Clinical characteristics and outcome of aortic endocarditis with periannular abscess in the International Collaboration on Endocarditis Merged Database

The aims of this study were to determine the clinical characteristics and outcome of patients who had definite infective endocarditis (IE) complicated by aortic ring abscess formation that was detected with transesophageal echocardiography (TEE) and to determine the prognostic significance of abscess formation in aortic valve IE. Patients who had aortic valve IE were selected from the International Collaboration on Endocarditis Merged Database (ICE-MD) if they underwent TEE. Among 311 patients who had definite aortic valve IE, 67 (22%) had periannular abscesses. They were more likely to have infection in the setting of a prosthetic valve (40% vs 19%, p <0.001) and coagulase-negative staphylococcal IE (18% vs 6%, p < 0.01) and less likely to have streptococcal IE than were patients who did not develop abscess (28% vs 46%, p = 0.01). Systemic embolization, central nervous system events, and heart failure did not differ between those who developed abscess and those who did not, but power was limited. Patients who had abscess were more likely to undergo surgery (84% vs 36%, p <0.001), and their in-hospital mortality rate was higher (19% vs 11%, p = 0.09). Multivariate analysis of prognostic factors of mortality in aortic IE identified age (odds ratio [OR] 1.6, 95% confidence interval [CI]1.2 to 2.1), Staphylococcus aureus (S. aureus) infection (OR 2.4, 95% CI 1.1 to 5.2), and heart failure (OR 2.9, 95% CI 1.4 to 6.1) as variables that were independently associated with increased risk of death. Periannular abscess formation showed a nonsignificant trend toward an increased risk of death (OR 1.9, 95% CI 0.9 to 3.8). Multivariate analysis of prognostic factors of mortality in complicated aortic IE with abscess formation identified S. aureus infection (OR 6.9, 95% CI 1.6 to 29.4) as independently associated with increased risk of death. In conclusion, in the current era of TEE and high use of surgical treatment, periannular abscess formation in aortic valve IE is not an independent risk factor for mortality. S. aureus infection is an independent prognostic factor for mortality in patients who have abscess formation.     

Determinants of in-hospital death and rupture in patients with a Stanford B aortic dissection.

BACKGROUND: In Stanford B acute aortic dissection (AAD), medical treatment is the choice of therapy in the acute phase, however, a portion of patients experience complications caused by serious clinical outcomes including aortic rupture and abdominal visceral ischemia. The objective of this study was to determine the predictors of in-hospital events in an Asian cohort of Stanford type B AAD. METHODS AND RESULTS: Hospital records were queried to identify patients that met following criteria: (1) AAD presenting within 14 days of symptom onset; and (2) computed tomography (CT) confirmation of a dissected descending aorta not involving the ascending aorta. An in-hospital event was defined as death, rupture/impending rupture, or organ malperfusion. Patient characteristics, inflammatory markers, and CT findings were obtained from clinical case records and retrospectively analyzed. Two hundred and twenty patients with Stanford B AAD were identified. In-hospital events occurred in 15 patients (there were 8 deaths, and 5 patients need to undergo emergent surgery because of impending rupture or rupture, and 4 patients experienced organ malperfusion). In univariate logistic regression analysis, the non-thrombosed type (odds ratio (OR) 3.88, 95% confidence interval (CI) 1.20-12.61, p=0.02) and maximum aortic diameter measured by an initial CT (each having a 5 mm increment: OR 1.61, 95% CI 1.20-2.15, p=0.001) were significant predictors of in-hospital events. In multiple logistic regression analysis, the only significant predictor was maximum aortic diameter measured by an initial CT (each having a 5 mm increment: OR 1.41, 95% CI 1.04-1.92, p=0.03). CONCLUSION: The results identified a large maximum aortic diameter as the independent predictor of in-hospital events in Stanford type B AAD. The non-thrombosed type might also help differentiate high-risk patients.     

