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At least 235 records · Page 13Linked to original sources
PubMed1994

Risk stratification for long-term outcome after elective coronary angioplasty: a multivariate analysis of 5,000 patients.

OBJECTIVES: We attempted to develop a statistical model to facilitate risk stratification for long-term outcome after elective coronary angioplasty. BACKGROUND: Our understanding of factors related to long-term outcome after coronary angioplasty is limited. Adequate assessment of risk indexes could potentially lead to more appropriate use of percutaneous revascularization. METHODS: We studied 5,000 consecutive patients and assessed 19 clinical and anatomic variables as predictors of long-term event-free survival. Events were defined as death of any cause, myocardial infarction, bypass surgery or repeat percutaneous transluminal coronary angioplasty. Cox proportional hazards models were used to develop an equation for predicting event-free survival in a subset of 4,000 patients. The equation was validated with the remaining 1,000 patients. Variables that were significantly associated with an adverse outcome in the multivariate model included age > 60 years, extent of disease, Canadian Cardiovascular Society functional class, previous coronary angioplasty, male gender, history of diabetes mellitus, history of hypertension and history of congestive heart failure. RESULTS: The statistical model was used to develop a simplified scoring system, and the patients were assigned to three risk subgroups. Event-free survival curves for the three groups were significantly different (p = 0.0001). High risk patients had worse outcomes for each of the end points compared with low and moderate risk patients (p < 0.02). CONCLUSIONS: We demonstrated that clinical and anatomic variables can be used to risk-stratify long-term outcome after angioplasty, that a simplified scoring system can be used for risk stratification and that high risk patients have a low event-free survival.

Aged↗
PubMed1995

Improved cardiac risk stratification in major vascular surgery with dobutamine-atropine stress echocardiography.

OBJECTIVES: This study sought to optimize preoperative cardiac risk stratification in a large group of consecutive candidates for vascular surgery by combining clinical risk assessment and semiquantitative dobutamine-atropine stress echocardiography. BACKGROUND: Dobutamine-atropine stress echocardiography has been used for the prediction of perioperative cardiac risk in a small group of patients scheduled for elective major vascular surgery on the basis of the presence or absence of stress-induced regional left ventricular wall motion abnormalities. METHODS: Clinical risk assessment and dobutamine-atropine stress echocardiography were performed in 302 consecutive patients presenting for major vascular surgery. The extent and severity of stress wall motion abnormalities and the heart rate at which they occurred, in addition to the presence of wall motion abnormalities at rest, were assessed. RESULTS: The absence of clinical risk factors (angina, diabetes, Q waves on the electrocardiogram, symptomatic ventricular tachyarrhythmias, age > 70 years) identified a low risk group of 100 patients with a 1% cardiac event rate (unstable angina). Dobutamine-atropine stress echocardiographic findings were positive in 72 patients. Twenty-seven patients had a perioperative cardiac event (cardiac death in 5, nonfatal infarction in 12, unstable angina pectoris in 10); all 27 patients had positive stress test results (positive predictive value 38%, negative predictive value 100%). The semiquantitative assessment of the extent and severity of ischemia did not provide additional prognostic information in patients with positive test results. In contrast, the heart rate at which ischemia occurred defined a high risk group with a low ischemic threshold (38 patients with 20 events [53%]) and an intermediate risk group with a high ischemic threshold (34 patients with 7 events [21%]). All 5 patients with a fatal outcome and 8 of 12 with a nonfatal myocardial infarction were in the high risk group with a low ischemic threshold. CONCLUSIONS: Clinical variables identify 33% of patients at very low risk for perioperative complications of vascular surgery in whom further testing is redundant. In all other candidates, dobutamine-atropine stress echocardiography is a powerful tool that identifies those patients at intermediate risk and a small group at very high risk. Risk stratification with a combination of clinical assessment and pharmacologic stress echocardiography has the potential to facilitate clinical decision making and conserve resources.

Adult↗
PubMed1996

Predictive power of increased heart rate versus depressed left ventricular ejection fraction and heart rate variability for risk stratification after myocardial infarction. Results of a two-year follow-up study.

