a functional graft and then remained elevated above the 99th percentile. This suggests, that ESRD is a non-cardiac source of elevated circulating hs-cTnT concentrations, which contributes about 50%, while the other 50% seem related to chronic cardiomyocyte injury. Further studies assessing the long-term effect of renal transplantation on hs-cTnT levels and cardiac function are needed.
Funding Acknowledgement
Type of funding sources: Public Institution(s). Main funding source(s): Swiss National Science FoundationSwiss Heart Foundation
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Prevalence, patient characteristics and outcome of hyponatremia in acute heart failure. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Hyponatremia is the most common electrolyte disturbance found in hospitalized patients. Previous studies have shown that low serum sodium levels at presentation are associated with increased mortality and morbidity in patients hospitalized with acute heart failure (AHF). However, given the complicated multifactorial origin of hyponatremia, the role of serum sodium level in risk stratification in patients with AHF is still largely unknown.
Purpose
To evaluate the prevalence and prognostic value of hyponatremia in patients presenting with AHF to the emergency department (ED).
Methods
Basics in Acute Shortness of Breath EvaLuation (BASEL V) was a prospective, multicenter, diagnostic study recruiting dyspneic patients at the ED. The final diagnosis of AHF was adjudicated by 2 independent physicians. Hyponatremia was defined as a serum sodium level of <135 mmol/l. The prognostic accuracy of hyponatremia in predicting all-cause mortality and a composite outcome of death and heart failure (HF) rehospitalization was quantified using multivariable adjusted Cox regression. Adjustments were made for the following variables: age, sex, history of ischemic heart disease, previous HF, infection as a trigger of AHF, systolic blood pressure, glomerular filtration rate and log-transformed N-terminal pro-B-type natriuretic peptide (NT-proBNP) at presentation. The incremental value of hyponatremia to the MEESSI-Score, a validated AHF risk score, was quantified using area under the curve (AUC) analyses.
Results
Among 1572 patients with AHF, 1499 patients were eligible for the main analysis, of whom 215 (14.3%) had hyponatremia, 1249 (83.3%) normonatremia and 35 (2.3%) hypernatremia at presentation. Of those with hyponatremia, 21 (9.8%) and 54 (25.1%) patients died, 27 (12.6%) and 79 (36.7%) patients experienced the composite outcome within 30 and 180 days, respectively. Multivariable adjusted hazard ratios (aHR) were 0.97 (95%-CI 0.94–1.01) and 0.97 (95%-CI 0.95–0.99) for mortality, 0.97 (95%-CI 0.94–1.00) and 0.98 (95%-CI 0.95–0.99) for the composite outcome within 30 and 180 days, respectively. The risk for mortality and a composite of all-cause mortality and HF rehospitalization within 180 days after presenting to the ED with AHF rose significantly with a lower sodium level at presentation. Each 1-unit decrease in sodium level [mmol/L] was associated with a 3% and 2.7% increase in the hazard rate of mortality (aHR 0.97, p=0.01) and the composite outcome (aHR 0.98, p=0.01), respectively. While in the 30-day analyses after multivariable adjustment sodium had no significant prognostic value. The already excellent predictive ability of the MEESSI-Score for 30-day mortality was not enhanced by sodium level (AUC 0.80 versus 0.80, p=0.834).
Conclusion
Hyponatremia at presentation is associated with a higher risk of 180-day mortality in patients with AHF. However, its role as an independent prognostic marker in risk stratification remains unclear.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Swiss National Science FoundationSchweizerische Herzstiftung
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Bone morphogenetic protein 10 as predictor for adverse outcomes in patients with atrial fibrillation. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Patients with atrial fibrillation (AF) face an increased risk of death and major adverse cardiovascular events (MACE). Bone morphogenetic protein 10 (BMP10) is a novel atrial-specific biomarker, but data about its prognostic value in AF patients are lacking.
Purpose
We aimed to assess the predictive value of BMP10 for death and MACE in AF patients in comparison to N-terminal prohormone of B-type natriuretic peptide (NT-proBNP).
Methods
Baseline concentrations of BMP10 and NT-proBNP were measured in stable patients with AF enrolled in Swiss-AF, a prospective multicenter observational cohort study. Primary outcomes were all-cause death and MACE (composite of heart failure hospitalization, cardiovascular death, stroke, systemic embolism, myocardial infarction). Measures of discriminative power were used to compare multivariable Cox proportional hazard models using the different biomarkers.
Results
A total of 2219 AF patients were included with a median follow-up of 4.3 years (IQR 3.9, 5.1). Mean age was 73±9 years and 27% were women. Incidence rate per 100 patient-years of all-cause death and MACE increased across BMP10 quartiles (Figure 1). In the multivariable adjusted Cox proportional hazard model, the hazard ratio (HR) and 95% confidence interval (CI) of BMP10 was 1.60 (1.37; 1.87) to predict all-cause death, and 1.54 (1.35; 1.76) to predict MACE. For all-cause death, the C-index (95% CI) was 0.783 (0.763; 0.809) for BMP10, 0.784 (0.765; 0.810) for NT-proBNP, and 0.789 (0.771; 0.815) for both biomarkers combined. For MACE, the C-index (95% CI) was 0.732 (0.715; 0.754) for BMP10, 0.747 (0.731; 0.768) for NT-proBNP, and 0.750 (0.734; 0.771) for both biomarkers combined. When grouping patients according to clinical used NT-proBNP categories (<300, 300–900, >900 ng/l), higher incidence rates and adjusted HRs were observed for the primary outcomes in patients with high BMP10 in the categories of low NT-proBNP (all-cause death aHR 2.28 [1.15; 4.52], MACE aHR 1.88 [1.07; 3.28]) and high NT-proBNP (all-cause death aHR 1.61 [1.14; 2.26], MACE aHR 1.38 [1.07; 1.80]) (Figure 2).
Conclusion
The novel atrial-specific biomarker BMP10 strongly predicts all-cause death and MACE in patients with AF. BMP10 provides additional prognostic information in low- and high-risk patients according to NT-proBNP stratification.
Funding Acknowledgement
Type of funding sources: Foundation. Main funding source(s): Swiss National Science Foundation, Swiss Heart Foundation
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0/1h-algorithm using a new high-sensitivity cardiac troponin I assay for early diagnosis of myocardial infarction. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
The clinical performance of the novel high-sensitivity cardiac troponin I EXL (hs-cTnI-EXL) assay is unknown so far.
Purpose
We aimed to validate the clinical performance of the hs-cTnI-EXL assay and to derive and validate an hs-cTnI-EXL-specific 0/1h-algorithm for the early diagnosis of myocardial infarction (MI).
Methods
This multicenter study included patients presenting to the emergency department with symptoms suggestive of myocardial infarction. Central adjudication of final diagnoses was performed by two independent cardiologists using all clinical information including cardiac imaging twice: first, using serial hs-cTnI-Architect (primary analysis) and second, using serial hs-cTnT-Elecsys (secondary analysis) concentrations in addition to those clinically used (hs)-cTn. Hs-cTnI-EXL was measured at presentation and at 1h. The primary objective was to directly compare diagnostic accuracy quantified by the area under the receiver-operating-characteristic curve (AUC) of hs-cTnI-EXL, hs-cTnI-Architect and hs-cTnT-Elecsys. Secondary objectives included the derivation and validation of an hs-cTnI- EXL-specific 0/1h-algorithm.
