The period following heart failure hospitalization (HFH) is a vulnerable time with high rates of death or recurrent HFH.OBJECTIVE To evaluate clinical characteristics, outcomes, and treatment response to vericiguat according to prespecified index event subgroups and time from index HFH in the Vericiguat Global Study in Subjects With Heart Failure With Reduced Ejection Fraction (VICTORIA) trial. DESIGN, SETTING, AND PARTICIPANTSAnalysis of an international, randomized, placebo-controlled trial. All VICTORIA patients had recent (<6 months) worsening HF (ejection fraction <45%). Index event subgroups were less than 3 months after HFH (n = 3378), 3 to 6 months after HFH (n = 871), and those requiring outpatient intravenous diuretic therapy only for worsening HF (without HFH) in the previous 3 months (n = 801). Data were analyzed between May 2, 2020, and May 9, 2020.INTERVENTION Vericiguat titrated to 10 mg daily vs placebo. MAIN OUTCOMES AND MEASURESThe primary outcome was time to a composite of HFH or cardiovascular death; secondary outcomes were time to HFH, cardiovascular death, a composite of all-cause mortality or HFH, all-cause death, and total HFH. RESULTS Among 5050 patients in the VICTORIA trial, mean age was 67 years, 24% were women, 64% were White, 22% were Asian, and 5% were Black. Baseline characteristics were balanced between treatment arms within each subgroup. Over a median follow-up of 10.8 months, the primary event rates were 40.9, 29.6, and 23.4 events per 100 patient-years in the HFH at less than 3 months, HFH 3 to 6 months, and outpatient worsening subgroups, respectively. Compared with the outpatient worsening subgroup, the multivariable-adjusted relative risk of the primary outcome was higher in HFH less than 3 months (adjusted hazard ratio, 1.48; 95% CI, 1.27-1.73), with a time-dependent gradient of risk demonstrating that patients closest to their index HFH had the highest risk. Vericiguat was associated with reduced risk of the primary outcome overall and in all subgroups, without evidence of treatment heterogeneity. Similar results were evident for all-cause death and HFH. Addtionally, a continuous association between time from HFH and vericiguat treatment showed a trend toward greater benefit with longer duration since HFH. Safety events (symptomatic hypotension and syncope) were infrequent in all subgroups, with no difference between treatment arms.CONCLUSIONS AND RELEVANCE Among patients with worsening chronic HF, those in closest proximity to their index HFH had the highest risk of cardiovascular death or HFH, irrespective of age or clinical risk factors. The benefit of vericiguat did not differ significantly across the spectrum of risk in worsening HF.
Background: Whether heart rate (HR) fluctuation after admission has an impact on the outcomes of critically ill myocardial infarction (MI) patients in intensive care unit remains unknown.Methods: A total of 2,031 MI patients were enrolled from the Medical Information Mart for Intensive Care (MIMIC-III) database. HR fluctuation was calculated as the maximum HR minus the minimum HR in the initial 24 h after admission. Participants were divided into 3 groups, namely, low HR fluctuation [<30 beats per minute (bpm)], medium HR fluctuation (30–49 bpm), and high HR fluctuation (≥ 50 bpm). The main outcomes were 30–day and 1-year mortality. Cox regression and restricted cubic spline model were used.Results: Each 10-bpm increase in HR fluctuation was associated with a higher risk of 30-day mortality and 1-year mortality, with adjusted hazard ratios of 1.122 (95% CI, 1.083–1.162) and 1.107 (95% CI, 1.074–1.140), respectively. Compared with the low HR fluctuation group, the high HR fluctuation group suffered a significantly higher risk of mortality after adjustment, with hazard ratios of 2.156 (95% CI, 1.483–3.134) for 30-day mortality and 1.796 (95% CI, 1.354–2.381) for 1-year mortality. A typical J-type curve was observed in restricted cubic splines for the association between HR fluctuation and 30-day or 1-year mortality of MI patients, with the lowest risk on the HR fluctuation of 30 bpm. Sensitivity analyses emphasized the robustness of our results.Conclusions: This retrospective cohort study revealed an independent positive association between HR fluctuation and 30-day and 1-year mortality in critically ill MI patients, which warrants further investigation.
ObjectivesWe aimed to develop and validate a prognostic nomogram and evaluate the discrimination of the nomogram model in order to improve the prediction of 30-day survival of critically ill myocardial infarction (MI) patients.DesignA retrospective cohort study.SettingData were collected from the Medical Information Mart for Intensive Care (MIMIC)-III database, consisting of critically ill participants between 2001 and 2012 in the USA.ParticipantsA total of 2031 adult critically ill patients with MI were enrolled from the MIMIC-III database.Primary and secondary outcomeThirty-day survival.ResultsIndependent prognostic factors, including age, heart rate, white blood cell count, blood urea nitrogen and bicarbonate, were identified by Cox regression model and used in the nomogram. Good agreement between the prediction and observation was indicated by the calibration curve for 30-day survival. The nomogram exhibited reasonably accurate discrimination (area under the receiver operating characteristic curve, 0.765, 95% CI, 0.716 to 0.814) and calibration (C-index, 0.758, 95% CI, 0.712 to 0.804) in the validation cohort. Decision curve analysis demonstrated that the nomogram was clinically beneficial. Additionally, participants could be classified into two risk groups by the nomogram, and the 30-day survival probability was significantly different between them (p<0.001).ConclusionThis five-factor nomogram can achieve a reasonable degree of accuracy to predict 30-day survival in critically ill MI patients and might be helpful for risk stratification and decision-making for MI patients.
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