OBJECTIVES: The aim of this study was to compare the predictive value of mean RR interval assessed from predischarge Holter recordings with that of heart rate variability and left ventricular ejection fraction for risk stratification after myocardial infarction. BACKGROUND: Heart rate variability is a powerful tool for risk stratification after myocardial infarction. Although heart rate variability is related to heart rate, little is known of the prognostic value of 24-h mean heart rate. METHODS: A total of 579 patients surviving the acute phase of myocardial infarction were followed up for at least 2 years. Predischarge heart rate variability, 24-h mean RR interval and left ventricular ejection fraction were analyzed. RESULTS: During the first 2 years of follow-up, there were 54 deaths, 42 of which were cardiac (26 sudden). Shorter mean RR interval was a better predictor of all-cause mortality as well as cardiac and sudden death than depressed left ventricular ejection fraction. Depressed heart rate variability predicted the risk of death better than mean RR interval for sensitivities < 40%. For sensitivities > or = 40%, mean RR interval was as powerful as heart rate variability. All three variables performed equally well in predicting nonsudden cardiac death. For cardiac death prediction, a left ventricular ejection fraction < 35% had a 40% sensitivity, 78% specificity and 14% positive predictive accuracy; a mean RR interval < 700 ms had a 45% sensitivity, 85% specificity and 20% positive predictive accuracy; and a heart rate variability < 17 U had a 40% sensitivity, 86% specificity and 20% positive predictive accuracy. CONCLUSIONS: Predischarge 24-h mean heart rate is a strong predictor of mortality after myocardial infarction that can compete with left ventricular ejection fraction and heart rate variability.

Cohort Studies↗
PubMed1989

Performance of tests of significance based on stratification by a multivariate confounder score or by a propensity score.

Stratification by a multivariate confounder score or by a propensity score has been proposed for the multi-confounder situations that are commonly encountered in epidemiologic evaluations of the effects of a treatment or a triage decision. However, the use of these scores in clinical research has been limited, perhaps in part because of the concern that the stated level of statistical significance may be exaggerated when there is a high degree of correlation between the exposure and the set of confounders. We present a specific example and computer simulations to suggest that exaggeration of statistical significance occurs only under unusual circumstances when the correlation between the exposure and the confounders is extreme. Our simulations also suggest that an analysis based on stratification by a propensity score is less affected by high correlation between the exposure and the confounders than is an analysis based on a multivariate confounder score.

Computer Simulation↗
PubMed2006

Cardiovascular disease risk stratification with stress single-photon emission computed tomography technetium-99m tetrofosmin imaging in patients with the metabolic syndrome and diabetes mellitus.

The metabolic syndrome represents a constellation of risk factors caused by insulin resistance, dyslipidemia, hypertension, and obesity, resulting in elevated coronary disease risk. From a multicenter prospective registry of 7,849 patients, the relation among the metabolic syndrome, diabetes, and risk stratification with stress technetium-99m tetrofosmin single photon-emission computed tomography (SPECT) was evaluated. The percentage of stress myocardial defects was calculated as < or = 5%, 5.1% to 10%, 10.1% to 15%, and > 15%. A Cox proportional-hazards model was used to estimate cardiovascular death or myocardial infarction (n = 752). Of 7,849 patients, 42% had the metabolic syndrome. Patients with the metabolic syndrome had an 84% 2-year event-free survival rate, lower than patients with normal metabolic status (p <0.0001). In patients with the metabolic syndrome, the percentage of moderate to severely abnormal SPECT findings ranged from 11% to 44% for those with 3 to 5 risk factors for the metabolic syndrome. There was an additive relation between the number of risk factors for the metabolic syndrome and the extent and severity of abnormalities in SPECT findings (p <0.0001). Patients with 5 risk factors for the metabolic syndrome were at the greatest risk, with hazard ratios from 7.8- to 14.1-fold for mild to severely abnormal SPECT findings. For diabetic patients requiring combined oral and insulin therapy, relative risk ratios increased from 15 to 21.4 for patients with > 5% to > 15% stress myocardial perfusion defects. In conclusion, cardiovascular prognosis is affected by the degree of metabolic dysfunction, and stress-induced reductions in myocardial perfusion provide an accurate means for near-term risk stratification.