Results
MI was the adjudicated final diagnosis in 204/1454 (14%) patients. At presentation, the AUC for hs-cTnI-EXL was 0.94 (95% CI, 0.93–0.96), being comparable to hs-cTnI-Architect (0.95; 95% CI, 0.93–0.96) and hs-cTnT-Elecsys (0.93; 95% CI, 0.91–0.95; Figure 1). In the derivation cohort (n=813), an optimal hs-cTnI-EXL-0/1h-algorithm was rule-out of MI with <9ng/L if onset of chest pain >3h or <9ng/L & 0h-1h-change <5ng/L, and rule-in with ≥160ng/L or 0h-1h-change ≥100ng/L. In the validation cohort (n=345), this hs-cTnI-EXL-0/1h-algorithm also performed well: rule-out in 56% of patients, negative predictive value 99.5% (95% CI, 97.1–99.9), sensitivity 97.8% (95% CI, 88.7–99.6), rule-in in 9% of patients, positive predictive value 83.3% (95% CI, 66.4–92.7), specificity 98.3% (95% CI, 96.1–99.3; Figure 2). Secondary analyses confirmed the findings using adjudication including serial measurements of hs-cTnT-Elecsys.
Conclusions
Hs-cTnI-EXL has comparable diagnostic performance to the currently best-validated hs-cTnT/I assays.
Funding Acknowledgement
Type of funding sources: Foundation. Main funding source(s): Swiss National Foundation, Swiss Heart Foundation
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Using high-sensitivity cardiac troponin for the exclusion of inducible myocardial ischemia in patients without previously known coronary artery disease. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
The rapid and safe exclusion of functionally relevant coronary artery disease (CAD) is a crucial, yet unmet clinical need. High-sensitivity cardiac troponin (hs-cTn) may be an attractive strategy, particularly in patients without previously known CAD.
Purpose
To derive and internally validate optimal rule-out cutoffs for an early and safe exclusion of functionally relevant CAD in symptomatic patients without previously known CAD.
Methods
In an ongoing single-center, prospective, cohort study, we enrolled consecutive patients without previously known CAD that were referred with symptoms possibly related to functionally relevant CAD. Cardiac troponin concentrations were measured at presentation using two high-sensitivity assays (Elecsys hs-cTnT and Architect hs-cTnI). Presence of functionally relevant CAD was adjudicated by 2 independent cardiologists, blinded to hs-cTn measurements, using MPI-SPECT/CT in all patients, as well as coronary angiography and fractional flow reserve measurements, whenever available. The primary diagnostic outcome was safety for early rule-out of functionally relevant CAD, quantified by sensitivity and the negative predictive value (NPV). The co-primary prognostic outcomes were cumulative incidences of cardiovascular death and all-cause death after 5 years. A NPV ≥90% and sensitivity ≥90% were predefined as acceptable performance criteria. The derived cutoffs were further evaluated in pre-specified subgroups. Internal validity was assessed with a bootstrapping procedure for a realistic estimate in similar future patients. Cumulative incidence curves stratified by the presence of functionally relevant CAD and hs-cTn concentrations below and above the derived cutoffs were constructed.
Results
Among 2111 eligible patients, 498 (23.6%) had a final diagnosis of functionally relevant CAD. Median age was 68 years and 938 (44.4%) were female. For ruling out functionally relevant CAD, a hs-cTnT concentration <5 ng/L resulted in a sensitivity of 90.8% (95% CI: 87.9–93.0%) and a NPV of 90.2% (95% CI: 87.1–92.5), triaging 468 (22.2%) patients towards rule-out. Similarly, a hs-cTnI concentration <2 ng/L resulted in a sensitivity of 91.6% (95% CI: 88.8–93.7%) and a NPV of 90.0% (95% CI: 86.8–92.6), triaging 422 (20.0%) patients. Internal validation showed robustness of these findings. The diagnostic performance of the derived cutoffs did not significantly vary across the subgroups. Hs-cTn concentrations above the derived cutoffs were associated with a substantially higher cumulative event rate of cardiovascular death (hs-cTnT: 7.0% vs. 0.8%; hs-cTnI: 6.6% vs. 1.2%) and all-cause death (hs-cTnT: 14.3% vs. 2.4%; hs-cTnI: 13.1% vs. 4.4%) during 5-years follow-up (log rank p<0.001 for all).
Conclusion
In symptomatic patients without previously known CAD, very low hs-cTn concentrations may generally allow to safely and effectively exclude functionally relevant CAD.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Swiss National Science FoundationSwiss Heart Foundation
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Long term outcomes in different aetiologies of perioperative myocardial infarction/injury after noncardiac surgery. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Perioperative myocardial infarction/injury (PMI) occurring in the first 48h following noncardiac surgery is a frequent cardiac complication. Better understanding of the underlying aetiologies is urgently needed.
Aim
To explore the association of different aetiologies of PMI with long term outcomes.
Methods
In this prospective multicenter observational study, PMI aetiology was centrally adjudicated and hierarchically classified by two independent physicians based on all information obtained during clinically-indicated PMI work-up including cardiac imaging among consecutive high-risk patients undergoing major noncardiac surgery. PMI aetiology was classified into “extracardiac” if caused by a primarily extracardiac disease such as severe sepsis or pulmonary embolism; and “cardiac”, further subtyped into type 1 myocardial infarction (T1MI), tachyarrhythmia, acute heart failure (AHF), or likely type 2 myocardial infarction (lT2MI). Major adverse cardiac events (MACE) including T1MI, AHF (both only from day 3 to avoid inclusion bias), life-threatening arrhythmia, and cardiovascular death as well as all-cause death were assessed during 365-days follow-up.
Results
PMI occurred in 1016/7754 patients (13.1%). At least one MACE occurred in 684/7754 patients (8.8%) and 818/7754 patients died (10.5%) within 365 days. MACE and all-cause death occurred in 51% (95% CI 31–60) and 38% (95% CI 29–47), 41% (95% CI 28–51) and 27% (95% CI 16–34), 57% (95% CI 41–69) and 40% (95% CI 25–53), 64% (95% CI 45–76) and 49% (95% CI 30–62), as well as 25% (95% CI 22–28%) and 17% (95% CI 14–20) of patients with extracardiac PMI, T1MI, tachyarrhythmia, AHF, and lT2MI, respectively. These associations were confirmed in multivariable analysis.
Conclusion
At 365 days, most PMI aetiologies have unacceptably high rates of MACE and all-cause death, highlighting the urgent need for more intensive treatments.
Funding Acknowledgement
Type of funding sources: Other. Main funding source(s): Swiss National Science FoundationRoche Diagnostics
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Neurodevelopmental disorder with dystonia due to SOX6 mutations. Mol Genet Genomic Med 2022; 10:e2051. [PMID: 36069193 PMCID: PMC9747553 DOI: 10.1002/mgg3.2051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 06/30/2022] [Accepted: 08/18/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Mutations in SOX6 have recently been recognized as a new molecular cause of neurodevelopmental disorders characterized by intellectual disability, behavioral changes, and nonspecific facial and digital skeletal abnormalities. To date, <25 cases have been reported in the literature. METHODS AND FINDINGS Here we report a new case of SOX6-associated neurodegeneration and expand the phenotype to include ceratoconus. The clinical picture consisted of early onset mildly reduced intellectual function, facial asymmetry, and dystonic tremor of hands and neck, substantially improved by levodopa. Skeletal abnormalities included scoliosis and hypertrophy of the mandibular coronoid process. A heterozygous de novo loss-of-function variant in SOX6 (c.277 C>T. p.Arg93*) was molecularly confirmed which leads to truncation of the SOX6 protein in its N-terminus, upstream of any known functional domain. CONCLUSION SOX6-associated neurodevelopmental delayis ultrarare with less than 25 cases described in the literature. We report a new case who presented with early-onset mildly reduced intellectual function, facial asymmetry, skeletal abnormalities and dystonic tremor of hands and neck, substantially improved by levodopa. Given the therapeutic implications, SOX6 mutations should be considered in patients with complex dystonia parkinsonism.
