Malnutrition is a common comorbidity in elderly patients with severe aortic valve stenosis undergoing transcatheter aortic valve replacement (TAVR). The geriatric nutritional risk index (GNRI), a validated and easy-to-use tool, has been previously associated with short/mid-term outcomes in such patients. This study aimed to confirm this association in the long-term in the contemporary TAVR era using new-generation devices and to evaluate its impact on length of hospitalization. A total of 1090 consecutive patients aged ≥ 65 years undergoing TAVR between October 2015 and December 2021 at a single tertiary center were included. Patients were stratified into two groups based on baseline GNRI: the GNRI > 98 (low-risk) group and the GNRI ≤ 98 (moderate-to-high risk) group. The primary endpoint was all-cause mortality. Secondary endpoints included total length of hospitalization and length of intensive care unit stay. Kaplan-Meier curves and Cox regression models were used to assess survival differences and potential independent predictors. Patients with GNRI ≤ 98 had significantly higher cumulative mortality rates at all evaluated time points compared to patients with GNRI > 98 (30-day: 6.9% vs. 2.7%, 1-year: 39.1% vs. 11.4%, 5-year: 67.3% vs. 53.2%, all P < 0.05). A multivariable Cox regression analysis showed that GNRI was an independent predictor of long-term mortality (up to five years) after adjusting for clinical, echocardiographic and laboratory parameters (HR = 0.94, 95% CI: 0.92-0.96, P < 0.001), with an increasing effect over time. The impact of GNRI on clinical outcomes was observed in patients in all three EuroSCORE II categories (low risk, intermediate risk, and high risk). Total hospitalization and intensive care unit stays were longer in patients with GNRI ≤ 98 [8 (6-13) days vs. 7 (5-9) days, P < 0.001 and 3 (2-5) days vs. 2 (2-4) days, P < 0.001, respectively]. In this large European cohort, GNRI was confirmed to be an independent predictor for long-term mortality up to five years in the contemporary era of TAVR use with new-generation devices. Hospital stay was longer in patients with lower GNRI. This easy-to-use index could play a valuable role in the preprocedural assessment of patients undergoing TAVR and studies to explore the use of nutritional preprocedural optimization of patients with low GNRI values are warranted.
Many conditions may affect left ventricular (LV) phenotypes which have been classified according to LV mass and geometry. There is limited data on the prognostic value of LV phenotypes classified by cardiac magnetic resonance (CMR). This study aimed to determine the prognostic value of LV phenotypes in elderly and non-elderly patients with known or suspected coronary artery disease. This is a retrospective cohort study among patients who underwent stress or viability CMR. LV phenotypes were classified according to the LV mass index, the LV end-diastolic volume index and the LV mass/volume ratio, into normal, concentric remodeling, concentric hypertrophy, and eccentric hypertrophy. The primary outcome was a composite of death or heart failure. A total of 3289 patients was studied. The average age was 68.0 ± 12.7 years, 52.2% of patients were women. Elderly were defined as age ≥ 65 years accounting for 63.9% of the cohort. LV phenotypes were normal, concentric remodeling, concentric hypertrophy, and eccentric hypertrophy at 74.5%, 5.8%, 9.2%, and 10.5%, respectively. The median duration of follow-up was 41.4 months. The composite outcome of death or heart failure occurred in 7.3% of patients. The prognostic impact of LV phenotypes was more pronounced in the elderly, with eccentric hypertrophy showing the worst prognosis, followed by concentric hypertrophy and concentric remodeling with the adjusted hazard ratio (95% CI) of 2.37 (1.72-3.25), 1.53 (1.12-2.08), and 1.14 (0.76-1.71), respectively, compared to normal phenotype. Patients with eccentric hypertrophy also demonstrated abnormal global longitudinal LV strain, left atrial strain, and extracellular volume fraction. LV phenotypes by CMR independently predict adverse clinical outcomes in elderly patients with known or suspected coronary artery disease. In non-elderly patients, the prognostic value of LV phenotypes was less evident. Assessment of LV phenotypes may be useful for risk stratification.
