Congestion is a major cause of hospitalization for heart failure (HF). Peripheral venous pressure (PVP) strongly correlates with right atrial pressure. We recently reported that high PVP at discharge ...portends a poor prognosis in patients hospitalized for HF. In the same population, we aimed to analyze changes in PVP after discharge and to evaluate prognostic implications of post-discharge PVP.
PVP was measured at the forearm vein of 163 patients in the 1-month post-discharge follow-up visit. The primary outcome was a composite of cardiovascular death or re-hospitalization for HF after the 1-month follow-up visit up to 1 year after discharge.
Post-discharge PVP correlated with jugular venous pressure, the inferior vena cava diameter, and brain-type natriuretic peptide levels. The cumulative incidence of the primary outcome event was significantly higher in patients with PVP above the median (6 mmHg) than in those with median PVP or lower (39.8% versus 16.9%, Log-rank P = 0.04). Age- and sex-adjusted risk of PVP per 1 mmHg for the primary outcome measure was significant (hazard ratio: 1.12 95% confidence interval 1.03–1.21). 35% of patients who had PVP ≤6 mmHg at discharge had PVP >6 mmHg at the 1-month follow-up. PVP significantly decreased from discharge to 1-month follow-up in patients without the primary outcome event (from 6 4–10 to 6 4–8 mmHg, P=0.01), but remained high in those with the primary outcome event (from 8 5–11 to 7 5–10.5 mmHg, P = 0.9).
PVP measurements during the early post-discharge period may be useful to identify high risk patients.
Trial registration number: UMIN000034279.
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•Post-discharge congestion can be assessed by peripheral venous pressure (PVP).•PVP at 1-month post-discharge correlated with subsequent clinical outcomes.•Sustained increase in PVP after discharge portends worse clinical outcomes.•PVP may be useful to monitor congestion status and identify high risk patients.
•Peripheral venous pressure (PVP) can be measured easily in patients with heart failure.•PVP correlates strongly with right atrial pressure (RAP).•PVP predicted RAP better than conventional ...congestion assessments.•The predictive value of PVP should be evaluated in future studies.
Accurate bedside assessment of congestion in the management of patients with heart failure remains challenging. As a continuous conduit of circulating fluid, systemic congestion represented by high right atrial pressure (RAP) may be reflected by peripheral venous pressure (PVP). We evaluated the reliability of PVP measurements for assessing congestion beyond conventional clinical assessments.
We performed conventional congestion assessments and PVP measurements in 95 patients undergoing pulmonary artery catheterization. PVP was measured via the 22-gauge peripheral venous access placed in the upper extremity. The median RAP and PVP was 7 (interquartile range IQR: 5–11) mmHg and 9 (IQR: 7–12) mmHg, respectively, with a mean bias of 1.8 ± 2.6 mmHg. PVP exhibited a strong linear correlation with RAP (Spearman R = 0.81; P < 0.001). PVP demonstrated greater discriminatory power for both RAP ≤ 8 mmHg (area under the curve AUC: 0.91 95% confidence interval: 0.85–0.97; sensitivity: 75%; specificity: 87%) and RAP > 12 mmHg (AUC: 0.98 0.95–1.00; sensitivity: 88%; specificity: 95%) than edema, jugular venous pressure, pulmonary congestion on chest radiograph, B-type natriuretic peptide levels, and inferior vena cava diameter.
PVP measured via peripheral venous access strongly correlates with invasively obtained RAP. PVP measurements may improve current bedside assessments of congestion.
