Cultural and regulatory factors influence distribution and trajectory of invasive species in the United States: A wild pig case study.

Since 2012, control of invasive wild pigs (Sus scrofa) in the United States (US) has become a state and national priority due to their propensity to damage agricultural commodities and infrastructure, transmit disease, detrimentally affect ecological processes, and compete with native wildlife for resources. While several life-history characteristics certainly aided their proliferation, the recreational value of wild pigs was likely the stimulus for translocation and subsequent establishment of populations in ≥35 states, causing an annual economic burden of $1.5 billion in the US. Consequently, state-level legislative procedures regarding wild pigs are expanding in scope and priority, but policy among states lacks uniformity. States vary in their treatment of wild pig control based on differing resource appropriations and stakeholder interests. We conducted an evaluation to determine if policy was associated with state-level 1) presence of wild pigs, 2) spatial extent of wild pig population occupancy, and 3) trajectory of wild pig population occupancy. Our results suggest the presence of wild pigs in various states was influenced by hunting preserves and the sale of hunting opportunities. In occupied states, the spatial extent of wild pigs was again associated with the sale of hunting opportunities and a wild pig hunting culture. Finally, the trajectory of state-level wild pig spatial occupancy was positively influenced by the sale of hunting opportunities, and negatively influenced by transportation policies. Based on these findings, we propose state governments standardize transportation policy and fenced hunting regulations across regions of the US in a more prohibitive fashion to diminish range expansion through illegal and negligent introductions via transportation, release, and escapes from game farms. Moreover, in states where wild pigs have yet to establish, we strongly recommend states proactively prohibit transportation through intra- and interstate movement.

Validating patient prioritization in the 2018 Revised United Network for Organ Sharing Heart Allocation System: A single-center experience.

The 2018 Revised United Network for Organ Sharing Heart Allocation System (HAS) was proposed to reclassify status 1A candidates into groups of decreasing acuity; however, it does not take into account factors such as body mass index (BMI) and blood group which influence waitlist (WL) outcomes. We sought to validate patient prioritization in the new HAS at our center. We retrospectively evaluated patients listed for heart transplantation (n = 214) at Emory University Hospital from 2011 to 2017. Patients were reclassified into the 6-tier HAS. Multistate modeling and competing risk analysis were used to compare outcomes of transplantation and WL death/deterioration between new tiers. Additionally, a stratified sensitivity analysis by BMI and blood group was performed. Compared with tier 4 patients, there was progressively increasing hazard of WL death/deterioration in tier 3 (HR: 2.52, 95% CI: 1.37-4.63, P = .003) and tier 2 (HR: 5.03, 95% CI: 1.99-12.70, P < .001), without a difference in transplantation outcome. When stratified by BMI and blood group, this hierarchical association was not valid in patients with BMI ≥30 kg/m2 and non-O blood groups in our cohort. Therefore, the 2018 HAS accurately prioritizes the sickest patients in our cohort. Factors such as BMI and blood group influence this relationship and iterate that the system can be further refined.

Effect of Inorganic Nitrite vs Placebo on Exercise Capacity Among Patients With Heart Failure With Preserved Ejection Fraction: The INDIE-HFpEF Randomized Clinical Trial.