Transcatheter aortic valve implantation (TAVI) is the principal treatment for aortic stenosis in older and high-risk patients. Whilst important in holistic decision making, frailty indices vary in ease of use, objectivity, and accuracy. We assess prognostic ability of the Clinical Frailty Scale (CFS) and Essential Frailty Toolset (EFT) in predicting delayed discharge and 1-year mortality following TAVI. Prospective, single centre, observational cohort study of patients undergoing TAVI at a tertiary centre in the UK from 2020-2022. Clinical characteristics, CFS, and EFT were collected pre-procedurally. Primary outcomes were length of hospital stay following TAVI and mortality at 1- year post-procedure. Generalized regression with elastic net is used to assess the additive discriminative ability of frailty scores to predict outcomes. Stepwise regression is used to identify informative outcome predictors. One hundred and four patients were included with mean age 81.3 ± 5.9 years, 47% female. Median post-procedural stay length was 2 days (IQR 2.75). Use of EFT and CFS resulted in a statistically significant prediction of survival at 1 year post TAVI (EFT: ΔLogL of 2.68, ChiSq P = 0.021; RCFS ΔLogL: 1.42, ChiSq P = 0.092) compared to predictive model using conventional clinical characteristics. EuroSCORE II and TAVI2SCORe were poor predictors of outcomes. CFS and access site (femoral vs. non-femoral) significantly improved prediction of delayed discharge. EFT informs decision making on survival 1-year post-TAVI, beyond conventional measures. Use of non-femoral access site and high CFS are the best predictors of delayed discharge. Surgical risk stratification scores poorly predict medium-term TAVI survival and delayed discharge.
Acute Coronary Syndrome (ACS) is a major cause of hospitalizations and deaths worldwide. Conditions such as frailty worsen these outcomes. Frailty assessment improves risk stratification, complements scores and favors personalized treatments. However, there are numerous tools available for assessing frailty, and there is still no consensus on which would be the most recommended in conditions such as ACS. The objective was to evaluate which frailty diagnostic scale has the best predictive value for mortality in individuals with ACS. This meta-analysis was conducted using Medline, Embase, and Cochrane, with a search conducted on March 5, 2024. Studies that met the PECOS criteria were included: adult and elderly individuals diagnosed with ACS, frailty assessment determined by a scale, mortality registry and intervention studies or prospective and retrospective cohorts. The risk of bias and quality of evidence were assessed by two researchers using the Joana Briggs Institute Case Series tool and the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) system, respectively. The meta-analysis was conducted using Review Manager software and subgroup analyses using R software. The results of the meta-analysis indicate that frailty is associated with a significantly higher risk of mortality in patients with ACS (P < 0.001). However, the results of the meta-regression did not indicate a significant difference between the five scales evaluated (P = 0.227). The choice of scale, therefore, can be based on other factors such as practicality and availability of resources, without compromising the prognosis. Individuals with ACS and frailty have a higher chance of mortality, and all scales evaluated showed good predictive value, with no statistical difference. We suggest that the Clinical Frailty Scale (CFS) is suitable for hospital settings and acute conditions, such as ACS.
Despite effective control of low-density lipoprotein cholesterol, the residual risk of atherosclerotic cardiovascular disease (ASCVD) remains substantial, underscoring the urgent need to identify novel targets to further reduce ASCVD risk. This study aimed to investigate the association between apolipoprotein C-III (APOC3) levels and ASCVD, and further explore the potential impact of APOC3 intervention for reducing ASCVD risk. We leveraged the 20-year longitudinal data from the Chinese Multi-provincial Cohort Study-Proteomics Project, obtained totaling 5308 APOC3 measurements from 2550 participants, with up to four repeated measurements per participant. The intensity model was employed to estimate the association between time-varying APOC3 and ASCVD, accounting for time-varying potential confounders. The target trial emulation framework was used to emulate the effectiveness of various APOC3-targeted hypothetical interventions on ASCVD risk, with a guideline-directed low-density lipoprotein cholesterol-lowering strategy serving as a positive control. Of 2550 participants aged 57.5 ± 7.9 years at baseline, and 56% of participants were females. The median level of APOC3 was 5554.8 (interquartile range: 3936.5-7913.8) Relative Fluorescence Units. The level of time-varying APOC3 level were associated with an increased risk of incident ASCVD, and a stronger association was observed in populations with metabolic abnormalities. Furthermore, more intensive reductions in APOC3 produced progressively larger decreases in ASCVD risk, with a maximum estimated reduction of 9.3% observed at a 90% APOC3 reduction. Our findings suggest that APOC3 may play an important role in ASCVD incidence and that targeting APOC3 may offer additional cardiovascular benefits beyond conventional lipid-lowering strategies.