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EP08.01-109 TACTI-002: A Phase II Study of Eftilagimod Alpha (Soluble LAG-3) & Pembrolizumab in 2nd line PD-1/PD-L1 Refractory Metastatic NSCLC. J Thorac Oncol 2022. [DOI: 10.1016/j.jtho.2022.07.681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Multidimensional Aspects of Nurse Staffing in Nursing Homes. Nurs Clin North Am 2022; 57:179-189. [DOI: 10.1016/j.cnur.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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11P Results of a phase II study investigating eftilagimod alpha (soluble LAG-3 protein) and pembrolizumab in second-line PD-1/PD-L1 refractory metastatic non-small cell lung carcinoma pts. Ann Oncol 2022. [DOI: 10.1016/j.annonc.2022.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Out of the Frying-Pan and into the Fire: Transplant Candidate Selection in Acute Lung Failure Due to SARS-CoV-2 Infection. J Heart Lung Transplant 2022. [PMCID: PMC8988482 DOI: 10.1016/j.healun.2022.01.387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose The COVID-19 pandemic led to unprecedented rates of acute lung failure (ALF), and a rise in lung transplantation (LTx) referrals. Data on LTx in ALF is limited to LTx outcomes, and the unpredictable course of SARS-CoV-2 makes candidate selection challenging. This study summarizes our experiences, in both patients transplanted and those we declined. Methods LTx referrals for ALF due to SARS-CoV-2 between 01Apr20-01Oct21 were reviewed. Set parameters were collected prospectively. Acceptance criteria reflected previous guidance. Cases were discussed at our multi-disciplinary meeting and suitable candidates evaluated at source before transfer for consent and listing. Internal follow-up and external data from declined patients were retrospectively analysed, with survival to discharge and length of hospital stay as end-points. Results 45 patients were referred (78% male). Median age was 55.8 [IQR 47.6-59.8] years. 36 (80%) required both mechanical ventilation and vvECMO, of median duration 46 [31-82] and 34 [24-72] days respectively. Consolidation was the commonest CT finding (47%). Bacterial colonisation (23/45, 51%), coagulopathy (21/45, 47%) and hepatic dysfunction (11/45, 24%) were common. Twenty-two patients were conscious, of whom 21 were evaluated. Five patients died during evaluation, from either sepsis or bleeding. One failed evaluation, and one withdrew consent. Six patients improved, making urgent LTx unnecessary, with 5 attending our review clinic. Of the 8 patients successfully evaluated, one died unexpectantly awaiting transfer, one improved at listing and a further patient died of sepsis after listing. Three patients underwent LTx, all being discharged home at 3 months post-LTx. Conclusion LTx candidate selection in critically ill SARS-CoV2 patients is challenging. Late recovery, particularly in non-fibrotic ALF is not unusual. Decision-making needs to include “acceptable morbidity” as a prelude to delayed evaluation and perhaps listing. More data is needed about declined candidates, particularly unweanable sedated patients with single-organ failure. Even successful awake recipients may experience significant psychological injury, underlining previous arguments in sedated patients. Equity to all candidates needs consideration, given the extraordinary demands on organ availability and care resources.
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2021 Canadian Surgery Forum01. Design and validation of a unique endoscopy simulator using a commercial video game03. Is ethnicity an appropriate measure of health care marginalization?: A systematic review and meta-analysis of the outcomes of diabetic foot ulceration in the Aboriginal population04. Racial disparities in surgery — a cross-specialty matched comparison between black and white patients05. Starting late does not increase the risk of postoperative complications in patients undergoing common general surgical procedures06. Ethical decision-making during a health care crisis: a resource allocation framework and tool07. Ensuring stability in surgical training program leadership: a survey of program directors08. Introducing oncoplastic breast surgery in a community hospital09. Leadership development programs for surgical residents: a review of the literature10. Superiority of non-opioid postoperative pain management after thyroid and parathyroid operations: a systematic review and meta-analysis11. Timing of ERCP relative to cholecystectomy in patients with ductal gallstone disease12. A systematic review and meta-analysis of randomized controlled trials comparing intraoperative red blood cell transfusion strategies13. Postoperative outcomes after frail elderly preoperative assessment clinic: a single-institution Canadian perspective14. Selective opioid antagonists following bowel resection for prevention of postoperative ileus: a systematic review and meta-analysis15. Peer-to-peer coaching after bile duct injury16. Laparoscopic median arcuate ligament release: a video abstract17. Retroperitoneoscopic approach to adrenalectomy19. Endoscopic Zenker diverticulotomy: a video abstract20. Variability in surgeons’ perioperative management of pheochromocytomas in Canada21. The contribution of surgeon and hospital variation in transfusion practice to outcomes for patients undergoing elective gastrointestinal cancer surgery: a population-based analysis22. Perioperative transfusions for gastroesophageal cancers: risk factors and short- and long-term outcomes23. The association between frailty and time alive and at home after cancer surgery among older adults: a population-based analysis24. Psychological and workplace-related effects of providing surgical care during the COVID-19 pandemic in British Columbia, Canada25. Safety of venous thromboembolism prophylaxis in endoscopic retrograde cholangiopancreatography: a systematic review26. Complications and reintervention following laparoscopic subtotal cholecystectomy: a systematic review and meta-analysis27. Synchronization of pupil dilations correlates with team performance in a simulated laparoscopic team coordination task28. Receptivity to and desired design features of a surgical peer coaching program: an international survey9. Impact of the COVID-19 pandemic on rates of emergency department utilization due to general surgery conditions30. The impact of the current COVID-19 pandemic on the exposure of general surgery trainees to operative procedures31. Association between academic degrees and research productivity: an assessment of academic general surgeons in Canada32. Laparoscopic endoscopic cooperative surgery (LECS) for subepithelial gastric lesion: a video presentation33. Effect of the COVID-19 pandemic on acute care general surgery at an academic Canadian centre34. Opioid-free analgesia after outpatient general surgery: a pilot randomized controlled trial35. Impact of neoadjuvant immunotherapy or targeted therapies on surgical resection in patients with solid tumours: a systematic review and meta-analysis37. Surgical data recording in the operating room: a systematic review of modalities and metrics38. Association between nonaccidental trauma and neighbourhood socioeconomic status during the COVID-19 pandemic: a retrospective analysis39. Laparoscopic repair of a transdiaphragmatic gastropleural fistula40. Video-based interviewing in medicine: a scoping review41. Indocyanine green fluorescence angiography for prevention of anastomotic leakage in colorectal surgery: a cost analysis from the hospital payer’s perspective43. Perception or reality: surgical resident and faculty assessments of resident workload compared with objective data45. When illness and loss hit close to home: Do health care providers learn how to cope?46. Remote video-based suturing education with smartphones (REVISE): a randomized controlled trial47. The evolving use of robotic surgery: a population-based analysis48. Prophylactic retromuscular mesh placement for parastomal hernia prevention: a retrospective cohort study of permanent colostomies and ileostomies49. Intracorporeal versus extracorporeal anastomosis in laparoscopic right hemicolectomy: a retrospective cohort study on anastomotic complications50. A lay of the land — a description of Canadian academic acute care surgery models51. Emergency general surgery in Ontario: interhospital variability in structures, processes and models of care52. Trauma 101: a virtual case-based trauma conference as an adjunct to medical education53. Assessment of the National Surgical Quality Improvement Program Surgical Risk Calculator for predicting patient-centred outcomes of emergency general surgery patients in a Canadian health care system54. Sustainability of a narcotic reduction initiative: 1 year following the Standardization of Outpatient Procedure (STOP) Narcotics Study55. Barriers to transanal endoscopic microsurgery referral56. Geospatial analysis of severely injured rural patients in a geographically complex landscape57. Implementation of an incentive spirometry protocol in a trauma ward: a single-centre pilot study58. Impostor phenomenon is a significant risk factor for burnout and anxiety in Canadian resident physicians: a cross-sectional survey59. Understanding the influence of perioperative education on performance among surgical trainees: a single-centre experience60. The effect of COVID-19 pandemic on current and future endoscopic personal protective equipment practices: a national survey of 77 endoscopists61. Case report: delayed presentation of perforated sigmoid diverticulitis as necrotizing