Cardiac troponins predict mortality and cardiovascular outcomes in patients with peripheral artery disease: A systematic review and meta‐analysis of adjusted observational studies

BackgroundA significant proportion of patients (pts) with peripheral artery disease (PAD) have concomitant coronary artery disease and polyvascular involvement contributes to increased risk of death and unfavorable cardiovascular events.HypothesisCardiac troponins are associated with adverse cardiovascular outcomes in PAD pts.MethodsWe systematically searched Medline and Scopus to identify all observational cohort studies published before June 2021 (combining terms “troponin,” “peripheral artery disease,” “peripheral arterial disease,” “intermittent claudication,” and “critical limb ischemia”) that evaluated the prognostic impact of troponin rise on admission on all‐cause mortality and/or major cardiovascular events (MACEs; composite of myocardial infarction, stroke, and cardiovascular death) in PAD pts followed up at least 6 months. A meta‐analysis was conducted using the generic inverse variance method. Heterogeneity between studies was investigated using Cochrane''s Q test and I ² statistic.ResultsEight studies were included in the final analysis (5313 pts) with a median follow‐up of 27 months (interquartile range: 12–59 months). The prevalence of troponin positivity was 5.3% (range: 4.4%–8.7%) in pts with intermittent claudication, and 62.6% (range: 33.6%–85%) in critical limb ischemia. Elevated troponins were significantly associated with an increased risk of all‐cause mortality (hazard ratio [HR]: 2.85, 95% confidence interval [CI]: 2.28–3.57; I ² = 50.97%), and MACE (HR: 2.58, 95% CI: 2.04–3.26; I ² = 4.00%) without publication bias (p = .24 and p = .10, respectively).ConclusionTroponin rise on admission is associated with adverse long‐term cardiovascular outcomes in symptomatic PAD.     

Hospital outcomes of community-acquired COVID-19 versus influenza: Insights from the Swiss hospital-based surveillance of influenza and COVID-19

BackgroundSince the onset of the COVID-19 pandemic, the disease has frequently been compared with seasonal influenza, but this comparison is based on little empirical data.AimThis study compares in-hospital outcomes for patients with community-acquired COVID-19 and patients with community-acquired influenza in Switzerland.MethodsThis retrospective multi-centre cohort study includes patients > 18 years admitted for COVID-19 or influenza A/B infection determined by RT-PCR. Primary and secondary outcomes were in-hospital mortality and intensive care unit (ICU) admission for patients with COVID-19 or influenza. We used Cox regression (cause-specific and Fine-Gray subdistribution hazard models) to account for time-dependency and competing events with inverse probability weighting to adjust for confounders.ResultsIn 2020, 2,843 patients with COVID-19 from 14 centres were included. Between 2018 and 2020, 1,381 patients with influenza from seven centres were included; 1,722 (61%) of the patients with COVID-19 and 666 (48%) of the patients with influenza were male (p < 0.001). The patients with COVID-19 were younger (median 67 years; interquartile range (IQR): 54–78) than the patients with influenza (median 74 years; IQR: 61–84) (p < 0.001). A larger percentage of patients with COVID-19 (12.8%) than patients with influenza (4.4%) died in hospital (p < 0.001). The final adjusted subdistribution hazard ratio for mortality was 3.01 (95% CI: 2.22–4.09; p < 0.001) for COVID-19 compared with influenza and 2.44 (95% CI: 2.00–3.00, p < 0.001) for ICU admission.ConclusionCommunity-acquired COVID-19 was associated with worse outcomes compared with community-acquired influenza, as the hazards of ICU admission and in-hospital death were about two-fold to three-fold higher.     

Association between dipeptidyl peptidase‐4 inhibitors and increased risk for bullous pemphigoid within 3 months from first use: A 5‐year population‐based cohort study using the Japanese National Database