Aged↗
PubMed2005

[Stratification scores for risk in the context of acute coronary syndromes].

The patients presenting acute coronary syndrome with or without ST segment elevation form a heterogeneous population and thus the short and long-term risk of death or recurrent ischemic events can vary considerably. During ACS without ST elevation (unstable angina and non-ST elevation MI), the evaluation of risk is an essential step in the management of such patients, because it determines ulterior strategy. This evaluation is simple and reliable, and is principally based on three scores: the TIMI, the GRACE Score or the PURSUIT. Thanks to this stratification, high and medium-risk patients are able to benefit from early invasive management (stents and anti-GPIIb/IIIa) as recent studies have clearly shown. Even if immediate management of patients with non-ST elevation ACS does not take account of risk stratification, using such information in the medium and long-term does help determine the prognosis. Finally, the risk profile score, whatever the score used is today an essential tool, which helps qualify and especially compare patients included in international clinical studies.

Angina, Unstable↗
PubMed2004

Acute type B aortic dissection in elderly patients: clinical features, outcomes, and simple risk stratification rule.

BACKGROUND: The clinical features and outcomes of elderly patients with acute type B aortic dissection (ABAD) are less well known. Accordingly, we sought to evaluate the clinical features and outcomes and derive a simple risk stratification rule for elderly with ABAD. METHODS: We categorized 383 patients with ABAD enrolled in the International Registry of Acute Aortic Dissection into two strata (aged less than 70 years and aged 70 years or more) and compared their clinical features and in-hospital outcomes. Further, we developed a clinical decision rule to risk-stratify elderly with ABAD. RESULTS: Forty-two percent (161 of 383) of patients with ABAD were aged 70 years or more. Hypertension, diabetes, history of prior aortic aneurysm, and arteriosclerosis were more common in the elderly patients, whereas Marfan syndrome and cocaine abuse were less common. The in-hospital complication of hypotension/shock was more common among elderly, and malperfusion of a visceral organ less frequent among elderly patients. In-hospital mortality was higher in the elderly cohort compared with the younger patients (16% versus 10%, p = 0.07). A classification tree identified that elderly patients with hypotension/shock had the highest risk of death (56%). In absence of this, any branch vessel involvement was associated with the next highest mortality rate (28.6%) followed by presence of periaortic hematoma (10.5%). In contrast, elderly patients without any of these three risk factors had an extremely low mortality rate (1.3%). CONCLUSIONS: Our study highlights important differences between older and younger patients with ABAD in their clinical characteristics, management, and outcomes. We also propose a simple decision rule that allows stepwise risk-stratification in elderly patients with ABAD.

Aged↗
PubMed2004

Risk stratification after hospitalization for decompensated heart failure.

BACKGROUND: Decompensated heart failure (HF) is among the most common indications for hospitalization in the United States, but little is known about features on admission that predict adverse events. We used data from the Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure (OPTIME-CHF) study to develop a model that would predict outcomes in patients with decompensated HF. METHODS AND RESULTS: OPTIME-CHF randomized 949 patients hospitalized with decompensated HF for 48 to 72 hours of infusion of either milrinone or placebo. We used multivariable modeling to evaluate variables on admission that would be predictive of 60-day mortality or the composite of death or rehospitalization at 60 days. Variables at presentation that predicted death at 60 days were increased age, lower systolic blood pressure, New York Heart Association class IV symptoms, elevated blood urea nitrogen (BUN), and decreased sodium. Predictors of the composite of death or rehospitalization within 60 days were the number of HF hospitalizations in the preceding 12 months, elevated BUN, lower systolic blood pressure, decreased hemoglobin, and a history of percutaneous coronary intervention (PCI). The discriminatory power of the model was substantial for the mortality model (c-index .77) but less for the composite endpoint (c-index .69). CONCLUSIONS: Risk stratification of patients with decompensated HF may be accomplished using easily assessed clinical variables. Further research into the validity of this model in independent samples will potentially aid in the development of risk stratification strategies.

Aged↗
PubMed2006

Plasma heart-type fatty acid binding protein is superior to troponin and myoglobin for rapid risk stratification in acute pulmonary embolism.