Heart failure with preserved ejection fraction (HFpEF) following acute myocardial infarction (AMI) carries substantial morbidity and mortality, yet reliable prognostic markers beyond conventional cardiovascular factors remain limited. Frailty, reflecting diminished physiological reserve, has emerged as a potential determinant of adverse outcomes in this high-risk population. Therefore, the aim of this study was to address a critical knowledge gap and to provide evidence that may guide frailty-adapted management strategies to improve prognosis and quality of life in this high-risk population. We conducted a multicenter retrospective cohort study including 4507 patients with HFpEF discharged after AMI across 82 hospitals in China (from January 2010 to March 2024). Frailty was assessed using the Hospital Frailty Risk Score (HFRS), with HFRS < 5 defined as non-frail and HFRS ≥ 5 as frail. Multivariable Cox proportional hazards models, adjusted for demographics, comorbidities, left ventricular ejection fraction, and therapies, were applied to evaluate associations between frailty and clinical outcomes. The primary endpoints were all-cause death and major adverse cardiovascular events (MACE), which defined as the composite of cardiovascular death and heart failure rehospitalization. Secondary endpoints included net adverse clinical events (NACE), which defined as the composite of all-cause death, stroke, recurrent myocardial infarction, revascularization, and major bleeding, as well as the individual components of MACE. Frailty was independently associated with a higher risk of all-cause death [adjusted hazard ratio (aHR) = 1.52, 95% CI: 1.31-2.03, P = 0.005] and NACE (aHR = 1.20, 95% CI: 1.02-1.41, P = 0.026). At one year, frail patients had higher unadjusted rates of all-cause death (9.0% vs. 2.9%) and NACE (19.8% vs. 13.7%) compared with non-frail patients. For cardiovascular death, the association did not reach statistical significance (aHR = 1.42, 95% CI: 0.99-2.03, P = 0.053). No significant associations were found for MACE (aHR = 1.05, 95% CI: 0.86-1.28, P = 0.636) or heart failure rehospitalization (aHR = 0.94, 95% CI: 0.75-1.19, P = 0.616). Frailty, as measured by the HFRS, is an independent predictor of one-year mortality and composite adverse events in post-AMI HFpEF patients. These findings support the use of HFRS at discharge to identify high-risk population who may benefit from closer follow-up, optimization of medical therapy, and targeted frailty-focused interventions.
Significant progress has been recently made in studying artemisinin and its derivatives for treating cardiovascular diseases, making this area a prominent research focus. Artemisinin, discovered with great acclaim, was initially and widely adopted in antimalarial treatments. As scientific research steadily progressed, its latent potential role in the cardiovascular system gradually captured the attention of the global scientific community. Artemisinin and its derivatives can reportedly play a protective role in the cardiovascular system through various mechanisms, including anti-inflammatory, anti-angiogenic, antioxidant, and anti-fibrotic effects, as well as the regulation of blood lipids and blood pressure. In particular, they have shown promising therapeutic effects in models of cardiovascular diseases such as atherosclerosis, myocardial ischaemia, and cardiac hypertrophy. In addition, artemisinin and its derivatives can improve cardiovascular function and prevent cardiovascular injury by regulating signalling pathways closely related to cardiovascular disease, such as AMPK and NF-kB. Although numerous ex vivo and in vivo experiments have verified the potential role of artemisinin in treating cardiovascular diseases, systematic studies to comprehensively elucidate its specific mechanism of action remain scarce. Further exploration of the precise roles of artemisinin and its derivatives in cardiovascular disease therapy, along with their potential clinical applications, could offer valuable insights for future research and treatment strategies.