Aims/IntroductionWe assessed the association between dipeptidyl peptidase‐4 inhibitors (DPP‐4is) and bullous pemphigoid (BP) and time‐dependent changes in the risk for developing BP after DPP‐4i initiation.Materials and MethodsThe present population‐based, real‐world study was carried out using the Japanese National Database dataset collected between 2013 and 2018. To assess independent correlations between DPP‐4is and the development of BP, the self‐controlled case series method was used.ResultsAmong the cohort followed up for a median of 1,540 days, 53,027 patients were likely to develop BP. The possible incidence rate of BP in all 150,328,339 patients was 10.4/100,000 person‐years. Among the 9,705,814 patients with type 2 diabetes, 15,634 were likely to develop BP. The possible incidence rate of BP in patients with type 2 diabetes was 38.1/100,000 person‐years, whereas that in patients with type 2 diabetes who did and did not use DPP‐4is was 40.7 and 30.0/100,000 person‐years, respectively. Analysis of the 28,705 patients with type 2 diabetes likely to develop BP after initial DPP‐4i use showed a risk ratio of 2.15 (95% confidence interval [CI] 1.75–2.63), 1.70 (95% CI 1.37–2.11), 1.44 (95% CI 1.15–1.82), 1.25 (95% CI 0.98–1.59), 0.84 (95% CI 0.63–1.10), 0.84 (95% CI 0.64–1.11) and 1.05 (95% CI 0.92–1.20), for the risk period of ≤30, 31–60, 61–90, 91–120, 121–150, 151–180 and 181–365 days, respectively.ConclusionsAlthough DPP‐4is were associated with increased risk for BP, the risk was particularly significant within 3 months from first use.     

Primary Bone Lymphoma: A 13 Year Retrospective Institutional Analysis in the Chemo-Immunotherapy Era

Primary Lymphoma of bone (PBL) is an uncommon extranodal tumor accounting for 1% of all malignant lymphomas. The incidence of PBL is so rare that many of its aspects remain unknown. We retrospectively analysed our data in order to know clinical characteristics and treatment outcome in Indian population in chemo-immunotherapy era. We identified 49 patients [2007–2019] (median age 52 years) of which, 35 (71.4%) were males. Nearly one-third patients (n = 18; 36.8%) were elderly (Age > 60). The most common histological subtype was DLBCL. Local pain /swelling (n = 23; 47%) and B symptoms (n = 20; 44.4%) was the most common presentation. Spine was the most frequently involved site (n = 25; 51%) followed by pelvis (n = 17; 34.7%). One third patients had poor ECOG-PS ≥ 2, (n = 16; 32.6). More than 50% of the population presented with IPI score ≥ 2 (n = 25; 55.5%). Majority of the patients presented with Ann-Arbor stage IV disease (n = 31; 63.2%). (n = 32; 71.1%) cases received chemotherapy alone and (n = 13; 28.9%) patients were treated in combination with local radiotherapy. R-CHOP was the most common treatment regimen given to patients (n = 43; 95.5%). Overall, three-fourth patients (n = 36; 80%) achieved a complete response. At a median follow-up of 45 ± 2 (range 3–144) months, 4-year OS (Overall Survival) and PFS (Progression free survival) was 83.1% and 74.5%, respectively, using Kaplan–Meier survival curves. Prognostic factors for OS on multivariate analysis were ECOG-PS 0–1 [p = 0.05], age < 60 [p = 0.03] and achievement of CR [p = 0.001]. PBL in India is usually of DLBCL subtype, with spine as the most common site. It has an excellent prognosis in the R-CHOP era. Chemo-immunotherapy with 6 R-CHOP followed by addition of Radiotherapy if partial response appears to provide good outcomes. However, the exact role of radiation still needs to be confirmed.     

Low‐density lipoprotein cholesterol lowering in real‐world patients treated with evolocumab

BackgroundLow‐density lipoprotein cholesterol (LDL‐C) is a risk factor for atherosclerotic cardiovascular disease (ASCVD). There are limited real‐world data on LDL‐C lowering with evolocumab in United States clinical practice.HypothesisWe assessed LDL‐C lowering during 1 year of evolocumab therapy.MethodsThis retrospective cohort study used linked laboratory (Prognos) and medical claims (IQVIA Dx/LRx and PharMetrics Plus^®) data. Patients with a first fill for evolocumab between 7/1/2015 and 10/31/2019 (index event) and LDL‐C ≥ 70 mg/dL were included (overall cohort; N = 5897). Additionally, a patient subgroup with a recent myocardial infarction (MI) within 12 months (median 130 days) before the first evolocumab fill was identified (N = 152). Reduction from baseline LDL‐C was calculated based on the lowest LDL‐C value recorded during a 12‐month follow‐up period.ResultsThe mean (SD) age was 65 (10) years; 61.9% of patients had ASCVD diagnoses and 70.7% of patients were in receipt of lipid‐lowering therapy. Following evolocumab treatment, changes in LDL‐C from baseline were −60% in the overall cohort (median [interquartile range (IQR)] 146 [115–180] mg/dL to 58 [36–84] mg/dL) and −65% in the recent MI subgroup (median [IQR] 137 [109–165] mg/dL to 48 [30–78] mg/dL). In the overall cohort and recent MI subgroup, 62.1% and 69.7% of patients achieved LDL‐C < 70 mg/dL, respectively.ConclusionsIn this real‐world analysis, evolocumab was associated with significant reductions in LDL‐C comparable to that seen in the FOURIER clinical trial, which were durable over 1 year of treatment.     