infection of the lower limb62. Investigating disparities in surgical outcomes in Canadian Indigenous populations63. Fundoplication is superior to medical therapy for Barrett esophagus disease regression and progression: a systematic review and meta-analysis64. Development of a novel online general surgery learning platform and a qualitative preimplementation analysis65. Hagfish slime exudate as a potential novel hemostatic agent: developing a standardized assessment protocol66. The effect of the first wave of the COVID-19 pandemic on surgical oncology case volumes and wait times67. Safety of same-day discharge in high-risk patients undergoing ambulatory general surgery68. External validation of the Codman score in colorectal surgery: a pragmatic tool to drive quality improvement69. Improved morbidity and gastrointestinal restoration rates without compromising survival rates for diverting loop ileostomy with colonic lavage versus total abdominal colectomy for fulminant Clostridioides difficile colitis: a multicentre retrospective cohort study70. Potential access to emergency general surgical care in Ontario71. Immersive virtual reality (iVR) improves procedural duration, task completion and accuracy in surgical trainees: a systematic review01. Clinical validation of the Canada Lymph Node Score for endobronchial ultrasound02. Venous thromboembolism in surgically treated esophageal cancer patients: a provincial population-based study03. Venous thromboembolism in surgically treated lung cancer patients: a population-based study04. Is frailty associated with failure to rescue after esophagectomy? A multi-institutional comparative analysis of outcomes05. Routine systematic sampling versus targeted sampling of lymph nodes during endobronchial ultrasound: a feasibility randomized controlled trial06. Gastric ischemic conditioning reduces anastomotic complications in patients undergoing esophagectomy: a systematic review and meta-analysis07. Move For Surgery, a novel preconditioning program to optimize health before thoracic surgery: a randomized controlled trial08. In case of emergency, go to your nearest emergency department — Or maybe not?09. Does preoperative SABR increase the risk of complications from lung cancer resection? A secondary analysis of the MISSILE trial10. Segmental resection for lung cancer: the added value of near-infrared fluorescence mapping diminishes with surgeon experience11. Toward competency-based continuing professional development for practising surgeons12. Stereotactic body radiotherapy versus surgery in older adults with NSCLC — a population-based, matched analysis of long-term dependency outcomes13. Role of adjuvant therapy in esophageal cancer patients after neoadjuvant therapy and curative esophagectomy: a systematic review and meta-analysis14. Evaluation of population characteristics on the incidence of thoracic empyema: an ecological study15. Determining the optimal stiffness colour threshold and stiffness area ratio cut-off for mediastinal lymph node staging using EBUS elastography and AI: a pilot study16. Quality assurance on the use of sequential compression stockings in thoracic surgery (QUESTs)17. The relationship between fissureless technique and prolonged air leak for patients undergoing video-assisted thoracoscopic lobectomy18. CXCR2 inhibition as a candidate for immunomodulation in the treatment of K-RAS-driven lung adenocarcinoma19. Assessment tools for evaluating competency in video-assisted thoracoscopic lobectomy: a systematic review20. Understanding the current practice on chest tube management following lung resection among thoracic surgeons across Canada21. Effect of routine jejunostomy tube insertion in esophagectomy: a systematic review and meta-analysis22. Recurrence of primary spontaneous pneumothorax following bullectomy with pleurodesis or pleurectomy: a retrospective analysis23. Surgical outcomes following chest wall resection and reconstruction24. Outcomes following surgical management of primary mediastinal nonseminomatous germ cell tumours25. Does robotic approach offer better nodal staging than thoracoscopic approach in anatomical resection for non–small cell lung cancer? A single-centre propensity matching analysis26. Competency assessment for mediastinal mass resection and thymectomy: design and Delphi process27. The contemporary significance of venous thromboembolism (deep venous thrombosis [DVT] and pulmonary embolus [PE]) in patients undergoing esophagectomy: a prospective, multicentre cohort study to evaluate the incidence and clinical outcomes of VTE after major esophageal resections28. Esophageal cancer: symptom severity at the end of life29. The impact of pulmonary artery reconstruction on postoperative and oncologic outcomes: a systematic review30. Association with surgical technique and recurrence after laparoscopic repair of paraesophageal hernia: a single-centre experience31. Enhanced recovery after surgery (ERAS) in esophagectomy32. Surgical treatment of esophageal cancer: trends in surgical approach and early mortality at a single institution over the past 18 years34. Adverse events and length of stay following minimally invasive surgery in paraesophageal hernia repair35. Long-term symptom control comparison of Dor and Nissen fundoplication following laparoscopic para-esophageal hernia repair: a retrospective analysis36. Willingness to pay: a survey of Canadian patients’ willingness to contribute to the cost of robotic thoracic surgery37. Radiomics in early-stage lung adenocarcinoma: a prediction tool for tumour immune microenvironments38. Effectiveness of intraoperative pyloric botox injection during esophagectomy: how often is endoscopic intervention required?39. An artificial intelligence algorithm for predicting lymph node malignancy during endobronchial ultrasound40. The effect of major and minor complications after lung surgery on length of stay and readmission41. Measuring cost of adverse events following thoracic surgery: a scoping review42. Laparoscopic paraesophageal hernia repair: characterization by hospital and surgeon volume and impact on outcomes43. NSQIP 5-Factor Modified Frailty Index predicts morbidity but not mortality after esophagectomy44. Trajectory of perioperative HRQOL and association with postoperative complications in thoracic surgery patients45. Variation in treatment patterns and outcomes for resected esophageal cancer at designated thoracic surgery centres46. Patient-reported pretreatment health-related quality of life (HRQOL) predicts short-term survival in esophageal cancer patients47. Analgesic efficacy of surgeon-placed paravertebral catheters compared with thoracic epidural analgesia after Ivor Lewis esophagectomy: a retrospective noninferiority study48. Rapid return to normal oxygenation after lung surgery49. Examination of local and systemic inflammatory changes during lung surgery01. Implications of near-infrared imaging and indocyanine green on anastomotic leaks following colorectal surgery: a systematic review and meta-analysis02. Repeat preoperative endoscopy after regional implementation of electronic synoptic endoscopy reporting: a retrospective comparative study03. Consensus-derived quality indicators for operative reporting in transanal endoscopic surgery (TES)04. Colorectal lesion localization practices at endoscopy to facilitate surgical and endoscopic planning: recommendations from a national consensus Delphi process05. Black race is associated with increased mortality in colon cancer — a population-based and propensity-score matched analysis06. Improved survival in a cohort of patients 75 years and over with FIT-detected colorectal neoplasms07. Laparoscopic versus open loop ileostomy reversal: a systematic review and meta-analysis08. Posterior mesorectal thickness as a predictor of increased operative time in rectal cancer surgery: a retrospective cohort study09. Improvement of colonic anastomotic healing in mice with oral supplementation of oligosaccharides10. How can we better identify patients with rectal bleeding who are at high risk of colorectal cancer?11. Assessment of long-term bowel dysfunction in rectal cancer survivors: a population-based cohort study12. Observational versus antibiotic therapy for acute uncomplicated diverticulitis: a noninferiority meta-analysis based on a Delphi consensus13. Radiotherapy alone versus chemoradiotherapy for stage I anal squamous cell carcinoma: a systematic review and meta-analysis14. Is the Hartmann procedure for diverticulitis obsolete? National trends in colectomy for diverticulitis in the emergency setting from 1993 to 201515. Sugammadex in colorectal surgery: a systematic review and meta-analysis16. Sexuality and rectal cancer treatment: a qualitative study exploring patients’ information needs and expectations on sexual dysfunction after rectal cancer treatment17. Video-based interviews in selection process18. Impact of delaying colonoscopies during the COVID-19 pandemic on colorectal cancer detection and prevention19. Opioid use disorder associated with increased anastomotic leak and major complications after colorectal surgery20. Effectiveness of a rectal cancer education video on patient expectations21. Robotic-assisted rectosigmoid and rectal cancer resection: implementation and early experience at a Canadian tertiary centre22. An online educational app for rectal cancer survivors with low anterior resection syndrome: a pilot study23. The effects of surgeon specialization on the outcome of emergency colorectal surgery24. Outcomes after colorectal cancer resections in octogenarians and older in a regional New