Risk factors related to the occurrence of silent myocardial ischemia in Mexicans

BACKGROUND: Silent myocardial ischemia is a growing world health problem. It has been related to factors that promote an increase in myocardial oxygen demand or affect coronary vasomotor tone. Coronary artery disease has shown an increasing trend in Mexico in this century. HYPOTHESIS: The aim of the study was to estimate the strength of the association between some risk factors and the occurrence of silent myocardial ischemia. METHODS: A cross-sectional study was conducted and 249 individuals were screened by 24-h Holter electrocardiogram. Silent myocardial ischemia was diagnosed in patients with painless transient ST-segment depression. All subjects were interviewed for coronary risk factors and total serum cholesterol was measured. RESULTS: Silent ischemia was diagnosed in 115 patients (46%), who were older (59 +/- 9 vs. 57 +/- 11 years; p = 0.01). In a logistic regression analysis, a lower risk for silent ischemia was found in patients with thrombolysis [odds ratio (OR) 0.28; 95% confidence interval (CI 95%) 0.14-0.53], or those who followed their medical treatment (OR 0.16; CI 95% 0.04-0.68). The major risk factors were hypercholesterolemia (OR 1.6; CI 95% 0.9-2.9) and more severe coronary artery disease (OR 2.5; CI 95% 1.1-5.7). CONCLUSIONS: Some coronary risk factors are related to silent ischemia. It is still important to diagnose this entity, but modification of its related risk factors should be kept in mind to diminish its occurrence and its severe consequences.     

Prevalence of factor V Leiden and prothrombin variant G20210A in patients age <50 years with no significant stenoses at angiography three to four weeks after myocardial infarction

OBJECTIVES: We sought to determine the frequencies of factor V Leiden and prothrombin variant G20210A in patients age <50 years with no significant coronary stenoses three to four weeks after myocardial infarction (MI). BACKGROUND: Factor V Leiden and prothrombin variant G20210A occur frequently in patients with venous thromboembolism. However, the contribution of these mutations to the development of MI requires clarification. METHODS: The frequencies of factor V Leiden and prothrombin variant G20210A were determined in 41 patients age <50 years who had "normal" or "near normal" coronary arteries (no stenosis >50%) at angiography three to four weeks after MI (the study group) and compared with those in 114 patients who had at least one angiographic stenosis >50% after MI (the control group). Patients age > or =50 years with, or without, stenoses were also studied. RESULTS: The frequency of factor V Leiden was 14.6% in patients age <50 years in the study group compared with 3.6% in patients in the control group (odds ratio [OR] 4.7 [95% confidence interval (CI) 1.3-17.7], p = 0.02). The frequency of the prothrombin variant G20210A was 7.3% in the study group compared with 1.8% in the control group (OR 4.4 [95% CI 0.7-27.5], p = 0.12). One or both mutations were present in 8 of the 41 patients (19.5%) age <50 years in the study group compared with 6 of the 114 patients (5.5%) in the control group (OR 4.4 [95% CI 1.4-13.5], p = 0.01). In all 271 patients (irrespective of age) with normal arteries, the frequency of factor V Leiden was 11.7% (7/60) compared with 4.3% (9/211) in patients with at least one >50% stenosis (OR 2.9 [95% CI 1.1-8.3], p = 0.04), and the frequency of prothrombin variant G20210A was 6.7% (4/60) compared with 1.4% (3/211) (OR 4.9 [95% CI 1.1-22.8], p = 0.04), respectively. CONCLUSIONS: The frequencies of factor V Leiden and/or prothrombin variant G20210A are increased in patients age <50 years with normal or near normal coronary arteries after MI.     

Factors associated with length of stay for pediatric asthma hospitalizations

Objective: Asthma is a leading cause of pediatric hospitalizations, but little is known about factors associated with length of stay (LOS) for asthma hospitalizations. The aim of this study was to identify factors associated with LOS for pediatric asthma hospitalizations. Methods: The Pediatric Health Information System (PHIS) was used to cohort patients 2–17 years old with a primary asthma diagnosis discharged from 42 PHIS hospitals in 2011. Sociodemographic, temporal and health-status factors were examined. Bivariate and generalized-estimating-equation logistic regression analyses were performed to identify factors associated with LOS, after adjusting for severity of illness (SOI). Results: In total, 25?900 children were hospitalized, with a mean LOS of 1.9 days. In bivariate analysis, mean LOS was longer (p?<?0.01) for patients with complex chronic conditions (CCC) (3.1 days versus 1.8 for non-CCC) and adolescents (2.3 versus 1.8 for 2–5 years old). In multivariable analysis, obstructive sleep apnea (OSA; OR 2.3; 95% CI: 1.8–2.9), older age (OR 1.3; 95% CI: 1.2–1.4), obesity (OR 1.3; 95% CI: 1.1–1.4), CCC (OR 1.3; 95% CI: 1.1–1.4), winter admissions (OR 1.2; 95% CI: 1.1–1.4), female gender (OR 1.1; 95% CI: 1.1–1.3), and weekend admissions (OR 1.1; 95% CI: 1.03–1.2) had higher odds of asthma LOS >2 days. Conclusions: OSA, older age, obesity, CCC, winter and weekend admissions, and female gender are associated with longer LOS for pediatric asthma hospitalizations, after adjustment for SOI. The study findings suggest that interventions focused on these at-risk groups may prove most useful in reducing LOS for pediatric asthma hospitalizations.     