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Recently, one observational study showed that patients with ST-segment elevation myocardial infarction (STEMI) without standard cardiovascular risk factors were associated with increased mortality ...compared with patients with risk factors. This unexpected result should be evaluated in other populations including those with non–ST-segment elevation acute coronary syndrome (NSTE-ACS) and chronic coronary syndrome (CCS). Among 30,098 consecutive patients undergoing first coronary revascularization in the CREDO-Kyoto PCI/CABG (Coronary Revascularization Demonstrating Outcome Study in Kyoto Percutaneous Coronary Intervention/Coronary Artery Bypass Grafting) registry cohort-2 and 3, we compared clinical characteristics and outcomes between patients with and without risk factors stratified by their presentation (STEMI n = 8,312, NSTE-ACS n = 3,386, and CCS n = 18,400). Patients with risk factors were defined as having at least one of the following risk factors: hypertension, dyslipidemia, diabetes, and current smoking. The proportion of patients without risk factors was low (STEMI: 369 patients 4.4%, NSTE-ACS: 110 patients 3.2%, and CCS: 462 patients 2.5%). Patients without risk factors compared with those with risk factors more often had advanced age, low body weight, and malignancy and less often had history of atherosclerotic disease and prescription of optimal medical therapy. In patients with STEMI, patients without risk factors compared with those with risk factors were more often women and more often had atrial fibrillation, long door-to-balloon time, and severe hemodynamic compromise. During a median of 5.6 years follow-up, patients without risk factors compared with those with risk factors had higher crude incidence of all-cause death. After adjusting confounders, the mortality risk was significant in patients with CCS (hazard ratio HR 1.22, 95% confidence interval CI 1.01 to 1.49, p = 0.04) but not in patients with STEMI (HR 1.06, 95% CI 0.89 to 1.27, p = 0.52) and NSTE-ACS (HR 1.07, 95% CI, 0.74 to 1.54, p = 0.73). In conclusion, among patients undergoing coronary revascularization, patients without standard cardiovascular risk factors had higher crude incidence of all-cause death compared with those with at least one risk factor. After adjusting confounders, the mortality risk was significant in patients with CCS but not in patients with STEMI and NSTE-ACS.
We sought to evaluate the prognostic impact of the B-type natriuretic peptide (BNP) levels in patients with asymptomatic severe aortic stenosis (AS), who were not referred for aortic valve ...replacement (AVR).
We used data from a Japanese multicentre registry, the Contemporary outcomes after sURgery and medical tREatmeNT in patients with severe Aortic Stenosis Registry, which enrolled 3815 consecutive patients with severe AS. Of those, 387 asymptomatic patients who were not referred for AVR without left ventricular dysfunction and very severe AS were subdivided into four groups based on their BNP levels (BNP<100 pg/mL, n=201; 100≤BNP<200 pg/mL, n=94; 200≤BNP<300 pg/mL, n=42 and BNP>300 pg/mL, n=50).
The cumulative 5-year incidence of AS-related events (aortic valve-related death or heart failure hospitalisation) was incrementally higher with increasing BNP level (14.2%, 29.6%, 46.3% and 47.0%, p<0.001). After adjusting for confounders, the risk for AS-related events was incrementally greater with increasing BNP levels (HR: 1.97, 95% CI: 0.97 to 3.98, p=0.06; HR: 3.59, 95% CI: 1.55 to 8.32, p=0.03 and HR: 7.38, 95% CI: 3.21 to 16.9, p<0.001, respectively). Notably, asymptomatic patients with BNPlevels of <100 pg/mL had an event rate of only 2.1% at 1 year.
Increased BNP level was associated with a higher risk for AS-related adverse events in patients with asymptomatic severe AS with normal left ventricular ejection fraction who were not referred for AVR. Asymptomatic patients with BNP levels of <100 pg/mL had relatively low event rate, who might be safely followed with watchful waiting strategy.
UMIN000012140.
Abstract
Background
Although infective endocarditis (IE) in pregnancy is rare, maternal and foetal mortality rates are very high. We herein report the successful treatment of a case of IE with ...simultaneous emergent caesarean section and mitral valve replacement performed at 27 weeks of gestation.
Case summary
A 29-year-old woman at 27 weeks of gestation was referred for congestive heart failure (HF) due to infective endocarditis (IE) with large mobile vegetations and overt disruption of the mitral valve. We held a multi-disciplinary conference and decided to perform mitral valve replacement immediately after caesarean section because of the high risk of embolism and sepsis, worsening and unstable haemodynamics, and sufficient foetal maturity for delivery. Although coronary artery embolization and asymptomatic multiple cerebral infarctions were observed, her post-operative course was uneventful. Ultimately, the patient was discharged 29 days after surgery. The neonate was treated in the NICU until the expected delivery date and was discharged home on Day 95 of life.
Discussion
Difficulties are associated with the selection of an operative plan and its timing for IE during pregnancy. Heart failure due to IE requires urgent surgery when medical treatment cannot stabilize the patient. However, cardiopulmonary bypass and medicine for pregnant women adversely affect the foetus. Therefore, the timing of surgery and delivery needs to be selected by a multi-disciplinary team and in consideration of the maternal condition and foetal maturity.