Myeloablative Versus Reduced Intensity Conditioning Regimens for Allogeneic Hematopoietic Stem Cell Transplant for Acute Myeloid Leukemia and Myelodysplastic Syndrome: A Retrospective Analysis

The conditioning regimens used for the allo-HSCT include either myeloablative conditioning (MAC) or reduced intensity conditioning (RIC) regimens based on the age, performance status and co-morbidities. Studies comparing the survival outcomes of RIC and MAC allo-HSCT in AML and MDS patients have reported contradictory results. We therefore retrospectively analyzed our data of AML and MDS patients who received MAC and RIC allo-HSCT at our center and compared the long term outcome of the two conditioning regimens. One hundred twenty six consecutive patients were evaluated, 32 (25.4%) underwent MAC allo-HSCT and 94 (74.6%) underwent RIC allo-HSCT. The most common MAC regimen used was busulfan plus cyclophosphamide and the most common RIC regimen used was fludarabine plus melphalan. The median age was higher in RIC group (44 years, range 4–75 years) compared to MAC group (31 yrs, range 6–51 yrs, p = 0.001). There was no significant difference in terms of overall survival (p = 0.498), relapse-free survival (p = 0.791) and non-relapse mortality (p = 0.366) between the two groups. In multivariate analysis, only chronic graft-versus-host disease resulted in decreased risk of relapse and improved overall survival irrespective of the conditioning regimens used.     

Beneficial effects of lifelong caloric restriction on endothelial function are greater in conduit arteries compared to cerebral resistance arteries

Endothelial dysfunction occurs in conduit and cerebral resistance arteries with advancing age. Lifelong caloric restriction (CR) can prevent the onset of age-related dysfunction in many tissues, but its effects on cerebral resistance artery function, as compared with conduit artery function, have not been determined. We measured endothelium-dependent dilation (EDD) in the carotid artery and middle cerebral artery (MCA) from young (5–7 months), old ad libitum fed (AL, 29–32 months), and old lifelong CR (CR, 40 % CR, 29–32 months) B6D2F1 mice. Compared with young, EDD for old AL was 24 % lower in the carotid and 47 % lower in the MCA (p < 0.05). For old CR, EDD was not different from young in the carotid artery (p > 0.05), but was 25 % lower than young in the MCA (p < 0.05). EDD was not different between groups after NO synthase inhibition with N^ω-nitro-l-arginine methyl ester in the carotid artery or MCA. Superoxide production by the carotid artery and MCA was greater in old AL compared with young and old CR (p < 0.05). In the carotid, incubation with the superoxide scavenger TEMPOL improved EDD for old AL (p > 0.05), with no effect in young or old CR (p > 0.05). In the MCA, incubation with TEMPOL or the NADPH oxidase inhibitor apocynin augmented EDD in old AL (p < 0.05), but reduced EDD in young and old CR (p < 0.05). Thus, age-related endothelial dysfunction is prevented by lifelong CR completely in conduit arteries, but only partially in cerebral resistance arteries. These benefits of lifelong CR on EDD result from lower oxidative stress and greater NO bioavailability.     

Association between sarcopenia and the severity of diabetic polyneuropathy assessed by nerve conduction studies in Japanese patients with type 2 diabetes mellitus

Aims/IntroductionThis study examined the association between the severity of diabetic polyneuropathy (DPN) based on the Baba classification, and sarcopenia and its related factors.Materials and MethodsThe participants were 261 patients with type 2 diabetes mellitus. DPN was classified as stages 0–4 according to the Baba classification. Sarcopenia was diagnosed based on measurements of the skeletal mass index, grip strength and walking speed, using the Asia Working Group for Sarcopenia 2019 diagnostic criteria.ResultsThe median age of the participants was 67 years, the proportion of men was 58.6%, the median estimated duration of diabetes was 10 years and the median values for glycated hemoglobin were 10.3%. With regard to DPN, the prevalence of Baba classification stages 0–2 was 90.8% (n = 237), and that of stage 3 or 4 was 9.2% (n = 24). The prevalence of sarcopenia was 19.9%. A trend toward an increase in the frequency of slow walking speed was seen as the stage of DPN progressed. The frequencies of sarcopenia and slow walking speed were higher in the group with the Baba classification stages 3 and 4 than in the group with stages 0–2. On multiple logistic regression analyses, however, DPN was not significantly related to sarcopenia and walking speed.ConclusionsAlthough severe DPN might be related to sarcopenia, the frequency of severe DPN is low in the clinical setting, indicating that its contribution to sarcopenia is modest.     

