666 Complete vs. culprit-only strategy in older MI patients with multi-vessel disease

Aims The revascularization strategy to pursue in older myocardial infarction (MI) patients with multivessel disease (MVD) is currently unknown. For this reason, while waiting for the results of dedicated trials, we sought to compare a complete vs. a culprit-only strategy in older MI patients by merging data from four registries. Methods and results The inclusion criteria for the target population of the present study were: (i) age ≥75 years; (ii) MI (STE or NSTE); (iii) MVD; and (iv) successful treatment of culprit lesion. Propensity scores (PS) were derived using logistic regression (backwards stepwise selection, P < 0.2. The primary outcome was all-cause mortality. Secondary outcomes were cardiovascular (CV) death, MI, major bleeding. Multivariable adjustment included the PS and inverse probability of treatment weighting (IPTW). The Kaplan–Meier plots were weighted for IPT. Among 2087 patients included, 1362 (65%) received culprit-only treatment whereas 725 (35%) complete revascularization. The mean age was 81.5 years, while mean Follow-up was 419 ± 284 days. Seventy-four patients (10%) died in the complete group and 223 in the culprit-only one (16%). The adjusted cumulative 1-year mortality was 9.7% in the complete and 12.9% in the culprit-only group (adjusted HR: 0.67, 95% CI: 0.50–0.89). Complete revascularization was associated with lower incidence of CV death (adjusted HR: 0.68, 95% CI: 0.48–0.95) and MI (adjusted HR: 0.67, 95% CI: 0.48–0.95). Conclusions Culprit-only is the default strategy in older MI patients with MVD. In our analysis, complete revascularization was associated with lower all-cause and CV mortality and with a lower MI rate.

Clinicopathological discordance in biopsy-proven nephrosclerosis: a nationwide cross-sectional study of the Japan Renal Biopsy Registry (J-RBR)

Background Patients with nephrosclerosis display heterogenous clinical phenotypes, often leading to a clinical diagnosis discordant with pathological nephrosclerosis diagnosis. However, little is known about clinical factors associated with clinicopathological discordance of biopsy-proven nephrosclerosis. Methods In a cross-sectional study of 891 patients with biopsy-proven nephrosclerosis registered in the Japan Renal Biopsy Registry (J-RBR) between July 2007 and June 2016, we examined clinical characteristics associated with a pre-biopsy clinical diagnosis discordant with pathological nephrosclerosis diagnosis using multivariable logistic regression with adjustment for relevant clinical characteristics. Results Overall, the mean (SD) age was 58.6 (13.7) years; 67.6% of patients were male; and 63.2% were on antihypertensive drugs. The median estimated glomerular filtration rate (eGFR) was 43.8 mL/min/1.73 m2 and the median proteinuria was 0.5 g/day. Of the 891 patients, 497 (55.8%) had a clinical diagnosis discordant with pathological nephrosclerosis diagnosis, with chronic nephritic syndrome being the most common (> 75%) discordant clinical diagnosis. After multivariable adjustment, age (odds ratio 1.34, [95% confidence interval, 1.16–1.55], per 10 years increase), eGFR (1.10 [1.00–1.21], per 10 mL/min/1.73 m2 increase), and proteinuria (1.20 [1.03–2.16], per 1 g/day decrease) were found to be significantly associated with the clinicopathological discordance. Conclusions Patients with older age, higher eGFR, and lower proteinuria had significantly higher likelihood of being clinically diagnosed with other glomerular disease in patients with biopsy-proven nephrosclerosis. Our findings highlight the heterogeneous clinical phenotypes of nephrosclerosis and suggest the need for continuous improvement of clinical diagnostic accuracy as well as for wider kidney biopsy indications for nephrosclerosis.

Association between immunologic markers and cirrhosis in individuals with chronic hepatitis B

