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Exercise testing provides valuable information but is rarely integrated to derive a risk prediction model in a referral population. In this study, we assessed the predictive value of conventional cardiovascular risk factors and exercise test parameters in 6,546 consecutive adults referred for exercise testing, who were followed for a period of 8.1 ± 3.7 years for incident myocardial infarction, coronary revascularization, and cardiovascular death. A risk prediction model was developed, and cross-validation of model was performed by splitting the data set into 10 equal random subsets, with model fitting based on 9 of the 10 subsets and testing in of the remaining subset, repeated in all 10 possible ways. The best performing model was chosen based on measurements of model discrimination and stability. A risk score was constructed from the final model, with points assigned for the presence of each predictor based on the regression coefficients. Using both conventional risk factors and exercise test parameters, a total of 9 variables were identified as independent and robust predictors and were included in a risk score. The prognostic ability of this model was compared with that of the Adult Treatment Panel III model using the net reclassification and integrated discrimination index. From the cross-validation results, the c statistic of 0.77 for the final model indicated strong predictive power. In conclusion, we developed, tested, and internally validated a novel risk prediction model using exercise treadmill testing parameters. [ABSTRACT FROM AUTHOR]

Utility of cardiopulmonary exercise test is unknown in patients with aortic stenosis. In this retrospective study, we examined the maximal indexes of cardiopulmonary testing at peak exercise in 155 consecutive patients with aortic valve area of £1.5 cm² who were referred for this test. The patients were passively followed up to assess their effect on the primary end point of all-cause mortality. We found that the absolute peak oxygen consumption (VO2) was significantly reduced in these patients, with age and genderepredicted peak VO2 of 80 - 23%. Peak VO2 was markedly reduced (<80% of predicted) in 54% of patients. During a follow-up of 5 - 4 years, a total of 41 patients died, and 72 underwent aortic valve replacement. Survival was significantly better in patients with higher absolute peak VO2 (hazard ratio [HR] 0.87, 95% confidence interval [CI] 0.80 to 0.93, p <0.001) and higher oxygen pulse (HR 0.80, 95% CI 0.74 to 0.9, p <0.001). In 83 patients who did not undergo valve replacement, higher peak VO2 and oxygen pulse were associated with better survival (HR 0.83, 95% CI 0.71 to 0.97, p [ 0.024 and HR 0.80, 95% CI 0.66 to 0.96, p [ 0.02, respectively). In conclusion, the peak VO2 is significantly reduced in patients with aortic stenosis. Higher peak VO2 is independently associated with better survival in these patients irrespective of whether they undergo valve replacement. [ABSTRACT FROM AUTHOR]

Porphyrias are a group of inherited disorders affecting enzymes in the heme biosynthesis pathway, leading to overproduction and/or accumulation of porphyrin or its precursors. Porphyrias have been associated with autonomic dysfunction, which in turn can develop atrial fibrillation (AF). The purpose of this study was to characterize the prevalence of AF and atrial flutter (AFl) in patients with porphyrias. A single-center retrospective cohort study was designed using data from chart reviews of patients who were admitted to the hospital from January 2000 to June 2008. Fifty-six distinct cases were found with a discharge diagnosis of porphyria including all its subtypes. From the same database, age- and gender-matched controls were identified using computer-generated random numbers. We selected 1 age- and gender-matched control for each case. Electrocardiograms and echocardiograms were reviewed by 2 independent reviewers. Only patients with available 12-lead electrocardiograms that showed AF/AFl were labeled with that diagnosis. All patients with a diagnosis of porphyria were included in the study irrespective of their age. Seven of 56 patients with porphyria met inclusion criteria, yielding a prevalence of AF/AFl of 12.5%. This association was significant (p = 0.028, relative risk 7.45, 95% confidence interval 1.01 to 66.14) compared with the age- and gender-matched control group (2%). In conclusion, our observations suggest that porphyria may be significantly associated with AF/AFl. [Copyright &y& Elsevier]

Transcatheter aortic valve implantation (TAVI) is associated with a significant learning curve. There is paucity of data regarding the effect of hospital volume on outcomes after TAVI. This is a cross-sectional study based on Healthcare Cost and Utilization Project's Nationwide Inpatient Sample database of 2012. Subjects were identified by International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes, 35.05 (Trans-femoral/Trans-aortic Replacement of Aortic Valve) and 35.06 (Trans-apical Replacement of Aortic Valve). Annual hospital TAVI volumes were calculated using unique identification numbers and then divided into quartiles. Multivariate logistic regression models were created. The primary outcome was inhospital mortality; secondary outcome was a composite of inhospital mortality and periprocedural complications. Length of stay (LOS) and cost of hospitalization were assessed. The study included 1,481 TAVIs (weighted n = 7,405). Overall inhospital mortality rate was 5.1%, postprocedural complication rate was 43.4%, median LOS was 6 days, and median cost of hospitalization was $51,975. Inhospital mortality rates decreased with increasing hospital TAVI volume with a rate of 6.4% for lowest volume hospitals (first quartile), 5.9% (second quartile), 5.2% (third quartile), and 2.8% for the highest volume TAVI hospitals (fourth quartile). Complication rates were significantly higher in hospitals with the lowest volume quartile (48.5%) compared to hospitals in the second (44.2%), third (39.7%), and fourth (41.5%) quartiles (p <0.001). Increasing hospital volume was independently predictive of shorter LOS and lower hospitalization costs. In conclusion, higher annual hospital volumes are significantly predictive of reduced postprocedural mortality, complications, shorter LOS, and lower hospitalization costs after TAVI. [ABSTRACT FROM AUTHOR]