Post‑COVID‑19 Syndrome in Outpatients: a Cohort Study

BackgroundAfter mild COVID-19, some outpatients experience persistent symptoms. However, data are scarce and prospective studies are urgently needed.ObjectivesTo characterize the post-COVID-19 syndrome after mild COVID-19 and identify predictors.ParticipantsOutpatients with symptoms suggestive of COVID-19 with (1) PCR-confirmed COVID-19 (COVID-positive) or (2) SARS-CoV-2 negative PCR (COVID-negative).DesignMonocentric cohort study with prospective phone interview between more than 3 months to 10 months after initial visit to the emergency department and outpatient clinics.Main MeasuresData of the initial visits were extracted from the electronic medical file. Predefined persistent symptoms were assessed through a structured phone interview. Associations between long-term symptoms and PCR results, as well as predictors of persistent symptoms among COVID-positive, were evaluated by multivariate logistic regression adjusted for age, gender, smoking, comorbidities, and timing of the survey.Key ResultsThe study population consisted of 418 COVID-positive and 89 COVID-negative patients, mostly young adults (median age of 41 versus 36 years in COVID-positive and COVID-negative, respectively; p = 0.020) and healthcare workers (67% versus 82%; p = 0.006). Median time between the initial visit and the phone survey was 150 days in COVID-positive and 242 days in COVID-negative patients. Persistent symptoms were reported by 223 (53%) COVID-positive and 33 (37%) COVID-negative patients (p = 0.006) and proportions were stable among the periods of the phone interviews. Overall, 21% COVID-positive and 15% COVID-negative patients (p = 0.182) attended care for this purpose. Four surveyed symptoms were independently associated with COVID-19: fatigue (adjusted odds ratio 2.14, 95% CI 1.04–4.41), smell/taste disorder (26.5, 3.46–202), dyspnea (2.81, 1.10–7.16), and memory impairment (5.71, 1.53–21.3). Among COVID-positive, female gender (1.67, 1.09–2.56) and overweight/obesity (1.67, 1.10–2.56) were predictors of persistent symptoms.ConclusionsMore than half of COVID-positive outpatients report persistent symptoms up to 10 months after a mild disease. Only 4 of 14 symptoms were associated with COVID-19 status. The symptoms and predictors of the post-COVID-19 syndrome need further characterization as this condition places a significant burden on society.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-07242-1.     

Left atrial reservoir strain is an outstanding predictor of adverse cardiovascular outcomes in patients undergoing maintenance hemodialysis: Assessment via three‐dimensional speckle tracking echocardiography

BackgroundThere is a paucity of literature focusing left atrium (LA) in patients undergoing maintenance hemodialysis (MHD).HypothesisWe used three‐dimensional speckle tracking echocardiography (3DSTE) to evaluate LA in MHD patients and to explore its predictive value for adverse outcomes.MethodsEchocardiography was performed on 130 consecutively enrolled MHD patients without previous cardiac diseases. Conventional and 3DSTE parameters of LA were obtained. The MHD cohort was then followed and the end point was major adverse cardiovascular events (MACEs). LA strain indices, including reservoir strain (LASr), conduit strain (LAScd), and contractile strain (LASct), were measured and compared between patients with and without MACEs.ResultsPatients were prospectively followed up for a median of 40.5 (interquartile range: 26.3–48.0) months. During follow‐up, 43 patients met the end point. These patients had larger LA size and reduced LA strains (LA maximal volume indexed: 45.1 ± 11.9 vs. 33.8 ± 6.9ml/m²; LASr: 20.2 ± 3.5 vs. 27.2 ± 3.3%; LAScd: −12.3 ± 5.2 vs. −14.5±4.0%; LASct: −8.0 ± 4.2 vs. −13.2 ± 3.7%; all p<.05), compared with those without MACEs. Multivariable regression analysis showed LASr was the strongest predictor of MACEs (hazard ratio, 0.69; 95% confidence interval, 0.54–0.89; p=.004). Univarite Kaplan–Meier analysis revealed the incidence of MACEs in the impaired LASr (<24.2%) group was significantly higher than in the normal LASr group (log rank p<.001).ConclusionsLASr derived from 3DSTE is an independent predictor of MACEs and cardiac death in MHD patients, superior to LV parameters and LA volume indices.     