Host immune response and chronic inflammation associated with chronic hepatitis B virus (HBV) infection play a key role in the pathogenesis of liver diseases such as cirrhosis and hepatocellular carcinoma (HCC). We sampled 175 HCC, 117 cirrhotic and 165 non-cirrhotic controls from a prospective cohort study of chronically HBV-infected individuals. Multivariable polytomous logistic regression and canonical discriminant analysis (CDA) were used to compare baseline plasma levels for 102 markers in individuals who developed cirrhosis vs. controls and those who developed HCC vs. cirrhosis. Leave-one-out cross validation was used to generate receiver operating characteristic curves to compare the predictive ability of marker groups. After multivariable adjustment, HGF (Q4v1OR: 3.74; p-trend = 0.0001), SLAMF1 (Q4v1OR: 4.07; p-trend = 0.0001), CSF1 (Q4v1OR: 3.00; p-trend = 0.002), uPA (Q4v1OR: 3.36; p-trend = 0.002), IL-8 (Q4v1OR: 2.83; p-trend = 0.004), and OPG (Q4v1OR: 2.44; p-trend = 0.005) were all found to be associated with cirrhosis development compared to controls; these markers predicted cirrhosis with 69% accuracy. CDA analysis identified a nine marker model capable of predicting cirrhosis development with 79% accuracy. No markers were significantly different between HCC and cirrhotic participants. In this study, we assessed immunologic markers in relation to liver disease in chronically-HBV infected individuals. While validation in required, these findings highlight the importance of immunologic processes in HBV-related cirrhosis.

COVID-19 vaccine hesitancy and acceptance in Mexico: a web-based nationwide survey

Objective. To identify factors associated with COVID-19 vaccine hesitancy and acceptance among the Mexican population. Methods. In a web-based nationwide survey in early December 2020, respondents were inquired about their sociodemographic characteristics and their willingness to accept a hypothetical COVID-19 vaccine given a 50% or 90% effectiveness. A logistic regression model was used to identify the factors associated with hesitancy and acceptance. Results. A total 3 768 responses were analyzed. A 90% effective vaccine was accepted by 85% of respondents, while only 46% would accept being vaccinated with a 50% effective vaccine. In univariate analysis, each age group (40–49, 50–59, and ≥60) was strongly associated with vaccine hesitancy for a 90% effective vaccine (OR 0.48, 95% CI 0.38, 0.63; OR 0.33, 95 CI 0.26, 0.41; and OR 0.28, 95 CI 0.21, 0.38, respectively) compared to the 18–39 age group. After multivariable adjustment, similar magnitudes of association were observed. Being female and higher socioeconomic status were also associated with higher vaccine hesitancy. Conclusions. Vaccine hesitancy represents a major public health problem in Mexico and is driven by multiple factors. Our study provides relevant insights for the development of effective policies and strategies to ensure widespread vaccination in Mexico.

Severity of anaemia and association with all-cause mortality in patients with medically managed left-sided endocarditis

ObjectiveTo assess the prevalence and severity of anaemia in patients with left-sided infective endocarditis (IE) and association with mortality.MethodsIn the Partial Oral versus Intravenous Antibiotic Treatment of Endocarditis trial, 400 patients with IE were randomised to conventional or partial oral antibiotic treatment after stabilisation of infection, showing non-inferiority. Haemoglobin (Hgb) levels were measured at randomisation. Primary outcomes were all-cause mortality after 6 months and 3 years. Patients who underwent valve surgery were excluded due to competing reasons for anaemia.ResultsOut of 400 patients with IE, 248 (mean age 70.6 years (SD 11.1), 62 women (25.0%)) were medically managed; 37 (14.9%) patients had no anaemia, 139 (56.1%) had mild anaemia (Hgb <8.1 mmol/L in men and Hgb <7.5 mmol/L in women and Hgb ≥6.2 mmol/L) and 72 (29.0%) had moderate to severe anaemia (Hgb <6.2 mmol/L). Mortality rates in patients with no anaemia, mild anaemia and moderate to severe anaemia were 2.7%, 3.6% and 15.3% at 6-month follow-up and 13.5%, 20.1% and 34.7% at 3-year follow-up, respectively. Moderate to severe anaemia was associated with higher mortality after 6 months (HR 4.81, 95% CI 1.78 to 13.0, p=0.002) and after 3 years (HR 2.14, 95% CI 1.27 to 3.60, p=0.004) and remained significant after multivariable adjustment.ConclusionModerate to severe anaemia was present in 29% of patients with medically treated IE after stabilisation of infection and was independently associated with higher mortality within the following 3 years. Further investigations are warranted to determine whether intensified treatment of anaemia in patients with IE might improve outcome.

