Prognostic Value of Ankle-Brachial Index in Prediction of Cardiovascular Events in an Asian Population with Multiple Atherosclerotic Risk Factors.

We aimed to evaluate the incremental prognostic value after incorporation of the ankle-brachial index (ABI) into the 10-year pool cohort equation (PCE) risk model in patients with multiple risk factors (MRFs). A total of 4332 MRFs patients were divided into 2 groups as ABI ≤.9 or >.9. The primary outcome was hard cardiovascular events (hCVE: including cardiovascular death, myocardial infarction, or ischemic stroke) over a median follow-up of 36 months. The Cox proportional hazards survival model, C-statistic, and net reclassification indices (NRI) were used. The occurrence of the primary outcome in the ABI ≤.9 group (3.7%) was significantly greater than in the ABI > .9 group (1.3%), P < .001. ABI is an independent predictor of hCVE in addition to the variables in the standard risk model (age, gender, and smoking status). ABI modestly improved the C-index when added to the PCE risk model (PCE .70 vs ABI+PCE .74). The addition of ABI to the PCE risk model did not significantly improve the classification of patients (NRI -.029; 95% CI: -.215 to .130). Despite ABI being one of the independent predictors of hCVE, integration of ABI into the PCE model did not improve the efficacy of risk reclassification in patients with MRFs.

Procedural success and outcomes after percutaneous balloon mitral valvuloplasty in rheumatic mitral stenosis with moderate mitral regurgitation: a retrospective cohort study.

Background: Percutaneous balloon mitral valvuloplasty (PBMV) is contraindicated in mitral stenosis (MS) with moderate mitral regurgitation (MR) according to the European guidelines. However, small-sized studies have demonstrated the feasibility and safety of PBMV in these patients. We aimed to study the procedural success and mid-term outcomes of PBMV in MS patients with moderate MR. Methods: The present study was a retrospective cohort study in consecutive patients with severe rheumatic MS who underwent PBMV with the Inoue technique in Songklanagarind hospital. The severity of mitral regurgitation was assessed with qualitative Doppler. The patients were grouped according to their MR severity before PBMV into moderate MR or less-than-moderate MR. Procedural success and a composite of all-cause death, mitral valve surgery or re-PBMV were compared between the two groups. Results: Of 618 patients with rheumatic MS who underwent PBMV in Songklanagarind hospital between January 2003 and October 2020, 598 patients (96.8%) had complete information of pre-PBMV MR severity and procedural success. Forty-nine patients (8.2%) had moderate MR before PBMV. Moderate MR before PBMV was not associated with a lower chance of PBMV success (moderate MR vs. less-than-moderate MR before PBMV; adjusted OR 0.65, 95% CI: 0.32-1.29, P=0.22). Survival probability of all-cause death, MV surgery or re-PBMV in the group with moderate MR before PBMV was not different from the group with less-than-moderate MR (adjusted HR 1.30, 95% CI: 0.98-1.62, P=0.10). Conclusions: PBMV is an effective and safe treatment in rheumatic MS with moderate MR.

Predicting mortality in cardiac care unit patients: external validation of the Mayo cardiac intensive care unit admission risk score.

AIMS: The Mayo Cardiac Intensive Care Unit Admission Risk Score (M-CARS) had excellent performance in predicting in-hospital mortality in the US population. We sought to validate the M-CARS for in-hospital and post-discharge mortality in Asian patients admitted to the cardiac care unit (CCU). METHODS AND RESULTS: Patients admitted to the CCU of a tertiary care centre between July 2015 and December 2019 were included into the study. Patients with intra-hospital transfer to the CCU due to intensive care unit overflow, postoperative cardiac surgery, or for monitoring after elective procedures were excluded. Cardiac arrest, cardiogenic shock, respiratory failure, Braden skin score, blood urea nitrogen, anion gap, and red cell distribution width, were used to calculate the M-CARS. Patients were stratified into three groups, according to the M-CARS (<2, 2-6, >6). Of 1988 patients in the study, 30.1% were female with a median age of 65 years. Prevalence of cardiogenic shock and respiratory failure at admission were 2.8% and 4.5%, respectively. One hundred and seventeen patients died during the admission (mortality rate of 5.9%). The in-hospital mortality rate in patients with M-CARS of <2, 2-6, and >6 was 1.1%, 9.8%, and 35.5%, respectively. C-statistic of M-CARS for in-hospital mortality was 0.840 (95% CI 0.805-0.873); whereas, it was 0.727 (95% CI 0.690-0.761) for 1-year post-discharge mortality. Calibration plot showed good agreement between predicted and observed in-hospital mortality in the majority of patients. CONCLUSIONS: The M-CARS was useful in our study, in terms of discrimination and calibration. M-CARS identified high-risk patients in CCU, who had unacceptably high mortality rate during hospital stay and thereafter.