Acute coronary syndromes without chest pain, an underdiagnosed and undertreated high-risk group: insights from the Global Registry of Acute Coronary Events

STUDY OBJECTIVES: The clinical manifestations of acute coronary syndromes (ACSs) vary, and patients present frequently with symptoms other than chest pain. In this analysis, a large contemporary database has been accessed to define the frequency, clinical characteristics, and outcomes of patients presenting without chest pain across different diagnostic categories of ACS. DESIGN AND SETTING: The Global Registry of Acute Coronary Events is a multinational, prospective, observational study involving 14 countries. PATIENTS: Patients presenting to the hospital with a suspected ACS were stratified according to whether their predominant presenting symptoms included chest pain (ie, typical) or did not (ie, atypical). Demographics, medical history, hospital management, and outcomes were compared. MEASUREMENTS AND RESULTS: Of the 20,881 patients in this analysis, 1,763 (8.4%) presented without chest pain, 23.8% of whom were not initially recognized as having an ACS. They were less likely to receive effective cardiac medications, and experienced greater hospital morbidity and mortality (13% vs 4.3%, respectively; p < 0.0001) than did patients with typical symptoms. After adjusting for potentially confounding variables, increased hospital mortality rates were noted in patients with dominant presenting symptoms of presyncope/syncope (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.4 to 2.9), nausea or vomiting (OR, 1.6; 95% CI, 1.1 to 2.4), and dyspnea (OR, 1.4; 95% CI, 1.1 to 1.9), and in those with painless presentations of unstable angina (OR, 2.2; 95% CI, 1.4 to 3.5) and ST-segment elevation myocardial infarction (OR, 1.7; 95% CI, 1.2 to 2.2). CONCLUSION: Patients with ACSs who present without chest pain are frequently misdiagnosed and undertreated. With the exception of diaphoresis, each dominant presenting symptom independently identifies a population that is at increased risk of dying. These patients experience greater morbidity and a higher mortality across the spectrum of ACSs.     

Presentations of Acute Myocardial Infarction in Men and Women

OBJECTIVE: To assess the influence of gender on the likelihood of acute myocardial infarction (AMI) among emergency department (ED) patients with symptoms suggestive of acute cardiac ischemia, and to determine whether any specific presenting signs or symptoms are associated more strongly with AMI in women than in men. DESIGN: Analysis of cohort data from a prospective clinical trial. SETTING: Emergency departments of 10 hospitals of varying sizes and types in the United States. PATIENTS: Patients 30 years of age or older (n = 10,525) who presented to the ED with chest pain or other symptoms suggestive of acute cardiac ischemia. MEASUREMENTS AND MAIN RESULTS: The prevalence of AMI was determined for men and women, and a multivariable logistic regression model predicting AMI was developed to adjust for patients' demographic and clinical characteristics. AMI was almost twice as common in men as in women (10% vs 6%). Controlling for demographics, presenting signs and symptoms, electrocardiogram features, and hospital, male gender was a significant predictor of AMI (odds ratio [OR] 1.7; 95% confidence interval [CI] 1.4, 2.0). The gender effect was eliminated, however, among patients with ST-segment elevations on electrocardiogram (OR 1.1; 95% CI 0.7, 1.7) and among patients with signs of congestive heart failure (CHF) (OR 1.1; 95% CI 0.8, 1.5). Signs of CHF were associated with AMI among women (OR 1.9; 95% CI 1.4, 2.6) but not men (OR 1.0; 95% CI 0.8, 1.3). Among patients who presented to EDs with chest pain or other symptoms suggestive of acute cardiac ischemia, AMI was more likely in men than in women. Among women with ST-segment elevation or signs of CHF, however, AMI likelihood was similar to that in men with these characteristics.     