Clinical and prognostic significance of the inflammatory markers GlycA and GlycB in chronic heart failure of both ischemic and non-ischemic etiologies

Background N-acetylglucosamine/galactosamine (GlycA) and sialic acid (GlycB) constitute evolving nuclear magnetic resonance (NMR) biomarkers of systemic inflammation. They have been increasingly studied and associated with cardiovascular (CV) disease and incident heart failure (HF), but little is known about its value in chronic HF population. Purpose We aimed to examine the association on long-term CV outcomes of GlycA and GlycB in chronic HF relative to aetiology. Methods We prospectively included a cohort of 429 HF patients admitted to an ambulatory HF Unit. Plasma GlycA and GlycB concentrations were determined using NMR spectroscopy. The primary endpoint was a composite of CV death and readmission due to HF. Competing risk regression models were performed with non-CV death as the competing event. Because an interaction existed between GlycA and GlycB with ischemic etiology (p&lt;0.01), we examined this further. Results The mean (SD) follow-up was 4.5±2.9 years. Median concentrations (IQR) for GlycA and GlycB were 5.4 (4.9–6.2) mmol/L and 1.9 (1.7–2.2) mmol/L, respectively. A total of 92 (41.1%) and 123 (60.0%) patients from non-ischemic and ischemic etiology, respectively, the clinical endpoint. In ischaemic HF patients (47.8%; n=205) both markers were not associated with the primary endpoint. Conversely, in non-ischemic HF patients (52.2%; n=224), GlycA and GlycB exhibited association with the primary endpoint in univariable and after multivariable adjustment (HR 1.14; 95% confidence interval [CI]: 1.02–1.28, p=0.018 and HR 1.91; 95% CI: 1.27–2.88, p=0.002; respectively. Figure 1 and 2). In this subgroup, a correlation analysis with well-known biomarkers (NT-proBNP, hs-TnT and ST2) only evidenced a positively and significantly correlation of GlycB with ST2 (r=0.26, p&lt;0.001). No association was found with NYHA functional class. Conclusions GlycA and GlycB represent an evolving approach of inflammation status with prognostic value of long-term CV related events in non-ischemic HF patients. FUNDunding Acknowledgement Type of funding sources: None. Figure 1. Probability of MACE by GlycA tertiles Figure 2. Probability of MACE by GlycB tertiles

Association Between Metabolic Syndrome and an Increased Risk of Hospitalization for Heart Failure in Population of HFpEF

Background: The association between metabolic syndrome and the development of heart failure (HF) with preserved ejection fraction (HFpEF) has not been completely clarified.Aim: To evaluate the association between metabolic syndrome and the risk of HF hospitalization for patients with HFpEF.Methods: Patient data were obtained from the American cohort of the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trial database. Data for the primary outcome (hospitalization for HF) and secondary outcomes (all-cause mortality, cardiovascular mortality, and all-cause hospitalization) were collected, and hazard ratios (HRs) for the patients with and without metabolic syndrome were analyzed by applying a multivariable Cox proportional hazard model.Results: Among the 1,548 total participants, 1,197 had metabolic syndrome. The patients with metabolic syndrome exhibited worse heart function and a lower quality of life than those without metabolic syndrome. During the 3.3 years of follow-up, 351 patients were hospitalized for HF. After a multivariable adjustment, the risk of hospitalization for HF and all-cause hospitalization (adjusted HR = 1.42, 95% CI: 1.01–2.00; p = 0.042 and adjusted HR = 1.27; 95% CI: 1.04–1.54; p = 0.017, respectively) were independently associated with HFpEF for the patients with metabolic syndrome. In addition, the risks of HF hospitalization and all-cause hospitalization among 267 propensity score-matched patients were higher for patients with metabolic syndrome (HR = 1.53, 95% CI = 1.05–2.23, and p = 0.025 and HR = 1.34, 95% CI = 1.08–1.67, and p = 0.009, respectively).Conclusion: The risks of HF hospitalization and all-cause hospitalization were higher for patients with HFpEF having metabolic syndrome than for those without metabolic syndrome.