BACKGROUND: Irreversible right ventricular (RV) failure with myocardial damage may precipitate fatal outcome in acute pulmonary embolism (APE). Cytoplasmic heart-type fatty acid binding protein (H-FABP) is a sensitive and specific biomarker of myocardial damage. We assessed which biomarker of myocardial damage or RV stretching is the most useful for short-term risk stratification in APE. METHODS: We analyzed 77 patients (51 F, 26 M) aged 65.3+/-16.0 years with confirmed APE. On admission, systemic blood pressure and transthoracic echocardiography (for RV overload) were recorded and plasma concentrations of myoglobin (Mb), cardiac troponin T (cTnT), N-terminal fragment of proBNP (NT-proBNP) and H-FABP were evaluated. RESULTS: Fifteen (19.5%) patients died and 24 (31.2%) experienced complicated clinical course (CCC)-death/thrombolysis/cardiopulmonary resuscitation/intravenous vasopressors. Hazard ratio analysis demonstrated that plasma H-FABP, Mb, cTnT and NT-proBNP concentrations predicted fatal outcome. When only APE-related deaths were considered, plasma H-FABP concentrations indicated fatal outcome. Multivariate hazard ratio analysis revealed H-FABP as the only 30-day mortality predictor (HR 1.02 CI 95% 1.01-1.05). CONCLUSIONS: H-FABP measured on admission is useful for short-term risk stratification in APE. It appears to be superior to cTnT, NT-proBNP and Mb in the prediction of 30-day APE-related mortality.

Acute Disease↗
PubMed2004

Evaluation and risk stratification of acute coronary syndromes using a low cut-off level of cardiac troponin T, combined with CK-MB mass determination.

OBJECTIVES: To study the usefulness of combined cardiac Troponin T (cTnT) and CK-MB mass determinations in risk stratification of acute coronary syndromes. DESIGN AND METHODS: Blood samples for cTnT and CK-MB mass were collected at arrival and 4, 8, and 12-24 later in 301 consecutive patients with recent acute chest pain (ACP). Data were also collected for cardiac events. RESULTS: Combined cardiac mortality/nonfatal myocardial infarction over a period of 15 months was lowest in patients with <0.04 microg/l cTnT and -<5.0 microg/l CK-MB mass intermediate in those with elevated cTnT but normal CK-MB mass and highest when both markers were elevated, in absence of early reperfusion. CONCLUSION: The use of a low cut-off point of cTnT, combined wit CK-MB mass determination, offers a good strategy for risk stratification of ACP patients.

Aged↗
PubMed2026

Proteomics as a theranostic compass in BCR::ABL1-negative myeloproliferative neoplasms: Integrating biomarker discovery with therapeutic stratification.

Classic BCR::ABL1-negative myeloproliferative neoplasms (MPNs)-polycythaemia vera, essential thrombocythaemia, and primary myelofibrosis-are clonal haematopoietic stem cell disorders with marked heterogeneity in clinical phenotype, disease trajectory, and therapeutic response. Genomic stratification by driver and cooperating mutations only partially accounts for this variability, leaving gaps in predicting thrombotic risk, fibrotic progression, leukaemic transformation, and treatment benefit. Proteomics bridges this gap by providing function-proximal readouts of protein abundance, post-translational modifications, pathway activity, and intercellular signalling that genomics and transcriptomics cannot capture, positioning it as a theranostic platform in which the same molecular readouts simultaneously inform diagnostic stratification and therapeutic decision-making. We propose a five-stage translational framework spanning from discovery-scale mass spectrometry and affinity-based plasma profiling to targeted validation, multicentre standardisation, and machine learning-integrated clinical panels. Proteomic evidence is synthesised across the following four disease axes: clonal fitness in haematopoietic stem and progenitor cells; bone marrow microenvironmental remodelling and fibrosis; chronic inflammation and thrombosis; and leukaemic transformation. We further describe how phosphoproteomics reveals resistance mechanisms to JAK inhibitors, including AXL-MAPK bypass and PP2A-autophagy-mediated tolerance, and how protein-level biomarkers (BCL2-BCL-XL, RAS-ERK, CAMK2G, and ROCK1/2) can guide individualised therapeutic selection. Affinity-based platforms (Olink PEA and SomaScan) and spatially resolved technologies (CODEX and single-cell proteomics) complement discovery proteomics. At present, however, this evidence base is constrained by small and heterogeneous cohorts, limited cross-platform reproducibility, and a scarcity of independent external validation for candidate protein panels. Realising this vision will require multicentre standardisation, analytically validated panel assays, and prospective clinical studies that translate molecular findings into decision-grade tools for patients with MPNs.