Syncope in acute aortic dissection: diagnostic,prognostic, and clinical implications

BACKGROUND: Syncope is a well-recognized symptom of acute aortic dissection, often indicating the development of dangerous complications such as cardiac tamponade. SUBJECTS AND METHODS: We identified consecutive patients with acute aortic dissection at 18 referral centers in six countries. Data on key clinical findings and outcomes were collected via extensive questionnaires. Multiple logistic regression models were used to determine the association between syncope and in-hospital mortality, adjusting for demographic characteristics, dissection type, comorbid conditions, and complications (e.g., cardiac tamponade). RESULTS: Syncope was reported in 96 (13%) of 728 patients. Patients with syncope were more likely to die in the hospital (34% [n = 33 deaths]) than were those without syncope (23% [144/632], P = 0.01). They were also more likely to have cardiac tamponade (28% [n = 27] vs. 8% [n = 49], P <0.001), stroke (18% [n = 17] vs. 4% [n = 27], P <0.001), and other neurologic deficits (25% [n = 24] vs. 14% [n = 88], P = 0.005). After multivariate adjustment, clinical factors independently associated with the occurrence of syncope included a proximal dissection (odds ratio [OR] = 5.5; 95% confidence interval [CI]: 2.5 to 12; P <0.001), cardiac tamponade (OR = 3.1; 95% CI: 1.7 to 5.4; P <0.001), and stroke (OR = 3.5; 95% CI: 1.7 to 7.2; P = 0.001). There was a significant association between in-hospital death and syncope after adjustment for demographic characteristics alone (OR = 2.0; 95% CI: 1.2 to 3.5; P = 0.01), but not after adjustment for dissection type, comorbid conditions, and complications. CONCLUSION: Patients with dissections complicated by cardiac tamponade or stroke are significantly more likely to present with syncope. If these complications are excluded, syncope alone does not appear to increase the risk of death independently.     

Contemporary outcome trends in the elderly undergoing percutaneous coronary interventions: results in 7,472 octogenarians. National Cardiovascular Network Collaboration

OBJECTIVES: We sought to define the risks facing octogenarians undergoing contemporary percutaneous coronary interventions (PCIs). BACKGROUND: The procedural risks of PCI for octogenarians have not been well established. METHODS: We compared the clinical characteristics and in-hospital outcomes of 7,472 octogenarians (mean age 83 years) with those of 102,236 younger patients (mean age 62 years) who underwent PCI at 22 National Cardiovascular Network (NCN) hospitals from 1994 through 1997. RESULTS: Octogenarians had more comorbidities, more extensive coronary disease and a two- to fourfold increased risk of complications, including death (3.8% vs. 1.1%), Qwave myocardial infarction (1.9% vs. 1.3%), stroke (0.58% vs. 0.23%), renal failure (3.2% vs. 1.0%) and vascular complications (6.7% vs. 3.3%) (p < 0.001 for all comparisons). Independent predictors of procedural mortality in octogenarians included shock (odds ratio [OR] 5.4, 95% confidence interval [CI] 3.3 to 8.8), acute myocardial infarction (OR 3.2, 95% CI 2.3 to 4.4), left ventricular ejection fraction (LVEF) <35% (OR 2.9, 95% CI 2.1 to 3.9), renal insufficiency (OR 2.8, 95% CI 2.0 to 3.8), first PCI (OR 2.3, 95% CI 1.7 to 3.3), age >85 years (OR 2.1, 95% CI 1.5 to 2.7) and diabetes mellitus (OR 1.5, 95% CI 1.1 to 2.0). For elective procedures, octogenarian mortality varied nearly 10-fold, and was strongly influenced by comorbidities (0.79% mortality with no risk factors vs. 7.2% with renal insufficiency or LVEF <35%). Despite similar case-mix, PCI outcomes in octogenarians improved significantly over the four years of observation (OR of 0.61 for death/myocardial infarction/stroke in 1997 vs. 1994; 95% CI 0.45 to 0.85). CONCLUSIONS: Risks to octogenarians undergoing PCI are two- to fourfold higher than those of younger patients, strongly influenced by comorbidities, and have decreased in the stent era.     

