Bi Huang

Usefulness of the Admission Shock Index for Predicting Short-Term Outcomes in Patients With ST-Segment Elevation Myocardial Infarction

Current risk scores of ST-segment elevation myocardial infarction (STEMI) need sophisticated algorithm and were limited for bedside use. Our study aimed to evaluate the usefulness of admission shock index (SI) for predicting the short-term outcomes in patients with STEMI. Included were 7,187 consecutive patients with STEMI. The admission SI was defined as the ratio of admission heart rate and systolic blood pressure. Patients were divided into 2 groups with SI <0.7 and ≥0.7, respectively, based on the receiver operating characteristic curve analysis. The major end points were 7- and 30-day all-cause mortality. Of 7,187 patients, 5,026 had admission SI <0.7 and 2,161 had admission SI ≥0.7. Those who presented with SI ≥0.7 had greater 7- and 30-day all-cause mortality and major adverse cardiovascular events than patients with SI <0.7. After multivariate adjustment, patients with SI ≥0.7 had a 2.2-fold increased risk of 7-day all-cause mortality (hazard ratio 2.21, 95% confidence interval [CI] 1.71 to 2.86) and 1.9-fold increased risk of 30-day all-cause mortality (hazard ratio 1.94, 95% CI 1.54 to 2.44). Moreover, admission SI ≥0.7 was also associated with 1.6- and 1.5-fold increased risk of 7- and 30-day major adverse cardiovascular events (hazard ratio 1.63, 95% CI 1.36 to 1.95 and hazard ratio 1.47, 95% CI 1.24 to 1.74, respectively). The C statistic of admission SI for predicting 7- and 30-day all-cause mortality was 0.701 and 0.686, respectively, compared with 0.744 and 0.738 from the Thrombolysis In Myocardial Infarction risk score. In conclusion, admission SI, an easily calculated index at first contact, may be a useful predictor for short-term outcomes especially for acute phase outcomes in patients with STEMI.

The relationship between elevated red cell distribution width and long-term outcomes among patients with atrial fibrillation.

OBJECTIVES Red cell distribution width (RDW) is associated with the incidence of atrial fibrillation (AF). The aim of this study was to evaluate the relationship between elevated RDW and long-term clinical outcomes among patients with AF. DESIGN AND METHODS We prospectively observed 300 consecutive patients with AF (50.3% males, mean age 62.6 ± 12.9 years) between February 2009 and October 2011. Baseline RDW levels and clinical data were collected. The primary clinical outcomes of interest included all-cause mortality and the incidence of major adverse events (MAEs). RESULTS During a median follow-up period of 3.2 years, 60 deaths and 92 MAEs were recorded. From the lowest to the highest RDW quartile, an increased risk of mortality (2.76, 3.98, 8.40 and 13.77 per 100 person-years, respectively) and an incidence of MAEs (6.46, 8.18, 13.79 and 20.27 per 100 person-years, respectively) were noted. In a multivariate Cox regression analysis, RDW was independently associated with both all-cause mortality (hazard ratio (HR): 1.024; 95% confidence interval (CI): 1.012-1.036, P < 0.001) and MAEs (HR: 1.012; 95% CI: 1.002-1.023, P = 0.023). A receiver operating characteristic (ROC) analysis revealed that RDW predicted both mortality and MAEs with areas under the ROC curves (AUCs) of 0.682 (P < 0.001) and 0.617 (P = 0.001); the best cutoff points were 13.85% and 13.55%, respectively. CONCLUSIONS Elevated RDW is an independent predictor of long-term adverse clinical outcomes, including all-cause mortality and MAEs, among patients with AF.

An in-vitro evaluation of direct thrombin inhibitor and factor Xa inhibitor on tissue factor-induced thrombin generation and platelet aggregation: a comparison of dabigatran and rivaroxaban.