Zealand setting — What are the predictors of mortality?25. Long-term outcomes after seton placement for perianal fistulae with and without Crohn disease26. A survey of patient and surgeon preference for early ileostomy closure following restorative proctectomy for rectal cancer — Why aren’t we doing it?27. Crohn disease independently associated with longer hospital admission after surgery28. Short-stay (≤ 1 d) diverting loop ileostomy closure can be selectively implemented without an increase in readmission and complication rates: an ACS-NSQIP analysis29. A comparison of perineal stapled rectal prolapse resection and the Altemeier procedure at 2 Canadian academic hospitals30. Mental health and substance use disorders predict 90-day readmission and postoperative complications following rectal cancer surgery31. Early discharge after colorectal cancer resection: trends and impact on patient outcomes32. Oral antibiotics without mechanical bowel preparation prior to emergency colectomy reduces the risk of organ space surgical site infections: a NSQIP propensity score matched study33. The impact of robotic surgery on a tertiary care colorectal surgery program, an assessment of costs and short-term outcomes — a Canadian perspective34. Should we scope beyond the age limit of guidelines? Adenoma detection rates and outcomes of screening and surveillance colonoscopies in patients aged 75–79 years35. Emergency department admissions for uncomplicated diverticulitis: a nationwide study36. Obesity is associated with a complicated episode of acute diverticulitis: a nationwide study37. Green indocyanine angiography for low anterior resection in patients with rectal cancer: a prospective before-and-after study38. The impact of age on surgical recurrence of fibrostenotic ileocolic Crohn disease39. A qualitative study to explore the optimal timing and approach for the LARS discussion01. Racial, ethnic and socioeconomic disparities in diagnosis, treatment and survival of patients with breast cancer: a SEER-based population analysis02. First-line palliative chemotherapy for esophageal and gastric cancer: practice patterns and outcomes in the general population03. Frailty as a predictor for postoperative outcomes following pancreaticoduodenectomy04. Synoptic electronic operative reports identify practice variation in cancer surgery allowing for directed interventions to decrease variation05. The role of Hedgehog signalling in basal-like breast cancer07. Clinical and patient-reported outcomes in oncoplastic breast conservation surgery from a single surgeon’s practice in a busy community hospital in Canada08. Upgrade rate of atypical ductal hyperplasia: 10 years of experience and predictive factors09. Time to first adjuvant treatment after oncoplastic breast reduction10. Preparing to survive: improving outcomes for young women with breast cancer11. Opioid prescription and consumption in patients undergoing outpatient breast surgery — baseline data for a quality improvement initiative12. Rectal anastomosis and hyperthermic intraperitoneal chemotherapy: Should we avoid diverting loop ileostomy?13. Delays in operative management of early-stage, estrogen-receptor positive breast cancer during the COVID-19 pandemic — a multi-institutional matched historical cohort study14. Opioid prescribing practices in breast oncologic surgery15. Oncoplastic breast reduction (OBR) complications and patient-reported outcomes16. De-escalating breast cancer surgery: Should we apply quality indicators from other jurisdictions in Canada?17. The breast cancer patient experience of telemedicine during COVID-1918. A novel ex vivo human peritoneal model to investigate mechanisms of peritoneal metastasis in gastric adenocarcinoma (GCa)19. Preliminary uptake and outcomes utilizing the BREAST-Q patient-reported outcomes questionnaire in patients following breast cancer surgery20. Routine elastin staining improves detection of venous invasion and enhances prognostication in resected colorectal cancer21. Analysis of exhaled volatile organic compounds: a new frontier in colon cancer screening and surveillance22. A clinical pathway for radical cystectomy leads to a shorter hospital stay and decreases 30-day postoperative complications: a NSQIP analysis23. Fertility preservation in young breast cancer patients: a population-based study24. Investigating factors associated with postmastectomy unplanned emergency department visits: a population-based analysis25. Impact of patient, tumour and treatment factors on psychosocial outcomes after treatment in women with invasive breast cancer26. The relationship between breast and axillary pathologic complete response in women receiving neoadjuvant chemotherapy for breast cancer01. The association between bacterobilia and the risk of postoperative complications following pancreaticoduodenectomy02. Surgical outcome and quality of life following exercise-based prehabilitation for hepatobiliary surgery: a systematic review and meta-analysis03. Does intraoperative frozen section and revision of margins lead to improved survival in patients undergoing resection of perihilar cholangiocarcinoma? A systematic review and meta-analysis04. Prolonged kidney procurement time is associated with worse graft survival after transplantation05. Venous thromboembolism following hepatectomy for colorectal metastases: a population-based retrospective cohort study06. Association between resection approach and transfusion exposure in liver resection for gastrointestinal cancer07. The association between surgeon volume and use of laparoscopic liver resection for gastrointestinal cancer08. Immune suppression through TIGIT in colorectal cancer liver metastases09. “The whole is greater than the sum of its parts” — a combined strategy to reduce postoperative pancreatic fistula after pancreaticoduodenectomy10. Laparoscopic versus open synchronous colorectal and hepatic resection for metastatic colorectal cancer11. Identifying prognostic factors for overall survival in patients with recurrent disease following liver resection for colorectal cancer metastasis12. Modified Blumgart pancreatojejunostomy with external stenting in laparoscopic Whipple reconstruction13. Laparoscopic versus open pancreaticoduodenectomy: a single centre’s initial experience with introduction of a novel surgical approach14. Neoadjuvant chemotherapy versus upfront surgery for borderline resectable pancreatic cancer: a single-centre cohort analysis15. Thermal ablation and telemedicine to reduce resource utilization during the COVID-19 pandemic16. Cost-utility analysis of normothermic machine perfusion compared with static cold storage in liver transplantation in the Canadian setting17. Impact of adjuvant therapy on overall survival in early-stage ampullary cancers: a single-centre retrospective review18. Presence of biliary anaerobes enhances response to neoadjuvant chemotherapy in pancreatic ductal adenocarcinoma19. How does tumour viability influence the predictive capability of the Metroticket model? Comparing predicted-to-observed 5-year survival after liver transplant for hepatocellular carcinoma20. Does caudate resection improve outcomes in patients undergoing curative resection for perihilar cholangiocarcinoma? A systematic review and meta-analysis21. Appraisal of multivariable prognostic models for postoperative liver decompensation following partial hepatectomy: a systematic review22. Predictors of postoperative liver decompensation events following resection in patients with cirrhosis and hepatocellular carcinoma: a population-based study23. Characteristics of bacteriobilia and impact on outcomes after Whipple procedure01. Inverting the y-axis: the future of MIS abdominal wall reconstruction is upside down02. Progressive preoperative pneumoperitoneum: a single-centre retrospective study03. The role of radiologic classification of parastomal hernia as a predictor of the need for surgical hernia repair: a retrospective cohort study04. Comparison of 2 fascial defect closure methods for laparoscopic incisional hernia repair01. Hypoalbuminemia predicts serious complications following elective bariatric surgery02. Laparoscopic adjustable gastric band migration inducing jejunal obstruction associated with acute pancreatitis: aurgical approach of band removal03. Can visceral adipose tissue gene expression determine metabolic outcomes after bariatric surgery?04. Improvement of kidney function in patients with chronic kidney disease and severe obesity after bariatric surgery: a systematic review and meta-analysis05. A prediction model for delayed discharge following gastric bypass surgery06. Experiences and outcomes of Indigenous patients undergoing bariatric surgery: a mixed-methods scoping review07. What is the optimal common channel length in revisional bariatric surgery?08. Laparoscopic management of internal hernia in a 34-week pregnant woman09. Characterizing timing of postoperative complications following elective Roux-en-Y gastric bypass and sleeve gastrectomy10. Canadian trends in bariatric surgery11. Common surgical stapler problems and how to correct them12. Management of choledocholithiasis following Roux-en-Y gastric bypass: a systematic review and meta-analysis. Can J Surg 2021; 64:S80-S159. [PMID: 35483046 PMCID: PMC8677574 DOI: 10.1503/cjs.021321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Abstract
Abstract
Background
Recent evidence confirms the elevation of CA 125 in non-tumor processes such as acute heart failure (AHF). However, the utility of this novel biomarker for diagnosis, prognosis, and therapy guidance in AHF remains unclear.