Can We Predict the Site of Entry Tear by Computed Tomography in Patients With Acute Type A Aortic Dissection?

Background:

In patients with acute type A aortic dissection (AAD), localization of the primary entry tear to be excluded is of major importance for intervention.

Hypothesis:

There are reliable indirect computed tomography (CT) findings to predict the entry site.

Methods:

In 83 patients with type A AAD whose primary entry tears were identified surgically between 2003 and 2009, we retrospectively examined the diagnostic CT scans regarding pericardial effusion, the largest short‐axial diameter of the aorta, widths of true and false lumens, and false lumen thrombosis at 6 levels of thoracic aorta from the aortic root to the descending aorta.

Results:

The primary entry sites identified intraoperatively were proximal ascending in 21 patients, middle ascending in 21, distal ascending in 21, arch in 17, and descending or unknown in 16. The multivariate logistic analysis revealed that pericardial effusion (odds ratio [OR]: 2.2, 95% confidence interval [CI]: 1.2–3.4, P < 0.001) and dilated ascending aorta (OR: 1.6, 95% CI: 1.1–2.4, P = 0.012) were the significant CT findings to predict the entry tear in the ascending aorta. It also revealed that the significant CT finding to predict the entry tear distal to the aortic arch was nonthrombosed false lumen in the descending aorta (OR: 1.2, 95% CI: 1.1–2.1, P = 0.048).

Conclusions:

We can predict the primary entry site by the preoperative CT findings in patients with type A AAD, considering pericardial effusion, aortic diameter, widths of true and false lumens, and false lumen thrombosis at different anatomic levels. Clin. Cardiol. 2012 DOI: 10.1002/clc.21991 The authors have no funding, financial relationships, or conflicts of interest to disclose.     

Usefulness of transthoracic echocardiography as a tool for risk stratification of patients undergoing major noncardiac surgery

Transthoracic echocardiography (TTE) is frequently ordered before noncardiac surgery, although its ability to predict perioperative cardiac complications is uncertain. To evaluate the incremental information provided by TTE after consideration of clinical data for prediction of cardiac complications after noncardiac surgery, 570 patients who underwent TTE before major noncardiac surgery at a university hospital were studied. Preoperative clinical data and clinical outcomes were collected prospectively according to a structured protocol. TTE data included left ventricular (LV) function, hypertrophy indexes, and Doppler-derived measurements. In univariate analyses, preoperative systolic dysfunction was associated with postoperative myocardial infarction (odds ratio [OR] 2.8, 95% confidence interval [CI] 1.1 to 7.0), cardiogenic pulmonary edema (OR 3.2, 95% CI 1.4 to 7.0), and major cardiac complications (OR 2.4, 95% Cl 1.3 to 4.5). Moderate to severe LV hypertrophy, moderate to severe mitral regurgitation, and increased aortic valve gradient were also associated with major cardiac events (OR 2.3, 95% CI 1.2 to 4.6; OR 2.2, 95% CI 1.1 to 4.3; OR 2.1, 95% CI 1.0 to 4.5, respectively). In logistic regression analysis, models with echocardiographic variables predicted major cardiac complications significantly better than those that included only clinical variables (c statistic 0.73 vs 0.68; p <0.05). Echocardiographic data added significant information for patients at increased risk for cardiac complications by clinical criteria, but not in otherwise low-risk patients. In conclusion, preoperative TTE before noncardiac surgery can provide independent information about the risk of postoperative cardiac complications in selected patients.     

Endovascular stent-grafts for acute and chronic type B aortic dissection: comparison of clinical outcomes

Within the recent months, endovascular repair of aor- tic aneurysms has become a rather interesting alternative to patients considering open surgery. In the past, the proce- dure was typically and more solely reserved to a selected group of elderly patients with several co-morbidities. Currently, there are a number of ongoing trials that are com-     

Clinical characteristics and outcome of inpatients versus outpatients with venous thromboembolism: Findings from the RIETE Registry