Heart failure (HF) is a complex clinical syndrome that promotes high morbidity and multi-systemic damage. Skeletal muscle can be directly affected by HF through a loss of physical capacity and various inflammatory, hormonal, and metabolic mechanisms observed in this cardiac condition, which collectively contribute to a high prevalence of sarcopenia in HF patients. Therefore, the aim of this review was to compile the main recent clinical and epidemiological data on muscle health in HF patients. Nine studies were selected from systematic reviews and clinical trials, which demonstrated a high prevalence of sarcopenia in patients with HF, particularly in males, hospitalized patients, the elderly, and those with HF with reduced ejection fraction. Oxidative stress markers and higher levels of natriuretic peptides were also observed in HF patients who exhibited damaged muscle parameters. Furthermore, the overall deterioration of prognosis in HF was associated with criteria defining sarcopenia, such as low muscle strength and lean mass loss. These findings reinforce the importance of evaluating skeletal muscle in HF patients, which can provide improvements in morbidity and functionality.
Few studies have investigated the associations between green space, the triglyceride-glucose (TyG) index, and cardiovascular health outcomes. This study aims to examine the relationships between green space and chronic cardiovascular diseases among middle-aged and older Chinese adults, while also evaluating the potential mediating effect of the TyG index. Baseline and follow-up data were collected from the 2011 and 2015 waves, respectively, of the China Health and Retirement Longitudinal Study (CHARLS). Inverse probability of treatment weighting was used to address selection bias. City-level cluster-robust logistic regression analysis was used to assess associations between green space (2011-2014) and hypertension, heart disease, and dyslipidemia. Counterfactual exploratory mediation analysis examined the mediating role of the TyG index. Restricted cubic splines were used to explore the dose-response relationships between green space and the outcomes. Among 11,925 participants, each 1 standard deviation (0.0922) increment in the Normalized Difference Vegetation Index (NDVI) was associated with a 13% lower risk of hypertension (OR = 0.87, 95% CI: 0.83-0.92, P < 0.001), with a linear dose-response relationship. No significant independent associations were observed for heart disease (OR = 0.92, 95% CI: 0.82-1.03, P = 0.142) or dyslipidemia (OR = 0.96, 95% CI: 0.86-1.06, P = 0.406). Mediation analysis showed that the TyG index partially mediated the NDVI-hypertension association (indirect effect P < 0.05), the proportion mediated was 2.9% (95% CI: 1.9%-4.1%). Long-term residential green space exposure is significantly associated with a lower risk of hypertension in middle-aged and older Chinese adults, with the TyG index playing a modest partial mediating role. No significant independent associations were observed for heart disease or dyslipidemia. Enhancing urban greening may be an effective environmental strategy for the primary prevention of hypertension.
This study evaluated the impact of the Medicine IN Geriatric (MINE) application, which integrates the Integrated Medicine Management (IMM) model and STOPP/START criteria, on improving prescribing practices in elderly patients with congestive heart failure (CHF). A two-phase study was conducted: validation of the IMM model and its implementation via the MINE app. A quasi-experimental pretest-posttest control group design was used in a hospital in East Kalimantan, Indonesia. Patients aged 60-79 years were randomly assigned to the intervention or control group. The intervention group received IMM-based pharmaceutical services, including medication reconciliation, repeated medication reviews, and individualized discharge counseling. The outcomes assessed included polypharmacy rates, potentially inappropriate medications (PIMs), potential prescribing omissions (PPOs), and health-related quality of life, using the EQ-5D-5L and EQ-VAS tools. Expert validation showed high content validity, with I-CVI ≥ 0.86 and S-CVI = 0.94. During implementation, the use of antiplatelets, statins, angiotensin converting enzyme inhibitors (ACEI), and angiotensin receptor β-blockers (ARB) declined from admission to discharge. PIMs, such as beta-blockers in patients with conduction disorders and ACE-I/ARBs in those with hyperkalemia, also decreased. The intervention group's EQ-5D-5L scores improved from 0.552 to 0.664, whereas the control group's scores declined slightly. EQ-VAS scores also increased significantly in the intervention group. The MINE-based IMM intervention effectively reduced inappropriate prescribing and enhanced the quality of life in elderly patients with CHF. This technology-enabled multidisciplinary approach supports safer prescribing in geriatric care.
