Brain Natriuretic Peptide as a Marker of Adverse Neurological Outcomes Among Survivors of Cardiac Arrest.

BACKGROUND: Neurological prognosis after cardiac arrest remains ill-defined. Plasma brain natriuretic peptide (BNP) may relate to poor neurological prognosis in brain-injury patients, though it has not been well studied in survivors of cardiac arrest. METHODS: We performed a retrospective review and examined the association of BNP with mortality and neurological outcomes at discharge in a cohort of cardiac arrest survivors enrolled from January 2012 to December 2016 at the Wake Forest Baptist Hospital, in North Carolina. Cerebral performance category (CPC) and modified Rankin scales were calculated from the chart based on neurological evaluation performed at the time of discharge. The cohort was subdivided into quartiles based on their BNP levels after which multivariable adjusted logistic regression models were applied to assess for an association between BNP and poor neurological outcomes as defined by a CPC of 3 to 4 and a modified Rankin scale of 4 to 5. RESULTS: Of the 657 patients included in the study, 254 patients survived until discharge. Among these, poor neurological status was observed in 101 (39.8%) patients that had a CPC score of 3 to 4 and 97 patients (38.2%) that had a modified Rankin scale of 4 to 5. Mean BNP levels were higher in patients with poor neurological status compared to those with good neurological status at discharge (P = .03 for CPC 3-4 and P = .02 for modified Rankin score 4-5). BNP levels however, did not vary significantly between patients that survived and those that expired (P = .22). BNP did emerge as a significant discriminator between patients with severe neurological disability at discharge when compared to those without. The area under the curve for BNP predicting a modified Rankin score of 4 to 5 was 0.800 (95% confidence interval [CI] 0.756-0.844, P < .001) and for predicting CPC 3 to 4 was 0.797 (95% CI 0.756-0.838, P < .001). BNP was able to significantly improve the net reclassification index and integrated discriminatory increment (P < .05). BNP was not associated with long-term all-cause mortality (P > .05). CONCLUSIONS: In survivors of either inpatient or out-of-hospital cardiac arrest, increased BNP levels measured at the time of arrest predicted severe neurological disability at discharge. We did not observe an independent association between BNP levels and long-term all-cause mortality. BNP may be a useful biomarker for predicting adverse neurological outcomes in survivors of cardiac arrest.

Impact of age and comorbidities on the effect of transcatheter versus surgical mitral valve repair on inpatient outcomes.

BACKGROUND: Transcatheter mitral valve repair (TMVR) has shown to be a safe and effective treatment option for symptomatic severe mitral regurgitation (MR) in patients who are at prohibitive surgical risk. Whether age and comorbidities impact the inpatient safety outcomes of TMVR versus surgical mitral valve repair (SMVR) is unknown. METHODS: Using the national inpatient sample, patients undergoing either elective TMVR or SMVR between 2012 and 2015 were analyzed. Logistic, generalized logistic, and linear regression were used to compare inpatient complications, discharge disposition, and length of stay (LOS). Heterogeneity in the effect of TMVR versus SMVR across Charlson comorbidity index (CCI, categorized as <2 and ≥2) and age (categorized as <75 years old and ≥75 years old) were assessed for effect modification. RESULTS: Overall, 8,716 hospitalizations were included, 7,950 (91%) SMVR and 766 (9%) TMVR. Compared with SMVR, patients undergoing TMVR were older (median age 79 vs. 62 years) and more likely to be female (45% vs. 40%) with a higher CCI score (median CCI 2 vs. 1). Despite being older with a higher comorbidity burden, patients undergoing TMVR had a lower incidence of permanent pacemaker implantation (OR 0.23, 95% CI: 0.11, 0.50), cerebrovascular accidents (OR 0.37, 95% CI: 0.15, 0.92), and major bleeding (OR 0.39, 95% CI: 0.32, 0.47). TMVR patients were also discharged 3 days earlier (CIE -3.26; 95% CI: -3.72, -2.80) and were less likely to be discharged to a skilled nursing facility (OR 0.72, 95% CI 0.55, 0.93). Additionally, the relative reduction in complications after TMVR versus SMVR was significantly higher in older (age ≥75 years) and more comorbid (CCI ≥2) patients (p for interaction <.05 for both). CONCLUSION: Patients treated with TMVR, as compared with SMVR, were older and had more comorbidities, but had a lower incidence of inpatient complications, shorter LOS, and better discharge disposition. Therefore, TMVR may be a safer option than SMVR in older patients and those with a higher burden of comorbidities.

Frontal QRS-T Angle and the Risk of Atrial Fibrillation in the Elderly.

BACKGROUND: Frontal QRS-T angle reflects changes in regional action potential duration and the direction of repolarization. Although it has been suggested that abnormal ventricular repolarization predisposes to atrial arrhythmias, it is unknown whether abnormal frontal QRS-T angle is associated with an increased risk of atrial fibrillation (AF). METHODS: We examined the association between frontal QRS-T angle and AF in 4282 participants (95% white; 41% male) from the Cardiovascular Health Study (CHS). QRS-T angle was computed from baseline electrocardiogram data. Abnormal QRS-T angle was defined as values greater than the sex-specific 95th percentile (men >131°; women: >104°). AF cases were identified from study electrocardiograms and from hospitalization discharge data through December 31, 2010. Cox regression was used to compute hazard ratios (HR) and 95% confidence intervals (CI) for the association between abnormal QRS-T angle and AF. RESULTS: Over a median follow-up of 12.1 years, a total of 1276 (30%) participants developed AF. In a Cox regression model, adjusted for socio-demographics and known AF risk factors, abnormal QRS-T angle was associated with a 55% increased risk of AF (HR = 1.55, 95%CI = 1.23, 1.97). When QRS-T angle was examined as a continuous variable, each 10° increase was associated with a 3% increased risk of AF (HR = 1.03, 95%CI = 1.01, 1.05). This finding was consistent in subgroups stratified by age, sex, and race. CONCLUSION: Our findings suggest that an abnormal frontal QRS-T angle on the electrocardiogram provides important prognostic information regarding AF risk in the elderly, and further implicate ventricular repolarization abnormalities in the pathogenesis of AF.