BackgroundPatients with venous thromboembolism (VTE) treated with anticoagulants are at risk of death from pulmonary embolism (PE) and/or bleeding. However, whether patients who develop VTE in hospital have a higher complication rate than those who develop VTE in an outpatient setting is unclear.Patients and methodsRIETE is an ongoing, prospective registry of consecutive patients with acute, objectively confirmed, symptomatic VTE. We compared the 3-month incidence of fatal PE and fatal bleeding in patients in whom the VTE had developed while in hospital for another medical condition (inpatients) with those who presented to the emergency ward because of VTE (outpatients).ResultsUp to April 2008, 22,133 patients with acute VTE were enrolled: 10,461 (47%) presented with PE, 11,672 with deep vein thrombosis. Overall, 6445 (29%) were inpatients. During the study period, those who developed VTE as inpatients had a significantly higher incidence of fatal PE (2.1% vs. 1.5%; odds ratio: 1.4; 95% CI: 1.1–1.7), overall death (7.0% vs. 5.4%; odds ratio: 1.3; 95% CI: 1.2–1.5), and major bleeding (2.9% vs. 2.1%; odds ratio: 1.4; 95% CI: 1.1–1.6) than outpatients. The incidence of fatal bleeding was not significantly increased (0.7% vs. 0.5%; odds ratio: 1.2; 95% CI: 0.9–1.8). In multivariable analysis, inpatient status was significantly associated with a higher risk for fatal PE (odds ratio: 1.3; 95% CI: 1.1–1.7).ConclusionsVTE occurring in hospitalized patients carries a significantly higher risk for death of PE than in outpatients, underscoring the importance of VTE prevention strategies in the hospital setting.     

平滑肌收缩功能障碍通路上的基因多态性与主动脉夹层的关系△

目的分析在平滑肌收缩功能障碍通路上MYHll、MMP9、FBLN5和TGFBR2基因多态性与主动脉夹层发病的相关性,探讨遗传因素对主动脉夹层发病的影响。方法从主动脉夹层患者（107例）及对照组（110例）外周血单核细胞提取基因组DNA,并利用已发表的文献资料以及最小等位基因频率（MAF≥10％）对MYHll、MMP9、FBLN5和TGFBR2的单核苷酸多态性（single nucleotide polymorphisms,SNPs）进行了选择。最后,通过基于单碱基引物延伸原理的MultiplexSNaPshotSNP分型技术对所有的DNA样本进行SNPs基因型检测。结果主动脉夹层组及对照组MYHll基因rsl050111C〉T纯合子表型（CC）的频率高于rsl050111C〉T杂合子（CT）频率,差异有统计学意义（88．7％US．11-3％．P〈0．05;77．3％m22．7％,P〈0．05）。T等位基因的比值比（oddsratio,OR）为2．137．95％可信区间（confidenceinterval,CI）为1．044-4．372;CT／TT等位基因的OR为2．304,95％CI为1．09-4．869。StanfordA型及B型的主动脉夹层患者中MMP9基因rsll7577G〉A的GG基因型的频率显著高于GA／AA基因型频率,差异有统计学意义（52．4％㈨47．6％,P〈O．05;78．9％。s．21．1％,P〈0．05）。A等位基因的OR为2．088．95％CI为0．992-4．396;GA／AA等位基因的OR值为2．262,95％CI为1．153-4．437。结论rsl050111C〉T可能是主动脉夹层发病的遗传易感因素;rsll7577G〉A可能是主动脉夹层StanfordA型的遗传易感因素。     

Low socioeconomic status is a risk factor for cardiovascular disease among adult obstructive sleep apnea syndrome patients requiring treatment

STUDY OBJECTIVE: To evaluate the possible role of low socioeconomic status (SES) as a risk factor for cardiovascular disease (CVD) among obstructive sleep apnea syndrome (OSAS) patients requiring treatment. DESIGN: Polysomnographic and demographic characteristics and associated morbidity were measured in 686 prospectively recruited adult OSAS patients from two regions in Israel. SETTING: Two university-affiliated sleep laboratories. MEASUREMENTS AND RESULTS: The multiple logistic regression (after adjusting for gender, body mass index [BMI], and smoking) revealed that the following are independent determinants for CVD in OSAS patients requiring treatment: each decrease in income level category (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.1 to 1.7), age > or = 1 year (OR, 1.07; 95% CI, 1.04 to 1.1), hypertension (OR, 2.0; 95% CI, 1.3 to 3.1), and hyperlipidemia (OR, 3.7; 95% CI, 2.4 to 5.8); area under the receiver operating characteristic (ROC) = 81.9%. The multivariate determinants describing the low-SES OSAS patients included: minorities and immigrants combined (OR, 6.0; 95% CI, 2.9 to 12), female gender (OR, 2.4; 95% CI, 1.6 to 3.9), increased BMI (OR, 1.9; 95% CI, 1.3 to 2.9), unmarried status (OR, 1.9; 95% CI, 1.2 to 3.1), and years of education (> or = 1 year) [OR, 0.8; 95% CI, 0.7 to 0.8]; area under the ROC = 78.1%. CONCLUSION: In addition to the already known traditional risk factors, low SES was found to be a novel independent risk factor for CVD among adult OSAS patients requiring treatment.     