There is evidence for the lower use of percutaneous mechanical circulatory support (pMCS) in women. We aimed to determine (1) whether gender differences exist regarding in-hospital mortality, hospital course, and procedures; (2) whether socio-demographic and treatment-related factors were associated with these differences. Using the National Inpatient Sample, we collected the International Classification of Diseases, Ninth Revision, Clinical Modification codes for cardiogenic shock (CS) because of acute myocardial infarction AMI or acutely decompensated advanced heart failure and included intra-aortic balloon pump, Impella or Tandem Heart percutaneous ventricular assist devices (pVADs), extracorporeal membrane oxygenation. Demographics, co-morbidities, in-hospital course and procedures were recorded, and the Charlson Co-morbidity Index was calculated. Multivariable hierarchical logistic regression analysis and additional sensitivity analyses were performed. We identified 376,116 cases of CS because of acute myocardial infarction or acutely decompensated advanced heart failure, of which 113,305 required pMCS. Women were more likely to be older, non-White, insured by Medicare, and have a higher burden of co-morbidities and higher Charlson Co-morbidity Index. pMCS devices were inserted in 35,516 women (24.9%) and 77,789 men (33.3%). Women were less likely to receive pVAD or pulmonary artery (PA) catheters. Blood transfusions and acute respiratory failure were more common in women than men. Women had 15% higher in-hospital mortality and in a multivariate analysis, women, older age, having no insurance, diabetes mellitus, chronic kidney disease, cerebrovascular disease, peripheral arterial disease, longer time to pMCS insertion, receiving PA catheter, pVAD or extracorporeal membrane oxygenation and having cardiac arrest were associated with higher in-hospital mortality. In conclusion, women requiring pMCS support had a higher co-morbidity load, in-hospital mortality, acute respiratory failure, blood transfusions, and lower PA catheter use. Studies addressing early gender-specific interventions in CS are needed to reduce these differences., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Data on the trend and impact of mechanical circulatory support (MCS) in patients with Takotsubo cardiomyopathy (TC) are scarce. We evaluated the incidence and outcomes of cardiogenic shock (CS) in TC patients and the trend in use of MCS over time. The National Inpatient Sample from 2005 to 2014 was used to identify patients admitted with TC and those receiving MCS. Multivariate logistic regression was performed to identify predictors of mortality. The Cochran-Armitage test was used for the trend analysis across the years. Admissions for TC showed a linear increase for the study period. From 2005 to 2014 the proportion of TC managed with MCS remained stable, with some yearly fluctuations. Crude in-hospital mortality rate was 2.5% in the patients admitted with TC but was significantly higher in those with CS (15.81% vs 1.68%, p < 0.001). There was no difference in mortality in TC patients with CS, both with and without the use of MCS. However, patients managed with MCS were more likely to be discharged to a skilled nursing facility (31% vs 25.55, p = 0.015) compared with TC patients with CS who were medically managed. The cost of care for patients with TC and CS, managed with MCS was significantly higher than those managed medically ($171K vs $128K, p <0.001). In patients managed with MCS, only sepsis was associated with a higher likelihood of death using multivariate analysis (Odds Ratio 2.538, Confidence Interval 1.245 to 5.172; p = 0.011). In conclusion, the incidence of TC has increased over the years, but the proportion of patients requiring MCS has declined. Crude mortality rate for TC was 2.5%, but was 15.8% in the TC patients with CS. The use of MCS did not lead to improved mortality but was associated with higher cost and increased likelihood of skilled nursing facility discharge., Competing Interests: Declaration of interests The authors declare that they have no known competing financial interests or personal relations that could have appeared to influence the work reported in this report., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Routine preprocedural chest and abdomen computed tomography is done prior to transcatheter aortic valve implantation (TAVI), which, in turn, have led to the discovery of radiographic potentially malignant incidental masses (pMIM). It is largely unknown whether pMIM impact the outcomes of patients undergoing TAVI. In this retrospective cohort study from a single center, 1,081 patients underwent TAVI from 2012 to 2016, who had available computed tomographies, survived the index hospitalization, and also had 1 year follow-up data for review. Machine learning (backward propagation neural network)-augmented multivariable regression for mortality by pMIM was conducted. In this cohort of 1,081 patients, the mean age was 79.1 (± 9.0), 48.8% were females, 16.8% had a history of prior malignancy, and 21.1% had pMIM. One-year mortality for the entire cohort was 12.6%. The most common prior malignancies were prostate, breast, and lymphoma and the most common pMIM were present in the lung, kidneys, and thyroid. In a fully adjusted regression analysis, neither prior malignancy nor pMIM increased mortality odds. However, having both was associated with a higher 1-year mortality (odds ratio 4.02, 95% confidence interval 1.50 to 10.73, p = 0.006). In conclusion, presence of pMIM alone was not associated with an increased 1-year mortality among patients undergoing TAVI. However, the presence of pMIM and a history of prior malignancy was associated with a significant increase in 1-year mortality., (Copyright © 2020 Elsevier Inc. All rights reserved.)