Dabigatran and rivaroxaban may simultaneously inhibit coagulation and platelet activation. This study aimed to reveal the in-vitro effects of dabigatran and rivaroxaban on thrombin generation and platelet aggregation (PAg) derived via tissue factor (TF) pathway. Citrated blood was obtained from six healthy adults (26–60 years old) and pretreated with increasing concentrations of dabigatran or rivaroxaban. Plasmatic endogenous thrombin potential (ETP) was measured by the calibrated automated thrombogram method. The whole blood PAg was evaluated via a kinetic counting method. TF produced an ETP of 1904.69 ± 121.42 nmol min and a PAg of 78 ± 5%. Dabigatran and rivaroxaban concentration-dependently reduced ETP with half-maximal inhibitory concentrations of 460.1 ± 1.4 and 678.1 ± 1.4 nmol/l, and inhibited PAg with half-maximal inhibitory concentrations of 119.5 ± 1.5 and 77.5 ± 1.6 nmol, respectively. Dabigatran and rivaroxaban significantly inhibit TF-induced hypercoagulation and platelet activation in vitro in a concentration-dependent manner. Rivaroxaban displays stronger inhibition on thrombin generation and PAg than dabigatran.

Clinical Characteristics and Impact of Diabetes Mellitus on Outcomes in Patients with Nonvalvular Atrial Fibrillation

Purpose Studies have shown that diabetes mellitus (DM) is a risk factor for cardiovascular disease, including atrial fibrillation (AF); however, the clinical characteristics and prognostic impact of DM in patients with nonvalvular AF have not been well understood in China. Materials and Methods Included were 1644 consecutive patients with nonvalvular AF. Endpoints included all-cause mortality, cardiovascular mortality, stroke, major bleeding, and combined endpoint events (CEE) during a 1-year follow-up. Results The prevalence of DM was 16.8% in nonvalvular AF patients. Compared with non-diabetic AF patients, diabetic AF patients were older and tended to coexist with other cardiovascular diseases. Most patients with DM (93.5%) were eligible for anticoagulation, as determined by CHADS2 scores. However, only 11.2% of patients received anticoagulation. During a 1-year follow-up, the all-cause mortality and CEE rate in the DM group were significantly higher than those of the non-DM group, while the incidence of stroke was comparable. After multivariate adjustments, DM was still an independent risk factor for 1-year all-cause mortality [hazard ratio (HR)=1.558; 95% confidence interval (CI) 1.126-2.156; p=0.007], cardiovascular mortality (HR=1.615; 95% CI 1.052-2.479; p=0.028), and CEE (HR=1.523; 95% CI 1.098-2.112; p=0.012), yet not for stroke (HR=1.119; 95% CI 0.724-1.728; p=0.614). Conclusion DM is a common morbidity coexisting with nonvalvular AF and is associated with an increased risk of 1-year all-cause mortality, cardiovascular mortality, and CEE. However, no increased risk of stroke was found during a 1-year follow-up in patients with AF and DM.

Radiofrequency Catheter Ablation of Atrial Fibrillation in Patients With Chronic Obstructive Pulmonary Disease: Opportunity and Challenge: Response to Dr Kumar's Comment

Results from a multicenter atrial fibrillation registry study. J Am Med Dir Assoc 2014;15:576e581. 2. Kumar N, Pison L, La Meir M, et al. Hybrid approach to atrial fibrillation ablation using bipolar radiofrequency devices epicardially and cryoballoon endocardially. Interact Cardiovasc Thorac Surg; June 30, 2014. pii: ivu189. [Epub ahead of print]. 3. Abe K, Oka J, Takahashi H, et al. Effect of high-frequency jet ventilation on oxygenation during one-lung ventilation in patients undergoing thoracic aneurysm surgery. J Anesth 2006;20:1e5. 4. Vestbo J, Hurd SS, Agusti AG, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med 2013;187:347e365. 5. Kuhne M, Knecht S, Altmann D, et al. Phrenic nerve palsy during ablation of atrial fibrillation using a 28-mm cryoballoon catheter: Predictors and prevention. J Interv Card Electrophysiol 2013;36:47e54. 6. Magnani JW, Hylek EM, Apovian CM. Obesity begets atrial fibrillation: A contemporary summary. Circulation 2013;128:401e405

The effect of admission serum potassium levels on in-hospital and long-term mortality in type A acute aortic dissection