Importance: There are few effective treatments for heart failure with preserved ejection fraction (HFpEF). Short-term administration of inorganic nitrite or nitrate preparations has been shown to enhance nitric oxide signaling, which may improve aerobic capacity in HFpEF. Objective: To determine the effect of 4 weeks' administration of inhaled, nebulized inorganic nitrite on exercise capacity in HFpEF. Design, Setting, and Participants: Multicenter, double-blind, placebo-controlled, 2-treatment, crossover trial of 105 patients with HFpEF. Participants were enrolled from July 22, 2016, to September 12, 2017, at 17 US sites, with final date of follow-up of January 2, 2018. Interventions: Inorganic nitrite or placebo administered via micronebulizer device. During each 6-week phase of the crossover study, participants received no study drug for 2 weeks (baseline/washout) followed by study drug (nitrite or placebo) at 46 mg 3 times a day for 1 week followed by 80 mg 3 times a day for 3 weeks. Main Outcomes and Measures: The primary end point was peak oxygen consumption (mL/kg/min). Secondary end points included daily activity levels assessed by accelerometry, health status as assessed by the Kansas City Cardiomyopathy Questionnaire (score range, 0-100, with higher scores reflecting better quality of life), functional class, cardiac filling pressures assessed by echocardiography, N-terminal fragment of the prohormone brain natriuretic peptide levels, other exercise indices, adverse events, and tolerability. Outcomes were assessed after treatment for 4 weeks. Results: Among 105 patients who were randomized (median age, 68 years; 56% women), 98 (93%) completed the trial. During the nitrite phase, there was no significant difference in mean peak oxygen consumption as compared with the placebo phase (13.5 vs 13.7 mL/kg/min; difference, -0.20 [95% CI, -0.56 to 0.16]; P = .27). There were no significant between-treatment phase differences in daily activity levels (5497 vs 5503 accelerometry units; difference, -15 [95% CI, -264 to 234]; P = .91), Kansas City Cardiomyopathy Questionnaire Clinical Summary Score (62.6 vs 61.9; difference, 1.1 [95% CI, -1.4 to 3.5]; P = .39), functional class (2.5 vs 2.5; difference, 0.1 [95% CI, -0.1 to 0.2]; P = .43), echocardiographic E/e' ratio (16.4 vs 16.6; difference, 0.1 [95% CI, -1.2 to 1.3]; P = .93), or N-terminal fragment of the prohormone brain natriuretic peptide levels (520 vs 533 pg/mL; difference, 11 [95% CI, -53 to 75]; P = .74). Worsening heart failure occurred in 3 participants (2.9%) during the nitrite phase and 8 (7.6%) during the placebo phase. Conclusions and Relevance: Among patients with HFpEF, administration of inhaled inorganic nitrite for 4 weeks, compared with placebo, did not result in significant improvement in exercise capacity. Trial Registration: ClinicalTrials.gov Identifier: NCT02742129.

Impact of Insurance Precertification on Discharge of Stroke Patients to Acute Rehabilitation or Skilled Nursing Facility.

BACKGROUND AND PURPOSE: The purpose of this study is to determine if the common insurance practice of requiring precertification before a medically ready stroke patient can be discharged to a skilled nursing facility (SNF) or inpatient rehabilitation facility (IRF) causes a delay in discharge. Eliminating delays in discharge of stroke patients is important given the increasing demands for health-care efficiency after the passage of the Affordable Health Care Act. METHODS: A retrospective chart review of 1007 patients who were admitted to our comprehensive stroke center with the primary diagnosis of stroke over a 12-month period was performed. Out of the patient pool, 289 patients met the inclusion criterion of a primary diagnosis of stroke that required discharge to a SNF or IRF. All 289 patients were medically cleared for discharge to a SNF or IRF by a board-certified vascular neurologist. RESULTS: Of the 289 patients who met the inclusion criteria, 118 required insurance precertification and 171 did not require precertification before being discharged to a SNF or IRF. All 118 patients who required precertification had private health insurance. The patients who required insurance precertification had an average delay of discharge (DOD) of 1.5 days, and those patients who did not require precertification had an average DOD of .8 days (P value <.0001). After removing the outliers, the difference in the length of stay (LOS) between the 2 groups became statistically significant (P value < .04). CONCLUSION: The results of this study demonstrate that insurance precertification leads to delay in discharge, increased LOS, and increased hospital costs for stroke patients.

Rapid-Deployment Versus Conventional Bio-Prosthetic Aortic Valve Replacement.