Impact of chronic kidney disease on clinical outcomes in patients with Stage B progressive aortic regurgitation (mild to moderate and moderate grades)

BackgroundChronic kidney disease (CKD) is a significant comorbidity in patients with heart failure and valvular heart disease. Renal impairment is not well evaluated in the patients with Stage B progressive aortic regurgitation (AR) (mild to moderate and moderate grades in this study), for estimating outcome.HypothesisWe sought to investigate the prognostic factor, especially CKD, in the patients with progressive AR.MethodsWe enrolled 262 patients with Stage B progressive AR and preserved left ventricular systolic function (ejection fraction ≥ 50%). Based on the presence of CKD, the patients were divided into CKD (n = 70) and non‐CKD (n = 192) groups, which CKD was defined as estimated glomerular filtration rate < 60 ml/min/1.73 m². The primary outcome was major adverse cardiac events (MACEs), including cardiac death, myocardial infarction, hospitalization for heart failure, and aortic valve replacement.ResultsThe median follow‐up duration was 41.5 (interquartile range: 16.2–71.7) months. Between groups, the CKD patients were older; they had a higher pulse pressure and higher incidence of hypertension, diabetes mellitus, dyslipidemia, cerebrovascular accident, and atrial fibrillation. Compared to the non‐CKD group, the CKD group had lower eʹ velocity (4.36 ± 2.21 vs. 5.20 ± 2.30 cm/s, p = .009), higher right ventricular systolic pressure (38.02 ± 15.79 vs. 33.86 ± 11.77 mmHg, p = .047). The CKD group was associated with increased risk of MACEs (41.4% vs. 22.4%; unadjusted hazard ratio [HR]: 1.78, 95% confidence interval [CI]: 1.11–2.85, p = .017). In multivariate Cox regression analyses, the risk of MACEs was significantly different between groups (adjusted HR: 1.71, 95% CI: 1.11–2.62, p = .015); furthermore, the risk of hospitalization for heart failure (10.0% vs. 2.6%; adjusted HR: 2.30, 95% CI: 1.16–4.55, p = .017) was significantly higher in the CKD group than in the non‐CKD group.ConclusionsIn patients with Stage B progressive AR, CKD is an independent prognostic factor for clinical outcomes (composite clinical outcome, hospitalization for heart failure).     

Chronic biopsy proven post‐COVID myoendocarditis with SARS‐Cov‐2 persistence and high level of antiheart antibodies

PurposeTo study the clinical signs and mechanisms (viral and autoimmune) of myoendocarditis in the long‐term period after COronaVIrus Disease 2019 (COVID‐19).MethodsFourteen patients (nine male, 50.1 ± 10.2 y.o.) with biopsy proven post‐COVID myocarditis were observed. The diagnosis of COVID‐19 was confirmed by IgG seroconversion. The average time of admission after COVID‐19 was 5.5 [2; 10] months. An endomyocardial biopsy (EMB) of the right ventricle was obtained. The biopsy analysis included polymerase chain reaction diagnosis of viral infection, morphological, immunohistochemical (IHC) examination with antibodies to CD3, CD45, CD68, CD20, SARS‐Cov‐2 spike, and nucleocapsid antigens. Coronary atherosclerosis was ruled out in all patients over 40 years.ResultsThe new cardiac symptoms (congestive heart failure 3–4 New York Heart Association class with severe right ventricular involvement, various rhythm, and conduction disturbances) appeared 1–5 months following COVID‐19. Magnetic resonance imaging showed disseminated or focal subepicardial and intramyocardial late gadolinium enhancement, hyperemia, edema, and increased myocardial native T1 relaxation time. Antiheart antibodies levels were increased 3–4 times in 92.9% of patients. The mean left ventricular (LV) ejection fraction (EF) was 28% (24.5; 37.8). Active lymphocytic myocarditis was diagnosed in 12 patients, eosinophilic myocarditis in two patients. SARS‐Cov‐2 RNA was detected in 12 cases (85.7%), in association with parvovirus B19 DNA—in one. Three patients had also endocarditis (infective and nonbacterial, with parietal thrombosis). As a result of steroid and chronic heart failure therapy, the EF increased to 47% (37.5; 52.5).ConclusionsCOVID‐19 can lead to long‐term severe post‐COVID myoendocarditis, that is characterized by prolonged persistence of coronavirus in cardiomyocytes, endothelium, and macrophages (up to 18 months) in combination with high immune activity. Corticosteroids and anticoagulants should be considered as a treatment option of post‐COVID myoendocarditis.     