Side effects of messenger RNA vaccines and prior history of COVID-19, a cross-sectional study.

BACKGROUND: There are concerns regarding immunogenicity with coronavirus disease 2019 (COVID-19) mRNA vaccines among persons with prior history of COVID-19 (PHC). This study was to analyze the short-term side effects of mRNA vaccines among health care workers (HCWs) with and without PHC. METHODS: A cross-sectional study was performed using an independent online survey questionnaire that gathered responses from HCWs. RESULTS: Among 1,475 HCWs, 1268 (85.97%) completed the survey, 102/1268 (44/447 in Moderna group and 58/821 in Pfizer-BioNTech group) reported PHC during pre-vaccination period. Symptoms of flushing/P = .05, brain fogging/P= .005, vertigo/P= .041, numbness/P= .023, diarrhea/P= .047, hives/P= .028, itching/P= .028, swelling of lips/mouth/P= .001, shortness of breath/P= .022, and anxiety/P= .048 have greater occurrence among Pfizer-BioNtech group with PHC when compared to Pfizer-BioNtech group with no PHC. Symptoms of chills/P= .027, flushing/P= .045, tremor/P= .05, muscle spasm/P= .039, vomiting/P= .031, diarrhea/P= .015, and cough/P= .011 have higher occurrence among Moderna group with PHC when compared to Moderna group with no PHC. CONCLUSIONS: Few short-term side effects among mRNA vaccine recipients with PHC may have necessitated transient time-off from work. The PHC can be considered as a predictor for severity of side effects. While the vaccination program continues in the United States, a future COVID legislation that mandates vaccination among employees along with paid time off provision may help with higher compliance and acceptance.

Relation of Marital Status and QT Interval Prolongation (from the Third National Health and Nutrition Examination Survey).

Although the link between marital status and mortality is well established, the pathophysiological basis is unclear. An investigation of the association of marital status with prolonged QT interval may highlight the underlying mechanism for poor outcomes associated with being unmarried. This analysis included 6,562 participants (mean age 58.6 years, 52% women, 50.1% non-Hispanic whites) without a history of cardiovascular disease from the Third National Health and Nutrition Examination Survey. QT was automatically measured from digital 12-lead electrocardiogram in a central reading center. Marital status was defined by self-report as married and unmarried (never married, divorced/separated or widowed). A multivariable logistic regression model was used to examine cross-sectional association between marital status and prolonged QT interval (≥450 ms in men, ≥460 ms in women). Compared with married, unmarried was associated with 46% higher odds of the prolonged QT interval (odds ratio [OR] 95% confidence interval [95% CI]: 1.46[1.16-1.83]). This association was stronger among men versus women (OR[95% CI]: 1.75[1.27-2.41] vs 1.26[0.92-1.73] respectively; interaction p value = 0.03) and in younger versus older participants (OR [95% CI]: 1.72[1.21-2.42] vs 1.40[1.05-1.88], respectively; interaction p value = 0.002). When the types of unmarried were compared to married, a dose-response relation with prolonged QT was observed with the highest odds in never married followed by divorced/separated, and then widowed. In conclusion, marital status is associated with a prolonged QT interval, especially among men and younger participants. Prolonged QT interval may indicate a biologic substrate through which social isolation defined by unmarried state increases the risk of poor outcomes in the future.

Wake Forest University long-term follow-up of type 2 myocardial infarction: The Wake-Up T2MI Registry.

BACKGROUND: The Wake-Up T2MI Registry is a retrospective cohort study investigating patients with type 2 myocardial infarction (T2MI), acute myocardial injury, and chronic myocardial injury. We aim to explore risk stratification strategies and investigate clinical characteristics, management, and short- and long-term outcomes in this high-risk, understudied population. METHODS: From 1 January 2009 to 31 December 2010, 2846 patients were identified with T2MI or myocardial injury defined as elevated cardiac troponin I with at least one value above the 99th percentile upper reference limit and coefficient of variation of 10% (>40 ng/L) and meeting our inclusion criteria. Data of at least two serial troponin values will be collected from the electronic health records to differentiate between acute and chronic myocardial injury. The Fourth Universal Definition will be used to classify patients as having (a) T2MI, (b) acute myocardial injury, or (c) chronic myocardial injury during the index hospitalization. Long-term mortality data will be collected through data linkage with the National Death Index and North Carolina State Vital Statistics. RESULTS: We have collected data for a total of 2205 patients as of November 2018. The mean age of the population was 65.6 ± 16.9 years, 48% were men, and 64% were white. Common comorbidities included hypertension (71%), hyperlipidemia (35%), and diabetes mellitus (30%). At presentation, 40% were on aspirin, 38% on ß-blockers, and 30% on statins. CONCLUSION: Improved characterization and profiling of this cohort may further efforts to identify evidence-based strategies to improve cardiovascular outcomes among patients with T2MI and myocardial injury.