Risk factors for acute kidney injury and 30-day mortality after liver transplantation

Introduction. The aim of this study is to evaluate the risk factors for acute kidney injury (AKI) and 30-day mortality after liver transplantation.Material and methods. This is a retrospective cohort of consecutive adults undergoing orthotopic liver transplantation (OLT) at a referral hospital in Brazil, from January 2013 to January 2014. Risk factors for AKI and death were investigated.Results. A total 134 patients were included, with median age of 56 years. AKI was found in 46.7% of patients in the first 72 h after OLT. Risk factors for AKI were: viral hepatitis (OR 2.9, 95% CI = 1.2-7), warm ischemia time (OR 1.1, 95% CI = 1.01-1.2) and serum lactate (OR 1.3, 95%CI = 1.02-1.89). The length of intensive care unit (ICU) stay was longer in AKI group: 4 (3-7) days vs. 3 (2-4) days (p = 0.001), as well as overall hospitalization stay: 16 (9-26) days vs. 10 (8-14) days (p = 0.001). The 30-day mortality was 15%. AKI was an independent risk factor for mortality (OR 4.3, 95% CI = 1.3-14.6). MELD-Na ≥ 22 was a predictor for hemodialysis need (OR 8.4, 95%CI = 1.5-46.5). Chronic kidney disease (CKD) was found in 36 patients (56.2% of AKI patients).Conclusions. Viral hepatitis, longer warm ischemia time and high levels of serum lactate are risk factors for AKI after OLT. AKI is a risk factor for death and can lead to CKD in a high percentage of patients after OLT. A high MELD-Na score is a predictor for hemodialysis need.     

Association of metabolic syndrome with exercise capacity and heart rate recovery in patients with coronary heart disease in the heart and soul study

It is not known whether the metabolic syndrome is associated with poor exercise capacity among patients who have established coronary heart disease. We evaluated the association of the metabolic syndrome with treadmill exercise capacity and heart rate recovery among patients who had coronary heart disease. We measured treadmill exercise capacity (METs) and heart rate recovery (beats per minute) in 943 subjects who had known coronary heart disease. Of these, 377 (40%) had the metabolic syndrome as defined by criteria of the National Cholesterol Education Program. Participants who had the metabolic syndrome were more likely to have poor exercise capacity (METs <5, 33% vs 18%, p <0.0001) and poor heart rate recovery (相似文献   

Meta-analysis of usefulness of d-dimer to diagnose acute aortic dissection

Numerous studies have examined whether plasma D-dimer (DD) can be used to identify patients with acute aortic dissection (AAD). These studies have been inconclusive because of their limited sample sizes and the different cut-off values employed. We aimed to conduct a systematic review and meta-analysis to examine the utility of plasma DD as a screening tool for AAD. We systematically searched EMBASE and MEDLINE and hand-searched relevant articles to identify studies investigating plasma DD as a screening tool for AAD. A value of 500 ng/ml was defined as the threshold for a positive plasma DD finding because it is widely used for ruling out pulmonary emboli. Using DerSimonian-Laird random-effects models we pooled data across studies to estimate sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios (LRs). We identified 7 studies involving 298 subjects with AAD and 436 without. When data were pooled across studies, sensitivity (0.97, 95% confidence interval [CI] 0.94 to 0.99) and negative predictive value (0.96, 95% CI 0.93 to 0.98) were high. Specificity (0.56, 95% CI 0.51 to 0.60) and positive predictive value (0.60, 95% CI 0.55 to 0.66) were low. Negative LR showed an excellent discriminative ability (0.06, 95% CI 0.03 to 0.12), whereas positive LR did not (2.43, 95% CI 1.89 to 3.12). In conclusion, our meta-analysis suggests that plasma DD <500 ng/ml is a useful screening tool to identify patients who do not have AAD. Plasma DD may thus be used to identify subjects who are unlikely to benefit from further aortic imaging.     