Humans↗
PubMed2005

A potential role of apolipoprotein B in the risk stratification of diabetic patients with dyslipidaemia.

Diabetic dyslipidaemia is characterised by retention of atherogenic particles, which are depleted of cholesterol. Therefore, calculating or measuring LDL or VLDL cholesterol may not reflect the actual number of these atherogenic particles. We examined the potential role of apolipoprotein B in the risk stratification of Omani patients with type 2 diabetes and dyslipidaemia. Two hundred and twenty-one subjects with type 2 diabetes and 67 healthy controls were recruited. Diabetic subjects had significantly higher serum levels of triglycerides (P<0.0001), non-HDL cholesterol (P<0.0001), and total/HDL cholesterol ratio (P<0.04) and lower levels of HDL cholesterol (P<0.0001) and lipoprotein(a) compared to nondiabetic subjects. The ratio of apoB/LDL cholesterol ratio was significantly higher (P<0.002) among diabetic compared to nondiabetic subjects. Sixty percent of the diabetic subjects with abnormal apoB of >1.2g/L had an LDL cholesterol of less than 4.2 mmol/L compared to 7% of the nondiabetic subjects (sensitivity; 40% versus 93%, respectively). Furthermore, diabetic subjects with ischaemic heart disease (IHD) had significantly higher (P<0.003) apoB/non-HDL cholesterol ratio compared to those without IHD. These findings suggest that the ratios of apoB/LDL cholesterol and apoB/non-HDL cholesterol may have a role in the risk stratification of diabetic patients with dyslipidaemia.

Adult↗
PubMed2005

Risk stratification of women with peripartum cardiomyopathy at initial presentation: a dobutamine stress echocardiography study.

OBJECTIVES: We sought to determine the prognostic use of inotropic contractile reserve on risk stratification and prognostication of women with peripartum cardiomyopathy. BACKGROUND: Peripartum cardiomyopathy is a rare disorder effecting women in their prime years of life. There appears to be an initial high-risk period with 25% to 50% of women dying within the first 3 months postpartum. Early risk stratification and prognostication are, thus, crucial. However, only limited data are available. METHODS: In all, 7 women (mean age 31.8 years) with peripartum cardiomyopathy and severe left ventricular (LV) dysfunction (mean LV ejection fraction [LVEF] 25.3 +/- 9.5%) were studied. Of these, 6 underwent dobutamine stress echocardiography at baseline and a follow-up resting echocardiogram at a mean of 4.7 +/- 0.9 months after initial presentation. Resting and peak inotropic contractile reserve, and follow-up LVEF, were computed. RESULTS: The mean LVEF improved significantly from baseline (25.3 +/- 9.5%) to maximal inotropic contractile reserve (53.8 +/- 12.6%) (P = .0004) and at follow-up (53.0 +/- 16.4%) (P = .006). Importantly, LVEF at maximal inotropic contractile reserve and at follow-up (5.6 months) did not differ significantly (P = .5). The mean LVEF at maximal inotropic contractile reserve correlated well with the follow-up (LVEF R = 0.79). However, the baseline LVEF did not correlate with follow-up LVEF (P = not significant). CONCLUSIONS: In patients presenting with peripartum cardiomyopathy, inotropic contractile reserve during dobutamine stress echocardiography accurately correlates with subsequent recovery of LV function and confers a benign prognosis.

Adult↗
PubMed2006

Risk stratification in chronic heart failure: independent and incremental prognostic value of echocardiography and brain natriuretic peptide and its N-terminal fragment.