Original research: Provision and standards of care for treatment and follow-up of patients with Autoimmune Hepatitis (AIH)

BackgroundAutoimmune hepatitis (AIH) is a substantial UK health burden, but there is variation in care, facilities and in opinion regarding management. We conducted an audit of service provision and care of patients with AIH in 28 UK hospitals.MethodsCentres provided information about staffing, infrastructure and patient management (measured against predefined guideline-based standards) via a web-based data collection tool.ResultsHospitals (14 university hospitals (UHs), 14 district general hospitals (DGHs)) had median (range) of 8 (3–23) gastroenterologists; including 3 (0–10) hepatologists. Eight hospitals (29%, all DGHs) had no hepatologist. In individual hospital departments, there were 50% (18–100) of all consultants managing AIH: in DGH’s 92% (20–100) vs 46% (17–100) in UHs. Specialist nurses managed AIH in only 18%. Seventeen (61%) hospitals had a histopathologist with a liver interest, these were more likely to find rosettes than those without (172/795 vs 50/368; p<0.001).Of 999 steroid-treated patients with ≥12 months follow-up, 25% received steroids for <12 months. After 1 year of treatment, 82% of patients achieved normal serum alanine aminotransaminase (ALT); this was higher in UHs than DGHs. Three-monthly liver blood tests were inadequately recorded in 26%. Of potentially eligible patients with liver decompensation, transplantation was apparently not considered in 5% (n=7). The same standards were attained in different types of hospital.ConclusionManagement of AIH in UK hospitals is often shared between most gastroenterologists. Blood test monitoring and treatment duration are not always in line with recommendations. Some eligible patients with decompensation are not discussed with transplant teams. Care might be improved by expanding specialist input and management by fewer designated consultants.     

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

BackgroundRed blood cell distribution width (RDW) and N‐terminal pro brain natriuretic peptide (NT‐proBNP) may predict the prognosis of heart failure (HF). However, the impact of combined RDW and NT‐proBNP levels as a prognostic marker of HF remains unclear and the significance of this combination at various time‐points has not been sufficiently studied.HypothesisRDW can predict prognosis in HF at various time‐points and combination with NT‐proBNP improves the prognostic value.MethodsPatients admitted to HF care unit of Fuwai Hospital CAMS&PUMC (Beijing, China) with a diagnosis of HF from November 2008 to November 2018 were analyzed retrospectively.ResultsIn total, 3231 patients with available RDW data at admission were evaluated (median age 58 years, 71.9% males, 39.7% coronary heart disease, 68.6% New York Heart Association [NYHA] III or IV). Median RDW and NT‐proBNP at admission were 13.4% (interquartile range [IQR]: 12.7%–14.5%), and 1723.00 pg/ml (IQR: 754.00–4006.25 pg/ml), respectively. During 2.9‐year median follow‐up, all‐cause death occurred in 1075 (33.27%) patients. Kaplan–Meier survival curve and Cox proportional‐hazard models, showed patients in the top quarter RDW had a 32.0% increased mortality compared to the bottom quarter (hazard ratio: 4.39, 95% confidence interval: 3.59–5.38; p <.001). The top quarter RDW retained independent prognostic value across HF with reduced ejection fraction [HFrEF], HF with mid‐range ejection fraction [HFmrEF], and HF with preserved ejection fraction [HFpEF] subgroups. Patients were subsequently divided into four groups by median RDW and NT‐proBNP. Comparison of Kaplan–Meier survival curves for various groups showed good risk stratification (p < .001).ConclusionsRDW is an independent predictor of mortality among patients with HF in the short‐, medium‐, and long‐term. Combination of RDW and NT‐proBNP improves the prognostic value. This is true across all clinical subtypes of heart failure (HFrEF, HFmrEF, HFpEF), and among most subgroups of patients with various comorbidities (infection, diabetes, hypertension).     

