Objectives: We sought to evaluate the incidence and clinical impact of calcified nodule (CN) in patients with heavily calcified lesions requiring rotational atherectomy (RA). Background: It remains unclear whether CN impacts adversely on clinical outcomes in patients with heavily calcified lesions. Methods: Between January 2011 and February 2014, 264 patients after secondgeneration drug-eluting stent (DES) implantation following RA were retrospectively enrolled. CN was defined as a convex shape of the luminal side of calcium as assessed by intravascular ultrasound. The primary endpoint was the cumulative 5-year incidence of major adverse cardiac events (MACE), defined as a composite of cardiac death, clinically driven target lesion revascularization (CDTLR), and definite stent thrombosis (ST). Results: CN was observed in 128 patients (48.5%) with heavily calcified lesions. Cumulative 5-year incidence of MACE was significantly higher in the CN group than in the non-CN group, mainly driven by a higher rate of CDTLR and ST (35.4% vs. 18.8%, p < .001; 23.2% vs. 7.9%, p < .001; 7.0% vs. 0.93%, p = .009, respectively).
Background The usefulness of preprocedural nutritional status to stratify prognosis after transcatheter aortic valve implantation has been evaluated; however, the studies conducted so far have been relatively small and/or focused on a single nutritional index. This study sought to assess the prevalence and prognostic impact of malnutrition in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation. Methods and Results We applied the Controlling Nutritional Status score, Geriatric Nutritional Risk Index, and Prognostic Nutritional Index to 1040 consecutive older Japanese patients at high surgical risk who underwent transcatheter aortic valve implantation. According to the Controlling Nutritional Status score, Geriatric Nutritional Risk Index, and Prognostic Nutritional Index, 16.6%, 60.5%, and 13.8% patients had moderate or severe malnutrition, respectively; 89.3% were at least mildly malnourished by at least 1 score. Worse nutritional status was associated with older age, lower body mass index, higher degree of frailty, worse symptoms and renal function, atrial fibrillation, and anemia. During a median follow‐up of 986 days (interquartile range, 556–1402 days), 273 (26.3%) patients died. Compared with normal nutrition, malnutrition was associated with an increased risk for all‐cause death (adjusted hazard ratio for moderate and severe malnutrition, respectively: 2.19 (95% CI, 1.45–3.31; P <0.001) and 6.13 (95% CI, 2.75–13.70; P <0.001) for the Controlling Nutritional Status score, 2.02 (95% CI, 1.36–3.02; P =0.001) and 3.24 (95% CI, 1.86–5.65; P <0.001) for the Geriatric Nutritional Risk Index, and 1.60 (95% CI, 1.06–2.39; P =0.024) and 2.32 (95% CI, 1.50–3.60; P <0.001) for the Prognostic Nutritional Index). Conclusions Malnutrition is common in patients undergoing transcatheter aortic valve implantation and is associated with increased mortality.
We investigated the independent and incremental role of worsening arterial stiffness in new-onset heart failure (HF) in patients with preclinical HF. We retrospectively studied 456 consecutive asymptomatic patients with HF risk factors (hypertension, obesity, type 2 diabetes mellitus, atrial fibrillation and ischemic heart disease) who underwent paired applanation tonometry examinations (median interval of 2.4 years) during 2006-2011. Brachial ankle pulse wave velocity (baPWV) was measured as a surrogate marker of arterial stiffness. Patients were followed up for admission for new-onset HF over a median duration of 4.9 years after the second examination. HF was observed in 30 patients (7%). The change in baPWV (∆baPWV) was significantly associated with hospitalization for new-onset HF, independent of and incremental to comorbidities, renal dysfunction, left ventricular (LV) dysfunction and baPWV at baseline. Even in patients with an LV ejection fraction of ⩾40%, ∆baPWV was significantly associated with hospitalization for new-onset HF after similar adjustments. When the patients were divided into groups based on this cutoff value of ⩾15% ∆baPWV and the generally accepted external cutoff value of ⩾1750 cm s for baseline baPWV, the Kaplan-Meier estimates of the time of hospitalization for new-onset HF showed that a higher rate of HF was associated with higher baPWV at baseline and higher ∆baPWV (P=0.00005). In asymptomatic patients with cardiovascular risk factors, the deterioration in arterial stiffness was associated with hospitalization for new-onset HF, independent of and incremental with the clinical LV function and increased stiffness parameters at baseline.
ObjectivesReadmission is a common and serious problem associated with heart failure (HF). Unfortunately, conventional risk models have limited predictive value for predicting readmission. The recipients of long-term care insurance (LTCI) are frail and have mental and physical impairments. We hypothesised that adjustment of the conventional risk score with an LTCI certificate enables a more accurate appreciation of readmission for HF.MethodsWe investigated 452 patients with HF who were followed up for 1 year to determine all-cause readmission. We obtained their clinical and socioeconomic data, including LTCI. The three clinical risk scores used in our evaluation were Keenan (2008), Krumholz (2000) and Charlson (1994). We used net reclassification improvement (NRI) to assess the incremental benefit.ResultsPatients with LTCI were significantly older, and had a higher prevalence of cerebrovascular disease and dementia than those without LTCI. One-year all-cause readmission (n=193, 43%) was significantly associated with all risk scores, receiving LTCI and the category of LTCI. Receiving LTCI was associated with readmission independent of all risk scores (HR, 1.59 to 1.63; all p<0.01). Adding LTCI to all risk scores led to a significantly improved reclassification, which was observed in the subgroup of patients with HF with preserved ejection fraction (≥50%) but not in the subgroup with reduced ejection fraction (<50%).ConclusionsPossession of an LTCI certificate was independently associated with 1-year all-cause readmission after adjusting for validated clinical risk scores in patients with HF. Adding LTCI status significantly improved the model performance for readmission risk, particularly in patients with HF and preserved ejection fraction.
BackgroundLesions in the proximal left coronary artery (LCA) are associated with a poor prognosis compared with other lesional sites. Transthoracic Doppler echocardiography (TTDE) can help to detect proximal LCA flow, and an accelerated coronary flow velocity (CFV) indicates the presence of proximal LCA lesions. This study aimed to investigate the prognostic value of CFV in the proximal LCA measured by TTDE.MethodsWe enrolled 1472 consecutive hemodynamically stable patients with known or suspected heart disease whose CFV was successfully detected using TTDE accompanied by routine echocardiography between 2008 and 2011. The primary outcome was cardiac death (acute myocardial infarction, heart failure, or sudden cardiac death) and patients were followed up over a median of 6.3 years.ResultsOverall, 42 cardiac deaths (3%) were observed. An increased CFV was significantly associated with the outcome in several models based on potential confounders (age, rate pressure product, Framingham Risk Score, diabetes, coronary artery disease, hemoglobin, brain natriuretic peptide, estimated glomerular filtration rate, left ventricular mass, left ventricular ejection fraction, and E/e′). Using a receiver operating characteristic curve analysis, the optimal cut-off value for the CFV to the association of the outcome was 37 cm/s (area under the curve, 0.70; sensitivity, 82%; specificity, 62%). In sequential Cox proportional hazards models, the CFV added incremental prognostic information to the clinical and basic echocardiographic parameters (chi-squared: 110.7 to 146.6, P < 0.01).ConclusionsAn increased CFV in the proximal LCA was associated with cardiac death, incremental to the clinical and basic echocardiographic parameters.
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