BACKGROUND: The use of rapid-deployment aortic valve replacement (RD-AVR) has burgeoned in recent years. There are few studies comparing RD-AVR to conventional aortic valve replacement (cAVR) and no studies where both were inserted via full sternotomy. As such, we reviewed our experience and compared the two approaches. METHODS: From 2008 to 2015, 597 patients underwent isolated aortic valve replacement ± coronary artery bypass grafting (CABG) at a single centre. During this period, 41 (7%) patients received RD-AVR and 556 (93%) received cAVR. Of those receiving RD-AVR, surgical access was via full median sternotomy in 40 (98%). Propensity score matching yielded 41 matched pairs. Perioperative outcomes were compared. RESULTS: After propensity score matching, the RD-AVR group had shorter aortic cross clamp (X-clamp) (RD-AVR: 71±33min vs. cAVR: 106±42min, p<0.01) and cardiopulmonary bypass (CPB) times (95±42min vs. 134±47min, p<0.01). There was no difference in 30-day mortality (RD-AVR: 2% vs. cAVR: 2%, p>0.99). RD-AVR patients required shorter mean ventilation (17±25 vs. 63±131hrs, p<0.01) and intensive care unit (ICU) stay (51±45 vs. 108±157hrs, p=0.03) times. RD-AVR also had reduced rates of new postoperative atrial arrhythmias (8% vs. 20%, p=0.02). Total length of postoperative hospital stay was similar. Haemodynamic performance for the RD-AVR was within acceptable limits. CONCLUSIONS: The use of RD-AVR results in shorter X-clamp and CPB times and is associated with reductions in perioperative morbidity. RD-AVR is becoming a valuable component of the surgeon's armamentarium in selected patients. Long-term follow-up will reveal the full potential of these devices.

Chronic high-dose dimenhydrinate use contributing to early multifactorial cognitive impairment.

Dimenhydrinate is an over-the-counter antihistaminergic medication with anticholinergic properties used to treat nausea or motion sickness worldwide. There is a well-established correlation between the use of anticholinergic medications and dementia, however, it is unclear if a causal role exists. We report a case of minor neurocognitive disorder in a woman in her 40s with several years of high-dose daily dimenhydrinate abuse who subsequently developed significant delusional beliefs. Her clinical presentation was confounded by numerous other factors that could have impacted her cognition, such as a longstanding presumed learning disability, ankylosing spondylitis with adalimumab treatment, extensive cannabis use or potential development of a primary psychotic disorder. Her workup was within normal limits, and she has not responded to first-line antipsychotic medications to date. This case report adds to the growing evidence supporting concerns about potentially irreversible cognitive deficits in chronic misuse of anticholinergic agents, an association previously observed only in the elderly population.

How to optimize the systematic review process using AI tools.

Systematic reviews are a cornerstone for synthesizing the available evidence on a given topic. They simultaneously allow for gaps in the literature to be identified and provide direction for future research. However, due to the ever-increasing volume and complexity of the available literature, traditional methods for conducting systematic reviews are less efficient and more time-consuming. Numerous artificial intelligence (AI) tools are being released with the potential to optimize efficiency in academic writing and assist with various stages of the systematic review process including developing and refining search strategies, screening titles and abstracts for inclusion or exclusion criteria, extracting essential data from studies and summarizing findings. Therefore, in this article we provide an overview of the currently available tools and how they can be incorporated into the systematic review process to improve efficiency and quality of research synthesis. We emphasize that authors must report all AI tools that have been used at each stage to ensure replicability as part of reporting in methods.

Cigarette smoking exposure and heart failure risk in older adults: the Health, Aging, and Body Composition Study.