Usefulness of pulse deficit to predict in-hospital complications and mortality in patients with acute type A aortic dissection

Vascular compromise seen with pulse deficits is common in patients with type A dissection. However, patient characteristics and in-hospital outcomes associated with pulse deficits have not been evaluated. Accordingly, we studied 513 patients (mean age 62 +/- 14 years, 65% men) with acute type A aortic dissection enrolled in the International Registry of Acute Aortic Dissection. Pulse deficits, defined as decreased or absent carotid or peripheral pulses as noted by clinicians and later confirmed by diagnostic imaging, at surgery or at autopsy were noted in 154 patients (30%). Age <70 years, male gender, neurologic deficit(s), altered mental status, and hypotension, shock, or tamponade on admission were all significantly higher in patients with than without pulse deficits. The etiology of aortic dissection, clinical symptoms, and imaging findings were similar in the 2 groups. In-hospital complications (hypotension, coma, renal failure, and limb ischemia) and mortality (41% vs 25%, p = 0.0002) were significantly higher in patients with pulse deficit. Cox proportional-hazards regression analysis identified pulse deficit as an independent predictor of 5-day in-hospital mortality (risk ratio 2.73, 95% confidence interval 1.7 to 4.4; p <0.0001). Further, overall mortality rates increased with an increasing number of pulse deficits (p for trend <0.0001). Pulse deficits are common findings in patients with type A aortic dissection and identify those at high risk of in-hospital adverse events. This simple clinical sign should direct physicians to consider a diagnosis of aortic dissection in patients with acute chest pain, and should help identify a subgroup of patients who would benefit from more aggressive strategies.     

Characteristics of cerebrovascular accidents after percutaneous coronary interventions

OBJECTIVES: We sought to identify the incidence, predictors, and clinical implications of cerebrovascular accidents (CVAs) after percutaneous coronary interventions (PCIs). BACKGROUND: Cerebrovascular accidents after PCI, although rare, can be devastating. Limited information exists regarding the characterization of this complication. METHODS: The study population comprised 20,679 patients who underwent PCI between September 1993 and April 2002. A CVA was defined as a composite of transient ischemic attack (TIA) and stroke. The characteristics of those who had a periprocedural CVA were compared with those who did not. RESULTS: A CVA occurred in 92 patients (0.30% of procedures). Of these, TIA occurred in 13 patients (0.04%) and stroke in 79 patients (0.25%). On multivariate analysis, patients with this complication more frequently had diabetes mellitus (adjusted odds ratio [OR] 1.8, 95% confidence interval [CI] 1.1 to 3.0; p = 0.013), hypertension (OR 1.9, 95% CI 1.1 to 3.3; p = 0.033), previous CVA (OR 2.3, 95% CI 1.3 to 4.0; p = 0.0059), and creatinine clearance < or =40 ml/min (OR 3.1, 95% CI 1.8 to 5.2; p < 0.0001). They underwent urgent or emergent procedures (OR 2.7, 95% CI 1.3 to 5.5; p = 0.0092) with more thrombolytic (OR 4.7, 95% CI 2.3 to 9.7; p < 0.0001) and intravenous heparin (OR 1.9, 95% CI 1.1 to 3.4; p = 0.030) use before PCI, and they more often required emergent intra-aortic balloon pump placement (OR 2.2, 95% CI 1.1 to 4.3; p = 0.028). On multivariate analysis, CVA was independently associated with in-hospital death (OR 7.8, 95% CI 4.2 to 14.7; p < 0.0001), acute renal failure (OR 2.8, 95% CI 1.4 to 5.7; p = 0.0042), and new dialysis (OR 3.73, 95% CI 1.01 to 13.8; p = 0.049) after PCI. CONCLUSIONS: Cerebrovascular accidents after PCI, although rare, are associated with high rates of in-hospital death and acute renal failure, often requiring dialysis.