Post-contrast acute kidney injury (PC-AKI) is a common complication after percutaneous coronary intervention (PCI). However, it is unclear whether or not the effects of PC-AKI on long-term clinical ...outcomes were different between emergent and elective procedures. Among patients enrolled in the CREDO-Kyoto PCI/CABG (Coronary Revascularization Demonstrating Outcome Study in Kyoto Percutaneous Coronary Intervention/Coronary Artery Bypass Grafting) registry cohort 3, we identified 10,822 patients treated using PCI (emergent PCI stratum: n = 5,022 46% and elective PCI stratum: n = 5,860 54%). PC-AKI was defined as ≥0.3 mg/100 ml absolute or 1.5-fold relative increase of serum creatinine within 72 hours after PCI. The incidence of PC-AKI was significantly higher after emergent PCI than after elective PCI (10.5% vs 3.7%, p <0.001). In the multivariable logistic regression model, emergent PCI was the strongest independent risk factor for PC-AKI in the entire study population. The excess adjusted risk of patients with PC-AKI relative to those without remained significant for all-cause death in both the emergent and elective PCI strata (hazard ratio 1.87, 95% confidence interval 1.59 to 2.21, p <0.001 and hazard ratio 1.31, 95% confidence interval 1.03 to 1.68, p = 0.03, respectively). There was a significant interaction between the PCI setting (emergent and elective) and the effect of PC-AKI on all-cause death, with a greater magnitude of effect in the emergent PCI stratum than in the elective PCI stratum (p for interaction = 0.01). In conclusion, the incidence of PC-AKI was 2.8 times higher after emergent PCI than after elective PCI. The excess mortality risk of PC-AKI relative to no PC-AKI was greater after emergent PCI than after elective PCI.
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It is important to clarify the precise impact of mitral regurgitation (MR) on long-term outcomes in acute myocardial infarction (AMI) patients who underwent percutaneous coronary intervention (PCI). ...In the Coronary Revascularization Demonstrating Outcome study in Kyoto Acute Myocardial Infarction (CREDO-Kyoto AMI) Registry Wave-2, the study population consisted of 5,266 patients with AMI who underwent PCI. The clinical outcomes of all-cause death, cardiovascular death, and hospitalization for heart failure (HF) were compared according to the severity of MR. Mild and moderate/severe MR were identified in 2,112 (40%) and 531 patients (10%), respectively. Patients with greater severity of MR were more likely to be old, had more co-morbidities, and more often presented with large myocardial infarction with HF. During median follow-up duration of 5.6 (interquartile range: 4.2 to 6.6) years, as the MR severity increased from no, mild, to moderate/severe MR, the cumulative 5-year incidences of all-cause death, cardiovascular death and hospitalization for HF incrementally increased (15.3%, 19.6%, 33.3%, 8.9%, 11.7%, 21.0% and 5.9%, 12.4%, 23.9%, respectively, P for all<0.001). After adjusting for confounders, however, mild and moderate/severe MR were not independently associated with the higher risks for all-cause death (hazard ratio 95% confidence interval:1.05 0.92 to 1.19, p = 0.51, and 1.10 0.92 to 1.32, p = 0.28) and cardiovascular death (1.01 0.85 to 1.21, p = 0.89, and 0.93 0.73 to 1.18, p = 0.54) as compared with no MR. Both mild and moderate/severe MR were independently associated with the higher risks for hospitalization for HF (1.73 1.42 to 2.11, p <0.001, and 2.23 1.73 to 2.87, p <0.001). In a large population of patients with AMI who underwent PCI, MR was not independently associated with higher long-term mortality risk but was independently associated with higher risk for hospitalization for HF.
To elucidate the factors associated with high left ventricular mass index (LVMI) and to test the hypothesis that high LVMI is associated with worse outcome in severe aortic stenosis (AS).
We analysed ...3282 patients with LVMI data in a retrospective multicentre registry enrolling consecutive patients with severe AS in Japan. The management strategy, conservative or initial aortic valve replacement (AVR), was decided by the attending physician. High LVMI was defined as LVMI >115 g/m
for males and >95 g/m
for females. We compared the risk between normal and high LVMI in the primary outcome measures compromising aortic valve-related death and heart failure hospitalisation.