BACKGROUND: Although there is evidence linking smoking and heart failure (HF), the association between lifetime smoking exposure and HF in older adults and the strength of this association among current and past smokers is not well known. METHODS: We examined the association between smoking status, pack-years of exposure, and incident HF risk in 2,125 participants of the Health, Aging, and Body Composition Study (age 73.6 ± 2.9 years, 69.7% women, 54.2% whites) using proportional hazard models. RESULTS: At inception, 54.8% of participants were nonsmokers, 34.8% were past smokers, and 10.4% were current smokers. During follow-up (median 9.4 years), HF incidence was 11.4 per 1,000 person-years in nonsmokers, 15.2 in past smokers (hazard ratio [HR] vs nonsmokers 1.33, 95% CI 1.01-1.76, P = .045), and 21.9 in current smokers (HR 1.93, 95% CI 1.30-2.84, P = .001). After adjusting for HF risk factors, incident coronary events, and competing risk for death, a dose-effect association between pack-years of exposure and HF risk was observed (HR 1.09, 95% CI 1.05-1.14, P < .001 per 10 pack-years). Heart failure risk was not modulated by pack-years of exposure in current smokers. In past smokers, HR for HF was 1.05 (95% CI 0.64-1.72) for 1 to 11 pack-years, 1.23 (95% CI 0.82-1.83) for 12 to 35 pack-years, and 1.64 (95% CI 1.11-2.42) for >35 pack-years of exposure in fully adjusted models (P < .001 for trend) compared with nonsmokers. CONCLUSIONS: In older adults, both current and past cigarette smoking increase HF risk. In current smokers, this risk is high irrespective of pack-years of exposure, whereas in past smokers, there was a dose-effect association.

A combined aerobic and resistance exercise program improves physical functional performance in patients with heart failure: a pilot study.

BACKGROUND: Recent guidelines for exercise in patients with heart failure (HF) recommended aerobic and resistance exercise as being safe and effective; however, the clinical and functional significance of these combined training modalities has not been established. In this pilot study, combined aerobic and resistance training was hypothesized to improve physical function, muscle strength, and health-related quality of life (HRQOL) compared with an attention control wait list (ACWL). METHODS: The 10-item Continuous Scale Physical Functional Performance Test (CS-PFP10), which simulates common household chores; muscle strength (handgrip and knee extension); and HRQOL (Kansas City Cardiomyopathy Questionnaire) were evaluated at baseline (T1) and at 12 weeks (T2). The home-based moderate-intensity walking and resistance training program was performed 5 days a week. RESULTS: Twenty-four New York Heart Association class II to III HF patients (mean [SD] age, 60 [10] years; mean [SD] left ventricular ejection fraction, 25% [9%]) were randomized to a combined aerobic and resistance exercise program or to an ACWL group. Of the total group, 58% were New York Heart Association class III HF patients, 50% were white, and 50% were female. The CS-PFP10 total scores were significantly increased in the exercise group, from 45 (18) to 56 (16). The Kansas City Cardiomyopathy Questionnaire overall summary score was significantly improved (P < .001) at T2 in the exercise intervention group compared with the ACWL group. CONCLUSIONS: Participants provided the home-based, combined aerobic and resistance exercise program had significantly improved physical function, muscle strength, symptom severity, and HRQOL compared with the ACWL group. The findings of this study must be interpreted cautiously owing to the limitations of a small sample, data collection from a single center, and differences between control and interventions groups at baseline. A combined aerobic and resistance exercise approach may improve physical function in stable HF patients, but further study in a larger, more diverse population is recommended. However, in this study, the CS-PFP10 instrument demonstrated its ability to identify functional health status in HF patients and thus warrants further testing in a larger sample for possible use in clinical practice.

Knowledge and Use of Novel Psychoactive Substances in an Italian Sample with Substance Use Disorders.

This study aims to determine prevalence and frequency of use of novel psychoactive substances (NPS) and to identify the factors associated with NPS use in an Italian sample of patients diagnosed with substance use disorder (SUD). Prevalence and correlates of NPS knowledge and use were assessed in 185 patients with SUD in three addiction services (Padova, Belluno, Feltre) in the Veneto region with an ad-hoc designed survey. Two thirds of the samples reported knowing NPS and one third reported using them. NPS were considered by them less dangerous than "regular" substances of abuse (t = 6.06 mean 0.78, p < 0.001). Factors associated with NPS use were youth (OR = 4.81; p < 0.001), studentship (OR = 4.99; p = 0.004), subsequent mental disorders diagnosis (OR = 2.49; p = 0.027), suicide attempt history (OR = 11.67; p < 0.001), home detention (OR = 2.30; p = 0.040), residential care (OR = 5.66; p = 0.002), and polysubstance abuse (t = 8.99 mean 2.65 p < 0.001). NPS use in patients with SUD is highly prevalent, particularly in the youngest age group, and associated with psychiatric comorbidity and worse prognosis. It is crucial to systematically assess NPS use and inform addiction service users with SUD of the toxic and potentially lethal side effects. Mental healthcare professionals working in addiction services should receive education and training. Cohort and longitudinal studies are needed.