Validation of modified World Health Organization classification for pregnant women with heart disease in a tertiary care center in southern Thailand.

PURPOSE: To validate the modified World Health Organization (WHO) classification in pregnant women with congenital and acquired heart diseases. PATIENTS AND METHODS: The database of pregnant women with heart disease, who delivered at Songklanagarind Hospital between January 1995 and December 2016, was retrieved from the Statistical Unit, Department of Obstetrics and Gynecology, along with the Hospital Information System of Songklanagarind Hospital, Faculty of Medicine, Prince of Songkla University. Each patient was retrospectively classified according to the modified WHO classification of maternal cardiovascular risk. Comparison of maternal and fetal outcomes among the modified WHO classes were analyzed using the chi-square test or Fisher's exact test and one-way ANOVA test. A p-value of <0.05 was considered statistically significant. RESULTS: A total of 331 cases were studied: 157 cases with congenital heart disease and 174 cases with acquired heart disease. There were 48, 173, 32 and 78 cases in the modified WHO class I, II, III and IV, respectively. Congestive heart failure was the most common complication. The overall maternal mortality rate was 3.6%, all of which were in the modified WHO class IV. Maternal cardiovascular events occurred in 24.2% of cases, increasing rates with higher modified WHO class: 4.2%, 15.0%, 25.0% and 56.4% in class I, II, III and IV, respectively (p<0.001). Adverse fetal outcomes including preterm delivery, low birth weight, small for gestational age and neonatal intensive care unit admission were also significantly increased in class III and IV (p<0.05). CONCLUSION: The modified WHO classification is useful not only for obtaining a cardiovascular risk assessment in pregnant women with heart disease but also for predicting adverse fetal outcomes. It must, therefore, be implemented into routine care service at all levels of health care systems.

An equation to explain variations in blood NT-proBNP in ambulatory cardiac subjects.

BACKGROUND: NT-proBNP is being used as a biomarker for prognosticating and delineating cardiac dysfunction. The cut-off value for deciding normal versus abnormal levels has always been a point of contention since it depends on the degree of dysfunction as well as other associated conditions often termed non-cardiac factors and parameters. Such association had not been formally presented. OBJECTIVE: To determine the direction and magnitude of effect of cardiac and non-cardiac parameters on NT-proBNP variability. MATERIAL AND METHOD: The present study included 78 cardiac ambulatory patients with a history of heart failure and/or low left ventricular ejection fraction. Their cardiac and non-cardiac parameters were recorded at the time of blood sampling for NT-proBNP. Multivariate linear regression analysis was used to correlate cardiac and non-cardiac parameters with NT-proBNP level and, from this, a predictive equation was derived. RESULTS: Log [NT-proBNP (pmol/l)] was 1.424 + 0.348 (for EF of 18-27) + 0.636 (for EF < 18) + 0.021 CTR - 0.002 SMW- 0.326 for female + 0.430 Cr - 0.010 BW [EF = LV ejectionfraction in %; CTR = cardio-thoracic ratio in %; SMW = 6-minute walking distance in meters; Cr = serum creatinine in mg/dl; BW = body weight in kg]. The adjusted R-square for this regression was 0.659. Omitting the non-cardiac variables (sex, Cr, BW) would decrease the adjusted R-square to 0.493. CONCLUSION: Cut-off value for NT-proBNP concentration in subjects without severe systolic heart failure has to account for these non-cardiac factors.