Purpose
To investigate the potential of CA 125 for diagnosis, prognosis and therapy guidance in unselected AHF patients presenting with acute dyspnea to the emergency department (ED).
Methods
We quantified CA 125 in a blinded fashion among patients presenting with acute dyspnea to the ED in a multicenter diagnostic study. Final diagnosis of AHF including AHF-phenotype was centrally adjudicated by two independent cardiologists. To further characterize CA 125's potential in AHF correlations with established biochemical and imaging markers were assessed. Diagnostic accuracy for AHF was quantified by the area under the receiver operating characteristic curve (AUC). All-cause mortality within 360 days was the prognostic endpoint.
Results
Among 470 patients eligible for this analysis, 268 (57.0%) had adjudicated AHF. CA 125 concentrations at presentation were significantly higher among AHF patients vs. patients with other final diagnoses (45.8 U/ml [interquartile range (IQR), 18.5–110.3] vs. 16.2 U/ml [IQR, 9.6–31.6], p<.001). Patients with worsening heart failure had significant higher CA 125 levels compared to other heart failure phenotypes (p=.018). There was a significant positive correlation of CA 125 and high-sensitivity cardiac troponin T and NTproBNP and a significant negative correlation of CA 125 and left ventricular ejection fraction (correlation coefficients 0.204, 0.220, −0.331, respectively; all ps<.001). CA 125's AUC for AHF was significantly lower compared to NTproBNP's in the overall population (0.72, 95% confidence interval (CI) 0.67–0.76 vs. 0.93, 95% CI 0.90–0.95, p<.001, Figure 1) and in predefined subgroups according to age, gender and renal function. Among 268 AHF patients, 84 (31.3%) died within 360 days of follow-up. CA 125 plasma concentrations above the median indicated increased risk of all-cause mortality (hazard ratio 2.06, 95% CI 1.31–3.24; p=.002, Figure 2). CA 125's prognostic accuracy for 360-days mortality was comparable with NT-proBNP's and high-sensitivity cardiac troponin T's. CA 125 did not independently predict all-cause mortality at 360 days when used in validated multivariable regression models and had no interactions with medical therapies at discharge.
Conclusion
CA 125 may aid physicians in the risk stratification and rapid triage of patients with suspected AHF.
Funding Acknowledgement
Type of funding sources: Foundation. Main funding source(s): Swiss National Science FoundationSwiss Heart Foundation Figure 1. ROC curve comparisonFigure 2. Kaplan-Meier curve 360 days mortality
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Smooth muscle cell specific ablation of CXCL12 downregulates endothelial CXCR7 leading to defective coronary arteries and cardiac hypertrophy. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.3290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Aims
The chemokine CXCL12 plays a fundamental role in cardiovascular development, cell trafficking, and myocardial repair. Human genome-wide association studies even have identified novel loci downstream of the CXCL12 gene locus associated with coronary artery disease and myocardial infarction. Nevertheless, cell and tissue specific effects of CXCL12 are barely understood. Since we detected high expression of CXCL12 in smooth muscle (SM) cells, we generated a SM22-alpha-Cre driven mouse model to ablate CXCL12 (SM-CXCL12−/−).
Methods and results
SM-CXCL12−/− mice revealed high embryonic lethality (50%) with developmental defects, including aberrant topology of coronary arteries. Postnatally, SM-CXCL12−/− mice developed severe cardiac hypertrophy associated with fibrosis, apoptotic cell death, impaired heart function, and severe coronary vascular defects characterized by thinned and dilated arteries. Transcriptome analyses showed specific upregulation of pathways associated with hypertrophic cardiomyopathy, collagen protein network, heart-related proteoglycans, and downregulation of the M2 macrophage modulators. CXCL12 mutants showed endothelial downregulation of the CXCL12 co-receptor CXCR7. Treatment of SM-CXCL12−/− mice with the CXCR7 agonist TC14012 attenuated cardiac hypertrophy associated with increased pERK signaling.
Conclusion
Our data suggest a critical role of smooth muscle-specific CXCL12 in arterial development, vessel maturation, and cardiac hypertrophy. Pharmacological stimulation of CXCR7 might be a promising target to attenuate adverse hypertrophic remodeling.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): FWF-Austria
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Derivation and validation of a novel 3-hour pathway for the observe-zone of the ESC 0/1h-algorithm. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
The latest non-ST elevation myocardial infarction (NSTEMI) guidelines from the European Society of Cardiology (ESC) recommend a 3h cardiac troponin determination in patients triaged to the observe-zone of the ESC 0/1h-algorithm; however, no specific cut-off for further triage is endorsed.
Purpose
To derive and internally, as well as externally, validate a novel 3-hour pathway for the observe-zone of the ESC 0/1h-algorithm.
Methods
In an ongoing multicentre international diagnostic study, we prospectively enrolled unselected patients presenting to the emergency department with symptoms suggestive of myocardial infarction (MI). Final diagnoses were centrally adjudicated by two independent cardiologists applying the 4th universal definition of MI, based on complete cardiac work-up including cardiac imaging, serial high sensitivity cardiac troponin T (hs-cTnT) sampling and 90-day follow-up information. High sensitivity-cTnT concentrations were measured at presentation and after 1 and 3 hours. The primary outcome was safety, quantified by the sensitivity and NPV for early rule out of NSTEMI. External validation was performed in an independent multicentre international study.
Results
Among 2076 eligible patients, application of the ESC 0/1h-algorithm triaged 1512 patients (72.8%) to either rule-out or rule-in of NSTEMI, remaining 564 patients (27.2%) in the observe-zone (adjudicated NSTEMI prevalence 120/564 patients, 21.3%). The novel derived 3h-pathway for the observe-zone patients ruled-out NSTEMI with a 3h hs-cTnT concentration <15 ng/L and a 0/3h-hs-cTnT absolute change <4 ng/L, triaging 138 patients (25%) towards rule-out, resulting in a sensitivity of 99.2% (95% CI 96.0–99.9) and a NPV of 99.3% (95% CI 95.4–99.9). A 0/3h-hs-cTnT absolute change ≥6 ng/L ruled-in 63 patients (11.2%), resulting in a specificity of 98% (95% CI 96.2–98.9) and a PPV of 85.7% (95% CI75.0–92.3). The novel 3h-pathway reduced the number of patients in the observe zone by 36%, and the number of T1MI by 50% (Figure 1). Findings were confirmed in both internal and external validation.