BACKGROUND Mild fluctuations in serum potassium (K+) levels are related to the prognosis of cardiovascular disease. This study aimed to determine the effect of admission serum potassium levels on in-hospital and long-term mortality in patients with Stanford type A acute aortic dissection (AAD). MATERIALS AND METHODS A total of 588 consecutive patients with type A AAD were enrolled, and they were grouped according to admission serum potassium level: <3.5, 3.5 to <4.0, 4.0 to <4.5, 4.5 to <5.0, and ≥5.0mmol/L. Clinical outcomes were in-hospital death and long-term all-cause mortality. RESULTS The in-hospital and long-term all-cause mortality rates were 10.7% and 16.3%, respectively. A U-shaped relationship was observed between admission serum potassium levels and both in-hospital death and long-term mortality. Univariate Cox regression identified potassium levels outside the interval of <3.5 to 4.5mmol/L to be a risk factor for both in-hospital and long-term death. After adjusting for age, gender, surgery and other risk factors, potassium levels outside the interval of <3.5 to 4.5mmol/L still had a significant association with long-term death [hazard ratio (HR)=1.72, 95% confidence interval (95% CI): 1.07-2.74, P=0.024]. Surgical intervention was the main protective factor associated with both in-hospital (HR=0.01, 95% CI 0.01-0.06, P<0.001) and long-term survival (HR=0.06, 95% CI 0.03-0.12, P<0.001). CONCLUSIONS Among patients with Stanford type A AAD, admission serum potassium levels other than 3.5 to 4.5mmol/L might be associated with an increased risk of in-hospital death and long-term mortality.

Association of Admission Glycaemia With High Grade Atrioventricular Block in ST-Segment Elevation Myocardial Infarction Undergoing Reperfusion Therapy: An Observational Study.

AbstractSeveral studies have demonstrated the association between elevated admission glycaemia (AG) and the occurrence of some arrhythmias such as atrial fibrillation, ventricular tachycardia, and ventricular fibrillation after myocardial infarction. However, the impact of elevated AG on the high grade atrioventricular block (AVB) occurrence after ST-segment elevation myocardial infarction (STEMI) remains unclear.Included were 3359 consecutive patients with STEMI who received reperfusion therapy. The primary endpoint was the development of high grade AVB during hospital course. Patients were divided into non-diabetes mellitus (DM), newly diagnosed DM, and previously known DM according to the hemoglobin A1c level. The optimal AG value was determined by receiver operating characteristic curves analysis with AG predicting the high grade AVB occurrence.The best cut-off value of AG for predicting the high grade AVB occurrence was 10.05 mmol/L by ROC curve analysis. The prevalence of AG ≥ 10.05 mmol/L in non-DM, newly diagnosed DM, and previously known DM was 15.7%, 34.1%, and 68.5%, respectively. The incidence of high grade AVB was significantly higher in patients with AG ≥ 10.05 mmol/L than <10.05 mmol/L in non-DM (5.7% vs. 2.1%, P < 0.001) and in newly diagnosed DM (10.2% vs.1.4%, P < 0.001), but was comparable in previously known DM (3.6% vs. 0.0%, P = 0.062). After multivariate adjustment, AG ≥ 10.05 mmol/L was independently associated with increased risk of high grade AVB occurrence in non-DM (HR = 1.826, 95% CI 1.073–3.107, P = 0.027) and in newly diagnosed DM (HR = 5.252, 95% CI 1.890–14.597, P = 0.001). Moreover, both AG ≥ 10.05 mmol/L and high grade AVB were independent risk factors of 30-day all cause-mortality (HR = 1.362, 95% CI 1.006–1.844, P = 0.046 and HR = 2.122, 95% CI 1.154–3.903, P = 0.015, respectively).Our study suggested that elevated AG level (≥10.05 mmol/L) might be an indicator of increased risk of high grade AVB occurrence in patients with STEMI.

Clinical characteristics and short-term outcomes in patients with elevated admission systolic blood pressure after acute ST-elevation myocardial infarction: a population-based study.