Early cerebrovascular events (CVEs) following transcatheter aortic valve replacement (TAVR) are severe complications, but effective methods for predicting and preventing these events have not been well established. A systematic review and meta-analysis were performed to identify significant predictors of early CVEs post-TAVR. MEDLINE/Embase databases were searched for articles published between December 2015 and April 2023. Original studies evaluating predictors of CVEs within 30 days post-TAVR after adjusting for confounders were included. Two investigators independently extracted data following the PRISMA statement. Meta-analyses of multivariable data were performed using DerSimonian and Laird random-effects models, with results expressed as odds ratios (ORs) and 95% confidence intervals (CIs). Robustness was assessed via Harbord's test, nonparametric trim-and-fill analysis, leave-one-out sensitivity analysis, the QUIPS quality assessment tools, meta-regression, and subgroup analyses. Among the 74 included studies, multivariate meta-analyses identified 11 predictors of early CVEs, including 9 patient-level predictors-a CHA2DS2-VASc ≥ 5, no prior heart failure, diabetes, isolated aortic stenosis, carotid artery stenosis, peripheral artery disease, advanced age, New York Heart Association class ≥ III, and significant left ventricular outflow tract calcification-and 2 procedure-level predictors: the absence of cerebral embolization protection and post-dilation. Additionally, 10 patient-level factors and 5 procedure-level factors were not associated with early CVEs, although significant heterogeneity was observed in most analyses. This study identified multiple patient-level and procedure-level factors associated or not associated with early CVEs after TAVR. These findings support the development of a comprehensive risk prediction model that can accommodate diverse patient populations and evolving procedural techniques, thereby enhancing clinical risk management strategies.
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Frailty is common and significantly impacts prognosis in heart failure (HF). The Vulnerable Elders Survey-13 (VES-13), widely used in oncogeriatrics and public health, remains unexplored as a frailty screening tool in HF outpatients. In this study, we prospectively evaluated VES-13 against a multimodal screening assessment in detecting frailty and predicting individual risk of adverse prognosis. Frailty was assessed at the initial visit using both a multimodal approach, incorporating Barthel Index, Older American Resources and Services scale, Pfeiffer Test, abbreviated Geriatric Depression Scale, age > 85 years, lacking support systems, and VES-13. Patients scoring ≥ 3 on VES-13 or meeting at least one multimodal criterion were classified as frail. Endpoints included all-cause mortality, a composite of death or HF hospitalization, and recurrent HF hospitalizations. A total of 301 patients were evaluated. VES-13 identified 40.2% as frail and the multimodal assessment 33.2%. In Cox regression analyses, frailty identified by VES-13 showed greater prognostic significance than the multimodal assessment for all-cause mortality (HR = 3.70 [2.15-6.33], P < 0.001 vs. 2.40 [1.46-4.0], P = 0.001) and the composite endpoint (HR = 3.13 [2.02-4.84], P < 0.001 vs. 1.96 [1.28-2.99], P = 0.002). Recurrent HF hospitalizations were four times more frequent in VES-13 frail patients while two times in those identified as frail by the multimodal assessment. Additionally, stratifying patients by VES-13 tertiles provided robust risk differentiation. VES-13, a simple frailty tool, outperformed a comprehensive multimodal assessment and could be easily integrated into routine HF care, highlighting its clinical utility in identifying patients at risk for poor outcomes.
In patients with coronary artery disease, age is of known significance in predicting outcomes. Data on clinical outcomes in patients ≥ 85 years undergoing percutaneous coronary intervention (PCI) remain scarce. The study aim was to determine clinical characteristics, risk of adverse cardiovascular events, and mortality in patients aged ≥ 85 years compared to those aged < 85 undergoing PCI. In this retrospective study, data were obtained from the nationwide Netherlands Heart Registration on patients undergoing PCI between January 1st, 2017 and January 1st, 2021. The primary endpoint was all-cause mortality at long-term follow-up. A total of 155,683 patients underwent PCI, of which 100,209 (64.4%) acute coronary syndrome cases. Compared to patients aged < 85 years, patients aged ≥ 85 were more often female and showed a higher number of cardiovascular comorbidities, including impaired left ventricle ejection fraction and reduced kidney function. Mortality at short-term and long-term follow-up were significantly higher in those aged ≥ 85 (P < 0.001). Patients aged ≥ 85 were more likely to have a myocardial infarction within 30 days following the index intervention (0.9% vs. 0.7%; P = 0.024), though they less often underwent revascularization at long-term follow-up compared to patients aged < 85 (P < 0.001). The elderly (≥ 85 years) patient requiring PCI carries an extensive cardiovascular risk profile, translating in significant risk of recurrent cardiovascular events and increased mortality rate. Clinicians should carefully weigh perceived risks and potential benefits in the individual patient, considering the patients' age, cardiovascular risk profile, and associated risk of morbidity and mortality.