Hospitalization epidemic in patients with heart failure: risk factors, risk prediction, knowledge gaps, and future directions.

Patients with heart failure (HF) are hospitalized over a million times annually in the United States. Hospitalization marks a fundamental change in the natural history of HF, leading to frequent subsequent rehospitalizations and a significantly higher mortality compared with nonhospitalized patients. Three-fourths of all HF hospitalizations are due to exacerbation of symptoms in patients with known HF. One-half of hospitalized HF patients experience readmission within 6 months. Preventing HF hospitalization and rehospitalization is important to improve patient outcomes and curb health care costs. To implement cost-effective strategies to contain the HF hospitalization epidemic, optimal schemes to identify high-risk individuals are needed. In this review, we describe the risk factors that have been associated with hospitalization risk in HF and the various multimarker risk prediction schemes developed to predict HF rehospitalization. We comment on areas that represent gaps in our knowledge or difficulties in interpretation of the current literature, representing opportunities for future research. We also discuss issues with using HF readmission rate as a quality indicator.

Combined aerobic and resistance exercise program improves task performance in patients with heart failure.

OBJECTIVES: To assess the effects of a home-based aerobic and resistance training program on the physical function of adults with New York Heart Association (NYHA) class II and III patients and systolic heart failure (HF). DESIGN: Randomized controlled trial. SETTING: Home based. PARTICIPANTS: Stable patients (N=24; mean age, 60 ± 10 y; left ventricular ejection fraction, 25% ± 9%; 50% white; 50% women) with New York Heart Association (NYHA) classes II and III (NYHA class III, 58%) systolic heart failure (HF). INTERVENTION: A 12-week progressive home-based program of moderate-intensity aerobic and resistance exercise. Attention control wait list participants performed light stretching and flexibility exercises. MAIN OUTCOME MEASURES: A 10-item performance-based physical function measure, the Continuous Scale Physical Functional Performance test (CS-PFP10), was the major outcome variable and included specific physical activities measured in time to complete a task, weight carried during a task, and distance walked. Other measures included muscle strength, HRQOL (Minnesota Living With Heart Failure Questionnaire, Epworth Sleepiness Scale), functional capacity (Duke Activity Status Index), and disease severity (brain natriuretic peptide) levels. RESULTS: After the exercise intervention, 9 of 10 specific task activities were performed more rapidly, with increased weight carried by exercise participants compared with the attention control wait list group. Exercise participants also showed significant improvements in CS-PFP10 total score (P<.025), upper and lower muscle strength, and HRQOL (P<.001) compared with the attention control wait list group. Adherence rates were 83% and 99% for the aerobic and resistance training, respectively. CONCLUSIONS: Patients with stable HF who participate in a moderate-intensity combined aerobic and resistance exercise program may improve performance of routine physical activities of daily living by using a home-based exercise approach. Performance-based measures such as the CS-PFP10 may provide additional insights into physical function in patients with HF that more commonly used exercise tests may not identify. Early detection of subtle changes that may signal declining physical function that are amenable to intervention potentially may slow further loss of function in this patient population.

Serum albumin concentration and heart failure risk The Health, Aging, and Body Composition Study.