BACKGROUND: It was the aim of this study to compare the prognostic impact of echocardiography and brain natriuretic peptide and its N-terminal fragment (NT-proBNP) in patients with chronic heart failure (CHF). METHODS: In all, 73 patients with CHF underwent conventional 2-dimensional/Doppler echocardiography and Doppler tissue analysis of systolic, early and late diastolic mitral annular velocities. The mitral filling pattern was classified as restrictive or nonrestrictive. NT-proBNP measurements were carried out on a bench-top analyzer. A cardiac event (rehospitalization caused by worsening CHF, cardiac death, urgent cardiac transplantation) was defined as combined study end point. RESULTS: During follow-up of 226 +/- 169 days, 27 patients had an event (rehospitalization because of CHF, n = 18; cardiac death, n = 7; urgent transplantation, n = 2). On multivariate Cox regression analysis, a restrictive filling pattern, NT-proBNP, the ratio of peak early diastolic mitral flow to mitral annular E' velocity were independent prognostic predictors. A risk stratification model based on the 3 strongest independent predictors separated groups into those with good, intermediate, and poor outcome (event-free survival of 78%, 46%, and 0%, respectively). CONCLUSIONS: In patients with CHF, Doppler echocardiography, Doppler tissue imaging, and NT-proBNP provide independent and incremental prognostic information. A combined use of echocardiography and NT-proBNP may help to improve risk stratification in this patient population.

Biomarkers↗
PubMed2004

Admission Troponin T and measurement of ST-segment resolution at 60 min improve early risk stratification in ST-elevation myocardial infarction.

AIMS: The prognostic value of admission troponin T (tnT) levels and the resolution of the ST-segment elevation in ST-elevation myocardial infarction (STEMI) is well established. However, the combination of these two early available markers for predicting risk has not been evaluated. METHODS AND RESULTS: We evaluated 516 patients with fibrinolytic treated STEMI from the ASSENT-2 and ASSENT-PLUS studies, which had both admission tnT and ST-monitoring available. We used a prospectively defined cut-off value of tnT of 0.1microg/l. For ST-segment resolution, a cut-off of 50% measured after 60min was used. Both a tnT >/=0.1microg/l (n=116) and ST-segment resolution <50% (n=301) were related to higher one-year mortality, 13% vs 4% (P<0.001) and 8.4% vs 2.8% (P=0.009), respectively. In a multivariate analysis ST-segment resolution was and tnT showed a strong trend to be independently related to mortality. The combination of both further improved risk stratification. The one-year mortality in the group with elevation of tnT and without ST-segment resolution compared to the group without tnT elevation and with ST-segment resolution was 18.2% vs 2.8% (P<0.001). CONCLUSIONS: Both tnT on admission and ST-segment resolution after 60min are strong predictors of one-year mortality. The combination of both gives additive early information about prognosis and further improves risk stratification.

Arrhythmias, Cardiac↗
PubMed2004

Risk-stratification in thoracic aortic surgery: should the EuroSCORE be modified?

OBJECTIVES: Risk-stratification in cardiac surgical procedures is of major interest. Recent studies have shown, that the EuroSCORE is a very good and reliable risk-stratification score in CABG and in valve surgery. The aim of the study was to evaluate the EuroSCORE in patients undergoing surgery on the thoracic aorta. METHODS: Three hundred and sixty-seven consecutive patients underwent surgery of the thoracic aorta and were scored, according to the additive and logistic EuroSCORE algorithm. We compared correlation of predicted and observed mortality and evaluated a modification of the EuroSCORE in order to improve the scoring system. Score validity was assessed by calculating the area under the receiver operating characteristic curve (ROC). RESULTS: Overall hospital mortality was 10.1%. Additive EuroSCORE predicted mortality was 2.3% for 3-6% risk, 12.9% for 7-8% risk, 18.4% for 9-12% risk and 27.3% for a risk >12%. The modified score predicted mortality was 1% for 3-6% risk, 8.2% for 7-8% risk, 12.1% for 9-14% risk, 18.6% for 15-24% risk and 28.6% for a risk >24%. Area under the ROC-curve was 0.68 for the EuroScore and 0.91 in the modified score, 0.72 and 0.86 in the logistic model. CONCLUSIONS: The modified score, taking into account aortic dissection (6 points) and preoperative malperfusion (12 points) significantly improves the predictive value of the EuroSCORE in patients undergoing thoracic aortic surgery.