Conclusions
A novel derived pathway combining a 3h hs-cTnT concentration <15 ng/L and a 0/3h absolute change <4 ng/L allowed to very safely rule-out NSTEMI in patients remaining in the observe-zone of the ESC 0/1h-algorithm.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Swiss Heart FoundationThe Swiss National Science Foundation Figure 1
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Antihypertensive medication and outcome in patients with COVID-19 compared to non-COVID respiratory infections. Eur Heart J 2021. [PMCID: PMC8767616 DOI: 10.1093/eurheartj/ehab724.2395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Recent reports suggested no adverse effects of antihypertensive medication including inhibitors of the renin-angiotensin system on outcome of patients with coronavirus disease 19 (COVID-19). However, most of these studies lack adequate control groups, and regional and socio-economic differences may additionally affect clinical course and outcome of COVID-19. Methods In the prospective observational cohort COrona VIrus surviVAl (COVIVA) study at our university hospital, we consecutively enrolled patients presenting to the emergency department with symptoms suggestive of COVID-19 between March and June 2020. Patients tested positive for COVID-19 (cases) were compared with patients tested negative, who had a respiratory infection (respiratory control). Primary outcome measure was the composite of ICU admission, 3'-day mortality or rehospitalization for respiratory symptoms. Results The final analysis consisted of 191 patients with COVID-19 and 323 respiratory controls. Sixty cases (31.4%) and 87 (26.9%) respiratory control patients were on ACE inhibitors (ACE-I) or angiotensin II receptor blockers (ARB). In unadjusted models the hazard ratio [95% CI] for the composite outcome for patients on ACE-I/ARBs was 2.36 [1.34; 4.16], p=0.003 and 2.05 [1.03; 4.09], p=0.04 among patients with COVID-19 and respiratory controls, respectively. The corresponding multivariable adjusted HRs were 1.32 [0.68; 2.55], p=0.41 and 1.20 [0.58; 2.48], p=0.62. Furthermore, we did not observe an increased risk for the outcome when assessing ACE-Is and ARBs separately or other antihypertensive agents, both in COVID-19 patients and respiratory controls (Table). Conclusions In a Swiss cohort of patients with COVID-19 or non-COVID respiratory controls treatment with ACE-I/ARBs or other antihypertensive medication was not associated with adverse events after accounting for comorbidities and risk factors. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): Foundation for Cardiovascular Research Basel (FCVR Basel)Swiss Heart Foundation
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Machine learning to aid in the diagnosis of acute heart failure in the emergency department. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
B-type natriuretic peptide (BNP) and mid-regional pro-atrial natriuretic peptide (MRproANP) testing are recommended to aid in the diagnosis of acute heart failure. However, the application of these biomarkers for optimal diagnostic performance is uncertain.
Methods
We performed a systematic review and harmonised individual patient-level data to evaluate the diagnostic performance of BNP and MRproANP for the diagnosis of acute heart failure using random-effects meta-analysis. We subsequently developed and externally validated a decision-support tool called CoDE-HF for both BNP and MRproANP that combines the natriuretic peptide concentrations with clinical variables using machine learning to report the probability of acute heart failure for an individual patient.
Results
Fourteen studies from 12 countries provided individual patient-level data in 8,493 patients for BNP and 3,847 patients for MRproANP, in whom, 48.3% (4,105/8,493) and 41.3% (1,611/3899) had an adjudicated diagnosis of acute heart failure, respectively. The negative and positive predictive values of guideline-recommended thresholds for BNP (100 pg/mL) and MR-proANP (120 pg/mL) were 93.6% (95% confidence interval 88.4–96.6%) and 68.8% (62.9–74.2%), and 95.6% (92.2–97.6%) and 64.8% (56.3–72.5%), respectively. However, we observed significant heterogeneity in the diagnostic performance across important patient subgroups (Figure 1). In the external validation cohort, CoDE-HF was well calibrated with excellent discrimination in those without prior acute heart failure for both BNP and MRproANP (area under the curve of 0.946 [0.933–0.958] and 0.943 [0.921–0.964], and Brier scores of 0.105 and 0.073, respectively). CoDE-HF performed consistently across all subgroups for both BNP and MRproANP, and identified 30% and 65.7% at low-probability (negative predictive value of 99.1% [98.8–99.3%] and 99.1% [98.8–99.4%]), and 30% and 17.3% at high-probability (positive predictive value of 91.3% [90.7–91.9%] and 70.0% [68.5–71.4%]) in those without prior heart failure, respectively (Figure 2).
Conclusion
In an international collaborative analysis, we observed that guideline-recommended thresholds for BNP and MRproANP to diagnose acute heart failure varied significantly across patient subgroups. A decision-support tool using machine learning to combine natriuretic peptides as a continuous measure and other clinical variables provides a more accurate and individualised approach.
Funding Acknowledgement
Type of funding sources: Other. Main funding source(s): Medical Research Council and British Heart Foundation Figure 1. NPV of BNP threshold (100 pg/mL)Figure 2. NPV of the CoDE-HF rule-out score
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Myocardial tissue function and characterization in patients with idiopathic cardiac magnetic resonance myopericarditis: evolutionary analysis. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.0239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
The identification of prognostic markers related to the occurrence of events and recovery of ventricular function may be important in patients with acute myopericarditis (AMP). There is still a lack of data related to tissue characterization by cardiac magnetic resonance (CMR) of AMP, evolution and definition of possible long-term prognostic markers.
Purpose
To evaluate the myocardial tissue characterization of CMR related to the occurrence of combined events (death from all causes, heart failure and AMP recurrence) and the increase in left ventricular ejection fraction (LVEF) in patients with AMP.
Methods
Inclusion criteria were chest pain and/or electrocardiographic changes associated with elevated troponin (above the 99th percentile) in the absence of coronary stenosis and diagnosis of AMP by CMR <48 hours of admission confirmed by the presence of edema and/or late enhancement. After a follow-up of up to 24 months, 100 patients remained and in the assessment of the increase in LVEF (increase >5%), 36 cases remained, recalled for a new CMR between 6 and 18 months from the initial event.
Results
Significant differences in CMR were found between patients who had combined events (n=26) versus no combined events (n=74) in the following characteristics evaluated: initial LVEF (OR=0.938; CI: 0.895–0.984, p=0.008), left ventricular (LV) systolic volume index (OR=1.034; CI: 1.005–1.062, p=0.019), LV diastolic volume index (OR=1.029; CI: 1.002–1.056, p=0.038), presence of hypersignal in T2 (OR=11.325; CI: 2.247–57.075, p=0.003), presence of late anteroseptal enhancement (OR=0.160; CI: 0.037–0.685, p=0.014), basal anteroseptal (OR=0.255; CI: 0.071–0.914, p=0.036) and lateral apical (OR=5.902; CI: 1.236–28.187, p=0.026). In relation to the increase in LVEF, significant differences were found in CMR in the following characteristics evaluated: LVEF (OR=0.870; CI: 0.758–0.988, p=0.047), end systolic volume of the right ventricle (OR=1.047; CI: 1.001–1.096, p=0.047), LV systolic diameter (OR=1.283; CI: 1.034–1.593, p=0.023), LV diastolic diameter (OR=1.225; CI: 1.012–1.482, p=0.038), LV systolic volume index (OR=1.340; CI: 1.066–1.685, p=0.012), LV diastolic volume index (OR=1.111; CI: 1.017–1.213, p=0.019) and right ventricular systolic volume index (OR=1.116; CI: 1.006–1.236, p=0.037).