Objective Prognostic value of lower admission systolic blood pressure (SBP) in patients with acute myocardial infarction has been confirmed, but the impact of elevated admission SBP on short-term outcomes has been evaluated only by a limited number of studies and they have reported conflicting results. The aim of our study was to investigate the characteristics and short-term outcomes in patients with elevated admission SBP after ST-elevation myocardial infarction (STEMI). Design A population-based, observational study. Setting The multicentre registry in China. Participants A total of 7510 consecutive patients with STEMI were registered. Patients were divided into three groups according to admission SBP: normal admission SBP (100–139 mm Hg), modestly elevated admission SBP (140–179 mm Hg) and excessively elevated admission SBP (≥180 mm Hg). The primary outcomes were 7-day and 30-day all-cause mortality, major adverse cardiac events (MACE) and bleeding rate. Results Of 6591 patients, 4182 (63.5%) had normal admission SBP, 2187 (33.2%) modestly elevated admission SBP and 222 (3.4%) excessively elevated admission SBP. Patients with elevated admission SBP had a high-risk profile, such as were more likely to be older, with more concomitant cardiovascular morbidities, presenting with more events of anterior myocardial infarction and less reperfusion treatment. However, 7-day and 30-day all-cause mortality, MACE and bleeding rate were comparable among groups (all p>0.05). Survival curves and MACE curves were similar among groups (p=0.377 and 0.375, respectively). After multivariate adjustment, elevated admission SBP was not associated with increased risk of short-term death and bleeding, and MACE was comparable with normal admission SBP. Conclusions Although those with elevated admission SBP after STEMI were at a higher risk for cardiovascular events, they did not have poorer short-term outcomes compared with patients with normal admission SBP.

Onset seasons and clinical outcomes in patients with Stanford type A acute aortic dissection: an observational retrospective study

Objectives To evaluate the association of onset season with clinical outcome in type A acute aortic dissection (AAD). Design A single-centre, observational retrospective study. Setting The study was conducted in Fuwai Hospital, the National Centre for Cardiovascular Disease, Beijing, China. Participants From 2008 to 2010, a set of consecutive patients with type A AAD, confirmed by CT scanning, were enrolled and divided into four groups according to onset season: winter (December, January and February), spring (March, April and May), summer (June, July and August) and autumn (September, October and November). The primary end points were in-hospital death and all-cause mortality during follow-up. Results Of the 492 cases in this study, 129 occurred in winter (26.2%), 147 in spring (29.9%), 92 in summer (18.7%), and 124 in autumn (25.2%). After a median follow-up of 20.4 months (IQR 9.7–38.9), the in-hospital mortality in cases occurring in autumn was higher than in the other three seasons (23.4% vs 8.4%, p<0.01). Long-term mortality was comparable among the four seasonal groups (p=0.63). After adjustment for age, gender and other risk factors, onset in autumn was still an independent factor associated with increased risk of in-hospital mortality (HR 2.05; 95% CI 1.15 to 3.64, p=0.02) in addition to surgical treatment. Further analysis showed that the seasonal effect on in-hospital mortality (autumn vs other seasons: 57.4% vs 27.3%, p<0.01) was only significant in patients who did not receive surgical treatment. No seasonal effect on long-term clinical outcomes was found in this cohort. Conclusions Onset in autumn may be a factor that increases the risk of in-hospital death from type A AAD, especially in patients who receive conservative treatment. Immediate surgery improves the short-term and long-term outcomes regardless of onset season.

Impact of Admission White Blood Cell Count on Short- and Long-term Mortality in Patients With Type A Acute Aortic Dissection: An Observational Study.

Abstract Studies have shown inflammation is involved in the development of acute aortic dissection (AAD). The hypothesis that white blood cell count (WBCc) on admission may have an impact on the short- and long-term outcomes of type A AAD was tested in a large-scale, prospective observational cohort study. From 2008 to 2010, a total of 570 consecutive patients with type A AAD in Fuwai hospital were enrolled and were followed up. Baseline characteristics and WBCc on admission were collected. The primary outcomes were 30-day and long-term all-cause mortality. During a median of 1.89 years of follow-up, the 30-day and long-term all-cause mortality were 10.7% and 6.5%, respectively. Univariate Cox regression analysis identified admission WBCc as an independent predictor of 30-day mortality when considered as a continuous variable or as a categorical variable using the cutoff of 11.0  × 109 cells/L (all P < 0.05). After adjustment for age, sex, C-reactive protein, D-dimer, and surgical intervention, elevated admission WBCc (>11.0 × 109 cells/L) remained an independent predictor of 30-day mortality of AAD (hazard ratio = 3.31, 95% confidence interval 1.38–7.93, P = 0.007). No impact of admission WBCc was observed on the long-term all-cause mortality. In conclusion, elevated admission WBCc may be valuable as a predictor of 30-day mortality, and may be useful in the risk stratification of type A AAD during hospitalization.