Age was mean 77 (SD 9.6) years and peak aortic jet velocity (Vmax) was 4.1 (0.9) m/s. The factors associated with high LVMI (n=2374) included female, body mass index ≥22, absence of dyslipidemia, left ventricular ejection fraction <50%, Vmax ≥4 m/s, regurgitant valvular disease, hypertension, anaemia and end-stage renal disease. In the conservative management cohort (normal LVMI: n=691, high LVMI: n=1480), the excess adjusted 5-year risk of high LVMI was significant (HR: 1.53, 95% CI 1.26 to 1.85, p<0.001). In the initial AVR cohort (normal LVMI: n=217, high LVMI: n=894), the risk did not differ significantly between the two groups (HR: 0.96, 95% CI 0.60 to 1.55, p=0.88). There was a significant interaction between the initial treatment strategy and the risk of high LVMI (p=0.016).
The deleterious impact of high LVMI on outcome was observed in patients managed conservatively, but not observed in patients managed with initial AVR.
UMIN000012140; Post-results.
Abstract only Background: Rapid and accurate diagnosis of acute coronary syndrome (ACS) is critical to prevent the fatal complication accompanied with the delay of the treatment. However, the ...diagnosis of non-ST-segment elevation ACS (NSTE-ACS), especially shortly after the onset, is not straightforward because even high-sensitivity cardiac troponin (hs-cTn) is sometimes not elevated at that phase. We previously reported in a retrospective study that serum nardilysin is a potential biomarker for the early detection of NSTE-ACS. Here, we present the results of the Nardi-ACS study, a multicenter prospective study conducted at six centers in Japan to clarify the significance of nardilysin for the early detection of ACS. Methods and Results: We analyzed serum nardilysin and hs-cTnI (Architect; Abbott) in the sequential 2 independent cohorts; phase I primary cohort (435 patients with chest pain who consecutively visited to the emergency room (ER)) and phase II validation cohort (486 patients with a strong suspicion of ACS who underwent coronary angiography). The frequency of non-ACS, STEMI and NSTE-ACS was 64.4, 22.5, and 13.1 (%) in the phase I, and 14.0, 60.0, and 25.9 (%) in the phase II cohort, respectively. The cutoff value of serum nardilysin was set at 1350.9 pg/ml (mean +2SD) obtained in 246 healthy volunteers, while the cutoff of hs-cTnI was set at 52 pg/ml. The initial blood test in the phase I cohort revealed that nardilysin was significantly elevated in ACS patients, compared to non-ACS patients (p<0.05). The sensitivity of hsTnI, nardilysin, and nardilysin combined with hsTnI for the diagnosis of NSTE-ACS was 52.6, 57.9, and 78.9 (%), and the negative predictive value (NPV) was 90.7, 88.7, and 92.4 (%), respectively. When focused on hsTnI-negative patients, the sensitivity and NPV of nardilysin in STEMI and NSTE-ACS were 64.7/91.4 and 55.6/91.4 (%), respectively. Furthermore, the sensitivity of nardilysin for the early detection of STEMI and NSTE-ACS patients, whose blood was examined within 3 hours after the onset was 77.6 and 60.4 (%), respectively, both of which were higher than that of hsTnI (51.2 and 56.3%). Conclusion: Nardilysin could be a potential biomarker for the early diagnosis of troponin-negative NSTE-ACS.
The clinical significance of the CHADS
score remains unclear in patients with coronary artery disease (CAD) without atrial fibrillation (AF). Therefore, the purpose of this study was to evaluate the ...association between the CHADS
score and the long-term risk of ischemic stroke and its severity in patients with CAD with and without AF. Using the CREDO (Coronary Revascularization Demonstrating Outcome study)-Kyoto Registry Cohort-3, the present study population consisted of 11,516 patients with CAD who underwent percutaneous coronary intervention without oral anticoagulants at discharge. We divided the patients into 2 groups according to the presence (n = 721) or absence (n = 10,795) of AF. As the CHADS
score increased from 0 or 1 to 6, the cumulative 5-year incidence of ischemic stroke incrementally increased from 2.1% to 17.1% in patients without AF and from 4.2% to 40.7% in patients with AF. The cumulative 5-year incidence of ischemic stroke in patients without AF and a CHADS
score of 2 were numerically comparable to that in patients with AF and a CHADS
score of 1 (3.4% and 3.7%). In the 423 patients who developed ischemic stroke, the modified Rankin Scale score was not significantly different between patients with and without AF (p for trend = 0.12). In patients with and without AF, the increase in the CHADS
score was significantly associated with the greater prevalence of higher modified Rankin Scale scores (p for trend = 0.03 and <0.001, respectively). An increasing CHADS
score was associated with an incrementally increased risk for ischemic stroke and greater severity of ischemic stroke in patients with and without AF.
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