Heart failure (HF) and cognitive impairment (CI) frequently coexist. The objective of this meta-analysis was to synthesize evidence on the association between circulating biomarkers of neurodegenerative diseases and (1) the incidence of HF; (2) cognitive dysfunction in patients with HF; and (3) adverse HF outcomes. A comprehensive search of MEDLINE and EMBASE identified 17 studies assessing plasma levels of amyloid beta (Aβ), tau protein, neurofilament light chain (NfL), glial fibrillary acidic protein (GFAP), triggering receptor expressed on myeloid cells 2 (TREM2), ubiquitin C-terminal hydrolase L1 (UCHL1), and YKL-40 in relation to HF-related outcomes. Elevated Aβ40 and YKL-40 levels were significantly associated with all-cause mortality in HF, with respective hazard ratios (HR) of 1.34 (95% CI: 1.01-1.79; P = 0.0434) and 1.081 (95% CI: 1.002-1.166; P = 0.0443). There was a positive, but not significant, trend between elevated plasma tau levels and HF hospitalization, with HR of 1.21 (95% CI: 0.94-1.55; P = 0.1383). A pooled analysis of all biomarkers across various adverse outcomes demonstrated a significant association, with a HR of 1.20 (95% CI: 1.10-1.30; P < 0.0001). pTau-181, NfL, GFAP, and TREM2 demonstrated associations with memory impairment in HF. Aβ40, pTau-181, NfL, and YKL-40 were linked to incident HF in individual studies. Neurodegenerative biomarkers, particularly Aβ40 and YKL-40, are indicators of risk in HF populations. These data highlight the need to validate their clinical utility and elucidate shared potentially causative mechanistic pathways linking HF and neurodegenerative conditions, defining a neurodegenerative cardiomyopathy.
Quantitative flow ratio (QFR) based lesion selection for percutaneous coronary intervention (PCI) treatment has shown clinical benefits in terms of reduced risk for myocardial infarction and repeat revascularization. Whether this benefit is consistent across different age groups still needs further investigation. In this prespecified subgroup study of FAVOR III China trial, we compared long-term clinical outcomes between QFR-guided and angiography-guided PCI among different age groups among 3825 enrolled subjects. The primary endpoint was major adverse cardiac events (MACEs), a composite of all-cause death, myocardial infarction, and ischemia-driven revascularization. Of the 3825 patients, 1717 (44.9%) were aged ≥ 65 years. At baseline, patients ≥ 65 had higher rates of hypertension, hyperlipidaemia, stroke history (P < 0.0001), and peripheral vascular disease (P = 0.024) and had higher SYNTAX scores (P = 0.0095). Compared with standard angiography guidance, the QFR-guided strategy consistently reduced the 1-year (≥ 65 years, 6.04% vs. 9.19%, HR = 0.65, 95% CI: 0.46-0.92; < 65 years, 5.53% vs. 8.43%, HR = 0.65, 95% CI: 0.47-0.91) and 3-year MACE rates in both age groups (≥ 65 years, 11.8% vs. 15.2%, HR: 0.75, 95% CI: 0.58-0.98; < 65 years, 9.5% vs. 14.6%, HR = 0.63; 95% CI: 0.49-0.81), without a significant interaction (P interaction = 0.99). Within the QFR-guided group, the 3-year MACE rate in patients with deferred vessels was numerically greater in patients aged ≥ 65 years than in those aged < 65 years (8.3% vs. 3.0%, P = 0.10). Although with higher rate of comorbidities and more complex coronary anatomy, the long-term benefit of the QFR-guided PCI strategy remained consistent in patients ≥ 65 years, compared with those < 65 years.