Conclusion
We observed a significant association between combined events in the long-term follow-up with initial LVEF, LV systolic and diastolic volume indexes, T2 hypersignal and the presence of mid and basal anteroseptal and lateral apical late enhancement. Already related to the increase in LVEF in evolutionary CMR, we observed a significant association with initial LVEF, end systolic volume of the right ventricle, LV systolic and diastolic diameters, LV systolic and diastolic volume indexes and right ventricle systolic volume index.
Funding Acknowledgement
Type of funding sources: Public Institution(s). Main funding source(s): FAPESP
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Discordance in prognostic ability between physician assessed NYHA classification and self-reported health status in patients with acute heart failure. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Especially in patients with acute heart failure (AHF) the NYHA classification remains of uncertain representation of patients' actual health state. Alternatively, patient's subjective well-being, in terms of health-related quality of life (HRQL), showed to have an excellent prognostic ability in out clinic patients with chronic heart failure.
Objectives
It is unknown whether HRQL instruments can assess a more reliable prognostication in patients hospitalized due to AHF than the NYHA classification.
Methods
Goal Directed Afterload Reduction in Acute Congestive Cardiac Decompensation Study (GALACTIC) was a multicenter, randomized, open-label blinded-end-point trial that emphasized early intensive and sustained vasodilation in adult patients hospitalized due to AHF with NYHA functional class III/IV, however provided neutral findings. HRQL was assessed by the generic EQ-5D-3L which is a 3-leveled 5-item instrument and the disease-specific Kansas City Cardiomyopathy Questionnaire (KCCQ). Unadjusted and adjusted Cox regression models were performed after patients were grouped into low (EQ-5D −0.074<0.25; KCCQ 0<25), moderately low (0.25<0.5; 25<50), moderately high (0.5<0.75; 50<75) and high HRQL (0.75–1.0; 75–100).
Results
781 patients were enrolled in 10 centres in 5 countries over 2 continents among which 536 (69%) patientshad completed theEQ-5D and 419 (54%) the KCCQ shortly after admission. Within 180 days of follow-up69 (13%) and 54 (13%) patients died and 151 (28%) and 122 (29%) died or were rehospitalized due to AHF, respectively. Cumulative incidence as well as HRs in patients grouped according to NYHA (n=536) indicated a comparable or significantly lower risk in patients with NYHA IV: e.g. for the combined outcome HR 1.07 (95% CI 0.777–1.473) and aHR 0.463 (95% CI 0.245–0.875). Whereas HRs in patients grouped according to both, EQ-5D (n=536) and KCCQ (n=419), increased from the group with highest to the group with the lowest HRQL: e.g. aHR for moderately high 1.11 (95% CI 0.718–1.715), for moderately low 1.721 (95% CI 1.102–2.688) and for low EQ-5D index 1.891 (95% CI 1.136–3.149) referenced to high HRQL (EQ-5D index 0.75–1.0).
Conclusions
These findings corroborate and extend previous work suggesting that NYHA classification poorly discriminates AHF patients' prognosis and challenge its' extensive application. HRQL might be a possible alternative to easily assess these patients' heath state.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Swiss National Science Foundation, the Swiss Heart Foundation A. 180-day mortality; B. composite outcome
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Vitamin K epoxide reductase complex subunit 1-like 1 (VKORC1L1) inhibition induces a proliferative and pro-inflammatory vascular smooth muscle cell phenotype. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.3348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Vitamin K antagonists (VKA) like Warfarin are known to promote adverse cardiovascular remodelling. Contrarily, vitamin K supplementation has been discussed to decelerate cardiovascular disease. The recently described VKOR-isoenzyme Vitamin K epoxide reductase complex subunit 1-like 1 (VKORC1L1) is involved in vitamin K maintenance and exerts antioxidant properties. In this study, we sought to investigate the role of VKORC1L1 in neointima formation and on vascular smooth muscle cell (VSMC) function.
Methods and results
Treatment of wild-type mice with Warfarin increased maladaptive neointima formation after carotid artery injury. This was accompanied by reduced vascular mRNA expression of VKORC1L1.
In vitro, Warfarin was found to reduce VKORC1L1 mRNA expression in VSMC. VKORC1L1 downregulation by siRNA promoted viability, migration and formation of reactive oxygen species. VKORC1L1 knockdown further increased expression of key markers of vascular inflammation (NFκB, IL-6). Additionally, downregulation of the endoplasmic reticulum (ER) membrane resident VKORC1L1 increased expression of the main ER Stress moderator, glucose-regulated protein 78 kDa (GRP78). Moreover, treatment with the ER Stress inducer Tunicamycin promoted VKORC1L1, but not VKORC1 expression.
Finally, we sought to investigate, if treatment with vitamin K can mediate the protective properties of VKORC1L1. Thus, we examined effects of menaquinone-7 (MK7) on VSMC phenotype switch. MK7 treatment dose-dependently alleviated PDGF-induced proliferation and migration. In addition, we detected a reduction in expression of inflammatory and ER Stress markers.
Conclusion
VKA-induced neointima formation is associated with reduced vascular VKORC1L1 expression. VKORC1L1 inhibition contributes to an adverse VSMC phenotype while MK7 restores VSMC function. Thus, MK7 supplementation might be a feasible therapeutic option to modulate vitamin K- and VKORC1L1-mediated vasculoprotection.
Funding Acknowledgement
Type of funding sources: None.
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Prognostic value of self-reported subjective exercise capacity in patients with acute dyspnea. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Quantitative assessment of self-reported exercise capacity as provided by the Duke Activity Status Index (DASI) is a validated measure of exercise capacity in stable ambulatory patients.
Objectives
This study aimedto test whether the quantification of self-reported exercise capacityusing the DASI may aid physicians in the risk stratification of patients presenting with acute dyspnea to the emergency department (ED).
Methods
Basics in Acute Shortness of Breath EvaLuation (BASEL V) was a prospective cohort study recruiting dyspneic patients at the ED. The prognostic value and accuracy of theDASI assessed shortly after presentation were quantified using Cox regression analyses and the Area under the curve (AUC).
Results
Among 1019 patients eligible for this analysis 529 (51.9%) had an adjudicated final diagnosis of acute heart failure, 75 (7.4%) and 297 (29.1%) patients died within 90 and 720 days after presentation. Unadjusted hazard ratios (HR) and multivariable adjusted hazard ratios (aHR) for 90-day and 720-day mortality increased continuously from the fourth (best self-reported exercise capacity) to the first DASI-quartile (worst self-reported exercise capacity). For 720-day mortality in the first quartile theHR was 9.1 (95%-CI 5.5–14.9) (aHR 6.1 [95%-CI 3.7–10.1]), in the second quartile 6.4 (95%-CI 3.9–10.6) (aHR 4.4 [95%-CI 2.6–7.3]), while in the third quartile the HR was 3.2 (95%-CI 1.9–5.5) (aHR 2.4 [95%-CI 1.4–4.0]). The prognostic accuracy of the DASI was moderate-to-high and higher than that of B-type natriuretic peptide (BNP) and NT-proBNP (N-terminal pro-BNP) concentrations, e.g. for 720-day mortality prediction AUC 0.70 versus 0.64, p=0.020; 0.72 versus 0.68, p=0.074.
Conclusions
Quantification of self-reported subjective exercise capacityusing the DASI provides moderate-to-high prognostic accuracy in patients presenting with acute dyspnea to the ED and may aid physicians in further risk stratification.
Funding Acknowledgement
Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Union, the Swiss National Science Foundation. Duke Activity Status Index
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