BACKGROUND: How serum albumin levels are associated with risk for heart failure (HF) in the elderly is unclear. METHODS: We evaluated 2,907 participants without HF (age 73.6 +/- 2.9 years, 48.0% male, 58.7% white) from the community-based Health ABC Study. The association between baseline albumin and incident HF was assessed with standard and competing risks proportional hazards models controlling for HF predictors, inflammatory markers, and incident coronary events. RESULTS: During a median follow-up of 9.4 years, 342 (11.8%) participants developed HF. Albumin was a time-dependent predictor of HF, with significance retained for up to 6 years (baseline hazard ratio [HR] per -1 g/L 1.14, 95% CI 1.06-1.22, P < .001; annual rate of HR decline 2.1%, 95% CI 0.8%-3.3%, P = .001). This association persisted in models controlling for HF predictors, inflammatory markers, and incident coronary events (baseline HR per -1 g/L 1.13, 95% CI 1.05-1.22, P = .001; annual rate of HR decline 1.8%, 95% CI 0.5%-3.0%, P = .008) and when mortality was accounted for in adjusted competing risks models (baseline HR per -1 g/L 1.13, 95% CI 1.05-1.21, P = .001; annual rate of HR decline 1.9%, 95% CI 0.7%-3.1%, P = .002). The association of albumin with HF risk was similar in men (HR per -1 g/L 1.13, 95% CI 1.05-1.23, P = .002) and women (HR per -1 g/L 1.12, 95% CI 1.04-1.22, P = .005) and in whites and blacks (HR per -1 g/L 1.13, 95% CI 1.04-1.22, P< .01 for both races) in adjusted models. CONCLUSIONS: Low serum albumin levels are associated with increased risk for HF in the elderly in a time-dependent manner independent of inflammation and incident coronary events.

Serum resistin concentrations and risk of new onset heart failure in older persons: the health, aging, and body composition (Health ABC) study.

OBJECTIVE: Resistin is associated with inflammation and insulin resistance and exerts direct effects on myocardial cells including hypertrophy and altered contraction. We investigated the association of serum resistin concentrations with risk for incident heart failure (HF) in humans. METHODS AND RESULTS: We studied 2902 older persons without prevalent HF (age, 73.6+/-2.9 years; 48.1% men; 58.8% white) enrolled in the Health, Aging, and Body Composition (Health ABC) Study. Correlation between baseline serum resistin concentrations (20.3+/-10.0 ng/mL) and clinical variables, biochemistry panel, markers of inflammation and insulin resistance, adipocytokines, and measures of adiposity was weak (all rho <0.25). During a median follow-up of 9.4 years, 341 participants (11.8%) developed HF. Resistin was strongly associated with risk for incident HF in Cox proportional hazards models controlling for clinical variables, biomarkers, and measures of adiposity (HR, 1.15 per 10.0 ng/mL in adjusted model; 95% CI, 1.05 to 1.27; P=0.003). Results were comparable across sex, race, diabetes mellitus, and prevalent and incident coronary heart disease subgroups. In participants with available left ventricular ejection fraction at HF diagnosis (265 of 341; 77.7%), association of resistin with HF risk was comparable for cases with reduced versus preserved ejection fraction. CONCLUSIONS: Serum resistin concentrations are independently associated with risk for incident HF in older persons.

Diverting ß-Hydride Elimination of a π-Allyl PdII Carbene Complex for the Assembly of Disubstituted Indolines via a Highly Diastereoselective (4 + 1)-Cycloaddition.

A Pd0-catalyzed formal (4 + 1)-cycloaddition approach to 2,3-disubstituted dihydroindoles is described. The diastereoselective formation of dihydroindoles that is highlighted by a carbene migratory insertion/reductive elimination sequence proceeding via a π-allyl PdII-species compliments existing methods of indoline assembly.

Obstructive sleep apnea, sleep symptoms, and their association with cardiovascular disease.