Understanding the type and extent of coronary artery involvement in patients with acute type A aortic dissection (ATAAD) is vital for surgical planning. The Neri classification has been proposed as a guide for surgical strategies, however, its prognostic impact on postoperative mortality rates remains understudied in large-scale cohorts. We reviewed 600 ATAAD patients who underwent surgery and coronary computed tomography angiography from 2016 to 2020 at Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China. Patients were classified based on the Neri classification system: no coronary artery involvement, type A (ostial involvement), type B (dissection in coronary body), and type C (circumferential detachment or complete avulsion). The primary endpoint was 30-day mortality. Overall, 28.3% of the patients had coronary artery involvement, with Neri type A, Neri type B, and Neri type C accounting for 13.3%, 11.2%, and 3.8%, respectively. The right coronary artery was more frequently involved (25.3%) than the left coronary artery (8.0%). In the unadjusted analysis, patients with coronary artery involvement exhibited a numerically higher 30-day mortality compared to those without (5.3% vs. 2.3%) (OR = 2.35, 95% CI: 0.94-5.88, P = 0.07), though this difference did not reach statistical significance. However, multivariable adjustment revealed significant association (adjusted OR = 3.71, 95% CI: 1.05-13.13, P = 0.04). Interestingly, after additional adjustment for coronary artery bypass grafting, the impact of coronary artery involvement on 30-day mortality no longer remained statistically significant (adjusted OR = 3.13, 95% CI: 0.85-11.58, P = 0.09). The 1-year mortality was higher in those with coronary artery involvement, but this significant association disappeared after adjusting for potential confounding variables. Furthermore, no significant difference in 30-day and 1-year mortality were observed among patients with different Neri classifications. In patients with ATAAD who undergo surgery, the presence of coronary artery involvement is significantly associated with an increased risk of 30-day mortality. Proactive coronary artery bypass grafting may potentially mitigate the adverse impact of coronary artery involvement on 30-day mortality.
To investigate the effects of early in-hospital intensive lipid-lowering therapy (LLT) with proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors on lipid dynamics and clinical outcomes in Chinese acute coronary syndrome (ACS) patients, providing robust real-world evidence for its long-term benefits and optimal implementation timing to address the evidence gap in optimal lipid management for secondary prevention. This multicenter prospective real-world study (http://www.clinicaltrials.gov, NCT number: NCT06738758), which building upon the ELEGANT pilot registry (ChiCTR2200065861), will enroll 6000 consecutively hospitalized ACS patients with uncontrolled dyslipidemia across more than 30 Chinese centers. Participants are enrolled based on recommended stratified proportions [(1) diagnostic categories: ST-segment elevation myocardial infarction : non-ST-segment elevation myocardial infarction : intermediate-high-risk unstable angina = 1:1:3; and (2) lipid-lowering strategies: PCSK9 inhibitor ± statin : statin+ezetimibe/hybutimibe : statin = 2:1:2). Treatment assignment reflects real-world clinical decisions guided by low-density lipoprotein cholesterol levels and patient preference. Twelve-month follow-up assessments were conducted at predefined intervals: baseline hospitalization, discharge, and 1, 3, 6, 12 months post-discharge. Primary endpoints were the goal attainment (low-density lipoprotein cholesterol < 1.4 mmol/L) rates across treatment arms. Key secondary endpoints were the major adverse cardiovascular events (including myocardial infarction, ischemic stroke, cardiovascular mortality, coronary revascularization) and all-cause death, and other secondary endpoints encompassed time-to-lipid-goal, longitudinal changes in lipids profiles and inflammatory biomarkers, and perivascular fat attenuation index evolution quantified by coronary computed tomographic angiography. Propensity score matching and inverse probability treatment weighting will address confounding bias. This study will pioneer evidence clarifying the optimal therapeutic window and clinical benefits of in-hospital intensive LLT for Chinese ACS patients. By establishing the first Chinese population-derived evidence for the "early intensive and rapid target attainment" strategy, our findings may challenge stepwise LLT paradigms. These results may guide international guideline updates for high-risk ACS populations, particularly in East Asian cohorts with distinct lipid profiles.