High Hemoglobin Level is a Risk Factor for Maternal and Fetal Outcomes of Pregnancy in Chinese Women: A Retrospective Cohort Study

Background To examine the association of hemoglobin (Hb) levels during gestation with the risk of selected adverse pregnancy outcomes in Chinese women. Methods A total of 1911 singleton mothers were included. Hb levels were measured during the second (16-18th weeks) and third (28-30th weeks) trimesters of pregnancy, and pregnancy outcomes were followed. Statistical analysis was performed using multivariate logistic regression. Results After multivariable adjustment, Hb levels > 130 g/L in the second trimester increased the risk of low-birth-weight infants (LBW) (odds ratio [OR], 2.54; 95% confidence interval [CI], 1.12–5.77). In the third trimester of gestation, compared with women whose Hb levels between 110–119 g/L, women with Hb levels > 130 g/L had an increased risk of LBW (OR, 2.17; 95% CI, 1.05–4.48) and small-for-gestational-age infants (SGA) (OR, 1.98; 95% CI, 1.04–3.78). In addition, maternal Hb levels of < 110 g/L or > 130 g/L at the second week that were restored vs not restored in the third trimester decreased the risk of preterm birth (PTB) by 80% (95% CI, 0.07–0.58) and 86% (95% CI, 0.03–0.84), respectively. Conclusion Maternal Hb > 130 g/L was associated with increased risk of adverse pregnancy outcomes. Reduction of PTB risk was observed with correction of Hb level during the third trimester.

Racial Differences in Blood Pressure Control Following Stroke: The REGARDS Study

Background and Purpose: In the general population, Black adults are less likely than White adults to have controlled blood pressure (BP), and when not controlled, they are at greater risk for stroke compared with White adults. High BP is a major modifiable risk factor for recurrent stroke, but few studies have examined racial differences in BP control among stroke survivors. Methods: We used data from the REGARDS study (Reasons for Geographic and Racial Differences in Stroke) to examine disparities in BP control between Black and White adults, with and without a history of stroke. We studied participants taking antihypertensive medication who did and did not experience an adjudicated stroke (n=306 and 7693 participants, respectively) between baseline (2003–2007) and a second study visit (2013–2016). BP control at the second study visit was defined as systolic BP <130 mm Hg and diastolic BP <80 mm Hg except for low-risk adults ≥65 years of age (ie, those without diabetes, chronic kidney disease, history of cardiovascular disease, and with a 10-year predicted atherosclerotic cardiovascular disease risk <10%) for whom BP control was defined as systolic BP <130 mm Hg. Results: Among participants with a history of stroke, 50.3% of White compared with 39.3% of Black participants had controlled BP. Among participants without a history of stroke, 56.0% of White compared with 50.2% of Black participants had controlled BP. After multivariable adjustment, there was a tendency for Black participants to be less likely than White participants to have controlled BP (prevalence ratio, 0.77 [95% CI, 0.59–1.02] for those with a history of stroke and 0.92 [95% CI, 0.88–0.97] for those without a history of stroke). Conclusions: There was a lower proportion of controlled BP among Black compared with White adults with or without stroke, with no statistically significant differences after multivariable adjustment.

Association Between Preexisting Versus Newly Identified Atrial Fibrillation and Outcomes of Patients With Acute Pulmonary Embolism

Background Atrial fibrillation (AF) may exist before or occur early in the course of pulmonary embolism (PE). We determined the PE outcomes based on the presence and timing of AF. Methods and Results Using the data from a multicenter PE registry, we identified 3 groups: (1) those with preexisting AF, (2) patients with new AF within 2 days from acute PE (incident AF), and (3) patients without AF. We assessed the 90‐day and 1‐year risk of mortality and stroke in patients with AF, compared with those without AF (reference group). Among 16 497 patients with PE, 792 had preexisting AF. These patients had increased odds of 90‐day all‐cause (odds ratio [OR], 2.81; 95% CI, 2.33–3.38) and PE‐related mortality (OR, 2.38; 95% CI, 1.37–4.14) and increased 1‐year hazard for ischemic stroke (hazard ratio, 5.48; 95% CI, 3.10–9.69) compared with those without AF. After multivariable adjustment, preexisting AF was associated with significantly increased odds of all‐cause mortality (OR, 1.91; 95% CI, 1.57–2.32) but not PE‐related mortality (OR, 1.50; 95% CI, 0.85–2.66). Among 16 497 patients with PE, 445 developed new incident AF within 2 days of acute PE. Incident AF was associated with increased odds of 90‐day all‐cause (OR, 2.28; 95% CI, 1.75–2.97) and PE‐related (OR, 3.64; 95% CI, 2.01–6.59) mortality but not stroke. Findings were similar in multivariable analyses. Conclusions In patients with acute symptomatic PE, both preexisting AF and incident AF predict adverse clinical outcomes. The type of adverse outcomes may differ depending on the timing of AF onset.