OBJECTIVES: To determine the frequency of obstructive sleep apnea (OSA), insomnia, restless legs, and other sleep symptoms in patients with cardiovascular disease and the association of these sleep disorders with quantitative cardiovascular measures. METHODS: Study design was a cross-sectional survey and retrospective chart review. A questionnaire containing validated sleep symptoms was distributed to 202 patients with cardiovascular disease at a tertiary referral cardiology clinic. Following a focused review of these patients' medical charts, their questionnaire responses were examined for associations with clinical cardiovascular parameters. RESULTS: Twenty-one percent of patients reported a prior diagnosis of OSA. A total of 115 patients (60%) had at least one additional sleep symptom. Clinically significant insomnia was significantly associated with heart disease (relative risk [RR] = 1.5, confidence interval [CI] = 1.1 to 2.1), prior myocardial infarction or cerebrovascular accident (RR = 2.1, CI = 1.2 to 3.6), and heart failure (RR = 2.2, CI = 1.3 to 3.8). Left ventricular ejection fraction was significantly associated with insomnia by Insomnia Severity Index (ß = -0.52, CI = -0.89 to -0.13). CONCLUSION: The frequency of OSA in patients in this tertiary cardiology clinic was higher than the general population in the United States, with the majority of patients experiencing at least one sleep symptom. Insomnia symptoms were shown to be associated with multiple cardiovascular measures, including left ventricular ejection fraction. These findings imply an interwoven relationship between cardiovascular and sleep symptoms as captured by validated sleep questionnaires. LEVEL OF EVIDENCE: IV Laryngoscope, 130:1595-1602, 2020.

Incremental value of renal function in risk prediction with the Seattle Heart Failure Model.

BACKGROUND: Impaired renal function portends poor heart failure (HF) outcomes. The Seattle Heart Failure Score (SHFS), a multimarker risk assessment tool, however does not incorporate renal function. In this study, we assessed the incremental value of renal function over the SHFS in patients with advanced HF on contemporary optimal treatment. METHODS: Blood urea nitrogen (BUN), serum creatinine (sCr), BUN/sCr ratio, and estimated glomerular filtration rate were assessed in survival models with SHFS as the base model among 443 patients with HF (52 +/- 12 years, male 68.5%, white 52.4%, ejection fraction 0.18 +/- 0.08). Incremental value of renal function was assessed by changes in the likelihood ratio chi(2) and the area under the receiver operating characteristic curves for 1-, 2-, and 3-year event prediction. RESULTS: During a median follow-up of 21 months, 108 (24.5%) of 443 patients had an event (death [n = 92], urgent transplantation [n = 13], or ventricular assist device implantation [n = 3]). All renal parameters individually were associated with outcome (BUN, P < .001; sCr, P < .001; BUN/sCr ratio, P = .006; and estimated glomerular filtration rate, P = .006); however, only BUN was an independent predictor of events in multivariable analyses. Addition of BUN improved the predictive ability of SHFS (Deltalikelihood ratio chi(2) 5.03, P = .025); however, the increase in the area under the receiver operating characteristic curve was marginal (year 1, 0.786 to 0.791; year 2, 0.732 to 0.741; year 3, 0.745 to 0.754; all P > .2). CONCLUSION: Among the various renal function parameters, BUN had the strongest association with outcomes in patients with advanced HF. However, the incremental value of renal function over the SHFS for risk determination was marginal.

Echocardiography and risk prediction in advanced heart failure: incremental value over clinical markers.

BACKGROUND: Incremental value of echocardiography over clinical parameters for outcome prediction in advanced heart failure (HF) is not well established. METHODS AND RESULTS: We evaluated 223 patients with advanced HF receiving optimal therapy (91.9% angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, 92.8% beta-blockers, 71.8% biventricular pacemaker, and/or defibrillator use). The Seattle Heart Failure Model (SHFM) was used as the reference clinical risk prediction scheme. The incremental value of echocardiographic parameters for event prediction (death or urgent heart transplantation) was measured by the improvement in fit and discrimination achieved by addition of standard echocardiographic parameters to the SHFM. After a median follow-up of 2.4 years, there were 38 (17.0%) events (35 deaths; 3 urgent transplants). The SHFM had likelihood ratio (LR) chi(2) 32.0 and C statistic 0.756 for event prediction. Left ventricular end-systolic volume, stroke volume, and severe tricuspid regurgitation were independent echocardiographic predictors of events. The addition of these parameters to SHFM improved LR chi(2) to 72.0 and C statistic to 0.866 (P < .001 and P=.019, respectively). Reclassifying the SHFM-predicted risk with use of the echocardiography-added model resulted in improved prognostic separation. CONCLUSIONS: Addition of standard echocardiographic variables to the SHFM results in significant improvement in risk prediction for patients with advanced HF.