Takotsubo cardiomyopathy (TCM), defined by transient left ventricular dysfunction, is commonly triggered by acute emotional/physical stress. It is recognized as a cause of acute coronary syndrome, particularly in the elderly population, as they are vulnerable due to multiple comorbidities, including frailty, a condition marked by reduced functional reserve and increased susceptibility to stressors. A retrospective analysis of the National Inpatient Sample (2016-2021) was performed to identify patients aged 65 and older hospitalized with TCM using ICD-10-CM codes. Patients were classified based on frailty, defined by Johns Hopkins ACG frailty-defining diagnoses. Multivariable mixed-effects logistic regression was used to identify independent predictors of in-hospital outcomes and compare the groups. Propensity score matching was applied to 736 pairs to control for confounders and assess outcomes. Frail patients had significantly high in-patient mortality (5.71 vs. 1.09%, P < 0.001), cardiogenic shock (8.47 vs. 4.70%, P = 0.003), sudden cardiac arrest (3.12 vs. 1.49%, P = 0.037), sepsis (2.85 vs. 0.95%, P = 0.008), and major adverse cardiac events (22.55 vs. 18.21%, P = 0.038). There was no significant difference in acute stroke, pulmonary embolism, mechanical circulatory support utilization, cardiac arrhythmias, acute kidney injury, pacemaker insertion, and length of stay between the two groups. Frailty is associated with an increased in-hospital mortality among elderly patients with TCM. Understanding the importance of frailty in elderly population with TCM helps us in optimizing management strategies and improving patient outcomes.
To develop and validate a machine learning (ML) model for real-time monitoring of in-hospital mortality (IHM) risk and identification of major risk factors in heart failure (HF) patients admitted to intensive care units (ICUs). Data from ICU HF patients were extracted from the multicenter eICU-Collaborative Research Database (eICU-CRD. External validation used MIMIC-IV and a real-world Chinese dataset (CHN-dataset). Daily measurements from MIMIC-IV patients staying ≥ 3 days formed a Daily Measurement (DM) dataset. After rigorous preprocessing and feature selection, five ML algorithms were trained and optimized using eICU-CRD data. Model performance was evaluated using AUC, sensitivity, specificity, and balanced accuracy. The optimal model was benchmarked against APACHE and SOFA scores. SHapley Additive exPlanations (SHAP) interpreted feature contributions. A Windows application was developed for clinical deployment. XGBoost emerged as the optimal model (Final-ML model), which incorporated only 17 routinely collected clinical variables: age, non-invasive systolic blood pressure (NI-SBP), heart rate, respiratory rate, Glasgow Coma Scale eye opening score, white blood cell count (WBC), creatinine, bicarbonate, red cell distribution width (RDW), platelet count, glucose, calcium, mean corpuscular hemoglobin concentration (MCHC), sodium, mean corpuscular volume, red blood cell count, and potassium. It achieved high AUCs: 0.876 (95%CI: 0.836-0.915; eICU-CRD test data), 0.932 (95%CI: 0.921-0.942; MIMIC-IV), and 0.879 (95%CI: 0.846-0.912; CHN-dataset). It significantly outperformed APACHE (AUC = 0.740, 95%CI: 0.720-0.761) and SOFA (AUC = 0.717, 95%CI: 0.694-0.740) scores. The model demonstrated strong generalizability across ethnicities, ward types, and genders within MIMIC-IV. Using daily data (DM dataset), predicted IHM risk accurately tracked patient trajectories: risk decreased progressively for survivors and increased for non-survivors throughout the ICU stay. SHAP analysis identified key predictors: NI-SBP, age, heart rate, WBC, glucose, and notably, RDW and MCHC. Time-dependent Cox regression confirmed RDW increase (HR = 3.783, 95%CI: 2.237-6.398) and MCHC decrease (HR = 0.173, 95%CI: 0.040-0.741) as significant independent risk factors for IHM. The developed XGBoost model provides a reliable, generalizable tool for real-time IHM risk quantification and monitoring in ICU HF patients, using only 17 routinely collected clinical variables. It surpasses traditional scoring systems and enables dynamic risk assessment throughout the ICU stay. By identifying patient-specific major risk factors via SHAP values, the model facilitates timely, personalized treatment adjustments.