Acute Disease↗
PubMed2004

Risk stratification in paediatric open-heart surgery.

OBJECTIVE: The aims of this study were to identify independent risk factors for mortality following paediatric open-heart surgery and to develop risk models for use in clinical audit based on identified risk factors. The study also tests the validity of the recently proposed Risk Adjustment in Congenital Heart Surgery (RACHS-1) method of risk stratification as applied to open-heart operations. METHODS: A multiple logistic regression analysis was performed on all patients less than 18 years of age undergoing open-heart surgery at a single institution over a 3-year period. Preoperative and operative variables included for analysis were age at operation, weight, sex, American Society of Anaesthesiology (ASA) grade, RACHS-1 risk category, preoperative haemoglobin, bypass time, temperature, cross-clamp time, circulatory arrest time, blood transfusion on bypass and surgeon. The outcome measure was in-hospital death. RESULTS: 1085 consecutive open-heart cases were identified. There were 51 in-hospital deaths (4.7%). Variables identified as being independently significant risk factors for in-hospital death were age (P = 0.0002), RACHS-1 risk category (P < 0.0001), and bypass time. Based on these three variables, a risk model was constructed to predict mortality. The area under the receiver-operating-characteristic (ROC) curve for this model was 0.86. A second model was constructed ignoring bypass time. In this model, the significance of the 'preoperative' risk factors was (P = 0.0003) for age and (P < 0.0001), for RACHS-1 risk category. The area under the ROC curve was 0.81 for the second model. CONCLUSIONS: This study identifies age at operation, RACHS-1 risk category and bypass time as highly significant risk factors for mortality after paediatric open-heart surgery. It validates the RACHS-1 risk stratification method as applied to the subset of open-heart surgery, whilst accepting the limitations of such a system. The risk models formulated permit risk prediction and allow for analysis of surgical results. Such risk-adjustment is important when assessing performance and comparing outcomes amongst individuals or institutions.

Adolescent↗
PubMed2006

Importance of early combined N-terminal pro-brain natriuretic peptide and cardiac troponin T measurements for long-term risk stratification of patients with decompensated heart failure.

BACKGROUND: Markers of myocardial necrosis and natriuretic peptides are risk predictors in decompensated heart failure (DHF). We prospectively studied the optimal timing of combined cardiac troponin T (cTnT) and N-terminal pro-brain natriuretic peptide (NT-proBNP) measurements for long-term risk stratification. METHODS: cTnT and NT-proBNP were measured upon admission, and before discharge in 76 patients hospitalized for DHF (mean age 62.3 +/- 15 years; 71% men). RESULTS: During a mean follow-up of 252 +/- 120 days, 39.5% of patients died or were re-hospitalized for DHF. From receiver-operator-characteristic (ROC) curves, the selected cut-off values for cTnT and NT-proBNP were 0.026 ng/ml and 3,700 pg/ml on admission, and 0.030 ng/ml and 3,200 pg/ml, respectively, at discharge. Depending upon measurements above vs below cut-off, the population was distributed on admission and before discharge for three groups: both negative (24% and 30% of patients); one positive (43% and 42%); and both positive (33% and 28%). For the admission groups, the 1-year DHF-free re-hospitalization survival rates were 85%, 60% and 34%, respectively (p = 0.0047). One-year survival rates for DHF-free re-hospitalization were 63%, 71% and 26% (p = 0.0029), respectively, for the discharge groups. In the Cox proportional hazards model, systolic blood pressure (hazard ratio [HR]: 0.98; 95% confidence interval [CI]: 0.96 to 0.99), heart rate (HR: 0.97; 95% CI: 0.94 to 0.98), one positive biomarker on admission (HR: 10.5; 95% CI: 1.3 to 83.7) and two positive biomarkers on admission (HR: 13.9; 95% CI: 1.8 to 98.5) were independent predictors of long-term outcomes. However, NT-proBNP on admission was the most important predictor of long-term prognosis (HR: 5.1; 95% CI: 2.3 to 12.2). CONCLUSIONS: The combined measurements of cTnT and NT-proBNP on hospital admission were more reliable than their measurements before discharge in the long-term risk stratification of DHF. A single positive measurement on admission predicted a poor long-term outcome.

Aged↗