Hospitalization rate of respiratory syncytial virus‐associated acute lower respiratory infection among young children in Suzhou,China, 2010–2014

BackgroundThere is a limited amount of data in China on the disease burden of respiratory syncytial virus‐ (RSV) associated acute lower respiratory infection (ALRI) among young children. This study aimed to estimate the hospitalization rate of RSV‐associated ALRI (RSV‐ALRI) among children aged 0–59 months in Suzhou, China.MethodsAll cases from children hospitalized with ALRI who were aged 0–59 months in Suzhou University Affiliated Children''s Hospital during January 2010 to December 2014 were retrospectively identified. Detailed diagnosis and treatment data were collected by reviewing each individual''s medical chart. In accordance with the World Health Organization (WHO) influenza disease burden estimation, the hospitalization rate of RSV‐ALRI among children aged 0–59 months in Suzhou, China, was then estimated.ResultsOut of the 28,209 ALRI cases, 19,317 (68.5%) were tested for RSV, of which the RSV positive proportion was 21.3% (4107/19,317). The average hospitalization rate of RSV‐ALRI for children aged 0–59 months was 14 (95% confidence interval [CI]:14–14)/1000 children years, and that for children aged 0–5, 6–11, 12–23, and 24–59 months were 70 (95% CI: 67–73), 31 (95% CI: 29–33), 11 (95% CI: 10–12), and 3 (95% CI: 3–3)/1000 children years, respectively.ConclusionA considerable degree of RSV‐ALRI hospitalization exists among children aged 0–59 months, particularly in those under 1 year of age. Therefore, an effective monoclonal antibody or vaccine is urgently needed to address the substantial hospitalization burden of RSV infection.     

Decongestive treatment adjustments in heart failure patients remotely monitored with a multiparametric implantable defibrillators algorithm

AimsHeartLogic algorithm combines data from multiple implantable defibrillators (ICD)‐based sensors to predict impending heart failure (HF) decompensation. A treatment protocol to manage algorithm alerts is not yet known, although decongestive treatment adjustments are the most frequent alert‐triggered actions reported in clinical practice. We describe the implementation of HeartLogic for remote monitoring of HF patients, and we evaluate the approach to diuretic dosing and timing of the intervention in patients with device alerts.MethodsThe algorithm was activated in 229 ICD patients at eight centers. The median follow‐up was 17 months (25th–75th percentile: 11–24). Remote data reviews and patient phone contacts were undertaken at the time of HeartLogic alerts, to assess the patient''s status and to prevent HF worsening. We analyzed alert‐triggered augmented HF treatments, consisting of isolated increases in diuretics dosage.ResultsWe reported 242 alerts (0.8 alerts/patient‐year) in 123 patients, 137 (56%) alerts triggered clinical actions to treat HF. The HeartLogic index decreased after the 56 actions consisting of diuretics increase. Specifically, alerts resolved more quickly when the increases in dosing of diuretics were early rather than late: 28 days versus 62 days, p < .001. The need of hospitalization for further treatments to resolve the alert condition was associated with higher HeartLogic index values on the day of the diuretics increase (odds ratio: 1.11, 95% CI: 1.02–1.20, p = .013) and with late interventions (odds ratio: 5.11, 95% CI: 1.09–24.48, p = .041). No complications were reported after drug adjustments.ConclusionsDecongestive treatment adjustments triggered by alerts seem safe and effective. The early use of decongestive treatment and the use of high doses of diuretics seem to be associated with more favorable outcomes.     

Predictors of rhythm outcomes after cardiac resynchronization therapy in atrial fibrillation patients: When should we use an atrial lead?

BackgroundCardiac resynchronization therapy (CRT) is widely used in atrial fibrillation (AF) patients and could impact rhythm stability.HypothesisWe aimed to identify predictors of sinus rhythm (SR) stability or AF progression in a real‐word cohort of CRT‐AF patients.MethodsFrom 330 consecutive implantable cardioverter‐defibrillator implantations due to ischemic or dilated cardiomyopathy, 65 (20%) patients with AF history (paroxysmal, n = 32) underwent a CRT implantation with an atrial electrode and were regularly followed every 4–6 months. Rhythm restoration was attempted for most AF patients based on symptoms, biventricular pacing (BP), and lack of thrombi.ResultsAfter 33 months, 18 (28%) patients progressed to permanent mode switch (MS≥99%) and 20 (31%) patients had stable SR (MS < 1%). Logistic regression showed that history of persistent AF (OR: 8.01, 95%CI: 2.0–31.7, p = .003) is associated with higher risk of permanent MS. In persistent AF patients, a bigger left atrium (OR: 1.2 per mm, 95%CI: 1.03–1.4, p = .025) and older age (OR: 1.15 per life‐year, 95%CI: 1.01–1.3, p = .032) were predictors of future permanent MS. Paroxysmal AF at implantation (OR: 5.96, 95%CI: 1.6–21.9, p = .007) and increased BP (OR: 1.4 per 1%, 95%CI: 1.05–1.89, p = .02) were associated with stable SR. In persistent AF patients, stable SR correlated with higher BP (98 ± 2 vs. 92 ± 8%, p < .001).ConclusionIn patients with AF undergoing CRT implantation, persistent AF, LA dilatation and advanced age relate to future permanent MS (AF), whereas high BP promotes SR stability. These findings could facilitate the management of CRT‐AF patients and guide therapy in order to maximize its effect on rhythm.     

