Combinations of cardiac and non-cardiac predictors for prognoses in patients with acute heart failure.

AIMS: In contemporary heart failure (HF) practice, prognostic value for combinations of cardiac and non-cardiac predictors remains poorly understood. We analysed the combinatorial predictors of outcomes in acute HF patients. METHODS AND RESULTS: This longitudinal cohort study included consecutive patients admitted for acute decompensated HF between April 2015 and March 2018 in an urban hospital. The main outcomes are HF readmission within 6 months after discharge or all-cause death. A total of 451 patients with 662 admissions were enrolled and the data including frailty and echocardiographic parameters were analysed by multivariate and matched cohort analyses. The mean age of the patients was 76.8 years. We constructed a multi-frailty index (MFI) ranging from 0 to 3 points as a composite of non-cardiac comorbidities and biopsychosocial frailty. In matched cohort of patients with ejection fraction ≧50% (HFpEF), MFI ≧1, pulmonary hypertension (PH; peak flow velocity of tricuspid regurgitation ≧2.9 m/s by echocardiography), and pancytopenia at discharge were strong predictors of HF readmission [odds ratios (ORs), 4.33, 2.5, and 2.86; P = 0.02, 0.05, and 0.02, respectively], and MFI ≧2 was the only predictor for all-cause death. For ejection fraction <40%, age, BNP ≧800 pg/mL, increase in estimated glomerular filtration rate during hospitalization, and lymphocytopenia plus anaemia predicted HF readmission (ORs, 1.77, 2.72, 0.73, and 2.89; P = 0.001, 0.05, 0.04, and 0.03, respectively). In contrast, diabetes mellitus was the only specific predictor found in patients over 80 years old. CONCLUSION: These data identified multi-frailty and PH or mild pancytopenia as synergistic predictors of HF readmission in HFpEF patients.

The Amygdala in Schizophrenia and Bipolar Disorder: A Synthesis of Structural MRI, Diffusion Tensor Imaging, and Resting-State Functional Connectivity Findings.

Frequently implicated in psychotic spectrum disorders, the amygdala serves as an important hub for elucidating the convergent and divergent neural substrates in schizophrenia and bipolar disorder, the two most studied groups of psychotic spectrum conditions. A systematic search of electronic databases through December 2017 was conducted to identify neuroimaging studies of the amygdala in schizophrenia and bipolar disorder, focusing on structural MRI, diffusion tensor imaging (DTI), and resting-state functional connectivity studies, with an emphasis on cross-diagnostic studies. Ninety-four independent studies were selected for the present review (49 structural MRI, 27 DTI, and 18 resting-state functional MRI studies). Also selected, and analyzed in a separate meta-analysis, were 33 volumetric studies with the amygdala as the region-of-interest. Reduced left, right, and total amygdala volumes were found in schizophrenia, relative to both healthy controls and bipolar subjects, even when restricted to cohorts in the early stages of illness. No volume abnormalities were observed in bipolar subjects relative to healthy controls. Shape morphometry studies showed either amygdala deformity or no differences in schizophrenia, and no abnormalities in bipolar disorder. In contrast to the volumetric findings, DTI studies of the uncinate fasciculus tract (connecting the amygdala with the medial- and orbitofrontal cortices) largely showed reduced fractional anisotropy (a marker of white matter microstructure abnormality) in both schizophrenia and bipolar patients, with no cross-diagnostic differences. While decreased amygdalar-orbitofrontal functional connectivity was generally observed in schizophrenia, varying patterns of amygdalar-orbitofrontal connectivity in bipolar disorder were found. Future studies can consider adopting longitudinal approaches with multimodal imaging and more extensive clinical subtyping to probe amygdalar subregional changes and their relationship to the sequelae of psychotic disorders.

Impact of serum C-reactive protein elevation on the left ventricular spherical change and the development of mitral regurgitation after anterior acute myocardial infarction.

BACKGROUND/AIMS: Mitral regurgitation (MR) is frequently observed in patients with acute myocardial infarction (AMI), and is known to convey an adverse prognosis. We sought to clarify the relationship between MR and left ventricular (LV) remodeling, in association with serum C-reactive protein (CRP) elevation. METHODS/RESULTS: A total of 181 patients with first anterior ST-elevation AMI were examined. MR was detected in 68 patients by color Doppler echocardiography 2 weeks after AMI, and the patients with MR were associated with higher incidence of readmission for heart failure. Serum CRP was serially measured, and the peak serum CRP level was markedly increased in patients with MR compared with those without MR. Multiple logistic regression analysis showed that peak CRP tertile was an independent determinant of MR after AMI (p < 0.0001). In the substudy, the increases in LV end-diastolic volume and sphericity index were higher in patients with MR than in those without MR. CONCLUSIONS: MR during the early phase of anterior AMI was associated with LV spherical change and late-phase heart failure, in association with increased serum CRP level. These findings suggest an important role of the inflammatory response in the development of ischemic MR and LV remodeling.

Stenting after directional coronary atherectomy compared with directional coronary atherectomy alone and stenting alone: a serial intravascular ultrasound study.

BACKGROUND: Directional coronary atherectomy prior to stent implantation (DCA-stent) is expected to be an effective approach to reduce restenosis. The purpose of this study was to determine whether DCA-stent has advantages over DCA alone or stenting alone using serial intravascular ultrasound (IVUS). METHODS AND RESULTS: Serial (pre-, post- and follow-up) IVUS was performed in 187 native coronary lesions treated with each of the 3 strategies. External elastic membrane cross-sectional area (CSA), lumen CSA and plaque CSA were measured. Baseline characteristics were similar. Postprocedural lumen CSA was largest after DCA-stent (11.2+/-2.7 mm2) and DCA (10.8+/-2.5 mm2) than stenting alone (9.0+/-2.9 mm2) (p<0.0005). Follow-up lumen loss was similar. As a result, follow-up lumen CSA was largest after DCA-stent (DCA-stent: 9.1+/-3.4 mm2, DCA: 7.8+/-4.2 mm2, stent: 6.3+/-2.6 mm2, p<0.0005). There was a trend toward a lower rate of restenosis with DCA-stent (DCA-stent, 12.5%; DCA, 18.3%; stent, 18.8%; p=0.57). CONCLUSIONS: DCA-stent is superior to both DCA alone and stent alone in terms of the ability to gain a larger lumen as assessed by IVUS.