Association between heart rate and cardiovascular death in patients with coronary heart disease: A NHANES‐based cohort study

BackgroundDue to the lack of research, this study aimed to assess the association between the specific range of heart rate and cardiovascular (CV) death in coronary heart disease (CHD) patients.HypothesisHeart rate of 70–79 bpm may be associated with reduced risk of CV death in CHD patients.MethodsThis retrospective cohort study collected the data of CHD patients from the eight cycles of the Health and Nutrition Examination Survey (NHANES). The included patients were divided into four groups: <60, 60–69, 70–79, and ≥80 bpm. The start of follow‐up date was the mobile examination center date, the last follow‐up date was December 31, 2015. The average follow‐up time was 81.70 months, and the longest follow‐up time was 200 months. Competing risk models were developed to evaluate the association between heart rate and CV death, with hazard ratios (HRs) and 95% confidence intervals (CIs) calculated.ResultsA total of 1648 patients with CHD were included in this study. CHD patients at heart rate of <60 (HR, 1.35; 95% CI, 1.34–1.36), 60–69 (HR, 1.05; 95% CI, 1.04–1.06) or ≥80 (HR, 1.39; 95% CI, 1.38–1.41) bpm had a higher risk of CV death than those at heart rate of 70–79 bpm.ConclusionsHeart rate of <70 or ≥80 bpm was associated with an elevated risk of CV death among CHD patients. Continuous monitoring of heart rate may help to screen for health risks and offer early interventions to corresponding patients.     

The role of ramucirumab with docetaxel in epidermal growth factor receptor mutant and wild-type non-small cell lung cancer

BackgroundRamucirumab paired with docetaxel extends progression free survival and overall survival in non-small cell lung cancer (NSCLC) following progression on platinum therapy. There is some data that epidermal growth factor receptor (EGFR) mutant disease would respond better to vascular endothelial growth factor receptor (VEGFR) therapy than EGFR wild type disease.MethodsThis retrospective, single-institution cohort study reports outcomes of patients who received docetaxel with or without ramucirumab according to EGFR status. Clinical data including age, performance status, metastatic burden and prior treatment history was obtained and reported with time on treatment and overall survival as primary endpoints. Data analysis was performed for three cohorts: EGFR mutant disease receiving docetaxel and ramucirumab (EGFR-doce/ram), EGFR mutant disease receiving docetaxel alone (EGFR-doce) and EGFR wild type disease receiving docetaxel and ramucirumab (WT-doce/ram).ResultsPatients in the EGFR-doce/ram cohort had a median time on docetaxel of 1.4 months (95% CI: 0.72–5.2 months) and of 0.8 months (95% CI: 0.2–6.5 months) on ramucirumab. Patients in the EGFR-doce cohort were on docetaxel for a median 1.4 months (95% CI: 0.9–2.4 months). Patients in the WT-doce/ram cohort had a median time on docetaxel of 2.3 months (95% CI: 1.6–4.1 months) and on ramucirumab of 1.4 months (95% CI: 0.8–3.2 months). There was no significant difference between time on ramucirumab or docetaxel between the cohorts. Overall survival for the three cohorts was noted to be 6.7 months (95% CI: 2.5–16.2 months) for the EGFR-doce/ram cohort, 4.9 months (95% CI: 4.2–12.5 months) for the EGFR-doce cohort and 6.6 months (95% CI: 4.3–12.8 months) for the WT-doce/ram cohort. There was no significant difference in overall survival between the cohorts.ConclusionsOur data did not support the initial hypothesis that patients with EGFR mutant disease would do better with the addition of ramucirumab. Our study was limited by small sample size, retrospective nature and inability to control for confounders including prior bevacizumab or immune checkpoint inhibitor (ICI) exposure. This study offers real-world estimates to clinicians and patients about the length of time they can expect to derive benefit from the combination of ramucirumab and docetaxel.