Impact of Anemia on In-Hospital, One-Month and One-Year Mortality in Patients with Acute Coronary Syndrome from the Middle East
TL;DR: Admission anemia in patients with ACS from six Middle-Eastern countries was strongly associated with mortality at in-hospital, one-month, and at one-year, Hence, admission anemia must be considered in the initial risk assessment of ACS patients along with other risk scores.
Abstract: Aim
The aim of this study was to evaluate the impact of admission anemia on in-hospital, one-month, and one-year mortality in patients from the Middle East with acute coronary syndrome (ACS).
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TL;DR: Hemoglobin variability is not only important predictor in patients with chronic renal failure and cardiovascular disease but could also be considered as a useful predictor of mortality in the general population.
Abstract: Hemoglobin variability is known to be associated with mortality in patients with chronic renal failure and cardiovascular disease. However, the effect of hemoglobin variability on mortality in the general population has not yet been studied. We aimed to investigate the association between hemoglobin variability and mortality using Korean cohort from National Health Insurance Service-Health Screening 2002-2015 database. This study was conducted on 182,757 adults who underwent more than 4 health screenings from 2002 to 2009. Hemoglobin variability was assessed by 3 indices of coefficient of variation (CV), standard deviation (SD), and variability independent of the mean (VIM). Cox proportional hazard regression analysis was performed for each index of quartile groups (Q1-Q4). The hazard ratio and 95% confidence interval^l for all-cause mortality comparing Q2, Q3 and Q4 with Q1 of hemoglobin variability CV in the multivariable adjusted model were 1.07 [0.96-1.20], 1.18 [1.06-1.31] and 1.43 [1.29-1.58] respectively. As the 5% CV, SD, and VIM increased, the hazard ratio for mortality increased by 1.08 [1.06-1.10] in the multivariable adjusted model. Hemoglobin variability is not only important predictor in patients with chronic renal failure and cardiovascular disease but could also be considered as a useful predictor of mortality in the general population.
4 citations
TL;DR: The NHL score could be a novel model for predicting long-term MACCEs in patients with AMI and significantly improved the reclassification and integrated discrimination compared with NLR and SII.
Abstract: We developed and assessed whether a novel neutrophil-to-hemoglobin and lymphocyte (NHL) score would improve the ability to predict clinical outcome compared with neutrophil-to-lymphocyte ratio (NLR...
3 citations
TL;DR: It was found that in-hospital heart failure followed by anemia was the most important predictor of mortality, however, anemiawas the first most important predictors for both in- hospital heart failure, and bleeding.
Abstract: Acute coronary syndromes (ACS) are a leading cause of deaths worldwide, yet the diagnosis and treatment of this group of diseases represent a significant challenge for clinicians. The epidemiology of ACS is extremely complex and the relationship between ACS and patient risk factors is typically non-linear and highly variable across patient lifespan. Here, we aim to uncover deeper insights into the factors that shape ACS outcomes in hospitals across four Arabian Gulf countries. Further, because anemia is one of the most observed comorbidities, we explored its role in the prognosis of most prevalent ACS in-hospital outcomes (mortality, heart failure, and bleeding) in the region. We used a robust multi-algorithm interpretable machine learning (ML) pipeline, and 20 relevant risk factors to fit predictive models to 4,044 patients presenting with ACS between 2012 and 2013. We found that in-hospital heart failure followed by anemia was the most important predictor of mortality. However, anemia was the first most important predictor for both in-hospital heart failure, and bleeding. For all in-hospital outcome, anemia had remarkably non-linear relationships with both ACS outcomes and patients’ baseline characteristics. With minimal statistical assumptions, our ML models had reasonable predictive performance (AUCs > 0.75) and substantially outperformed commonly used statistical and risk stratification methods. Moreover, our pipeline was able to elucidate ACS risk of individual patients based on their unique risk factors. Fully interpretable ML approaches are rarely used in clinical settings, particularly in the Middle East, but have the potential to improve clinicians’ prognostic efforts and guide policymakers in reducing the health and economic burdens of ACS worldwide.
1 citations
TL;DR: The main symptoms of angina and dyspnea reported in the anamnesis, and the obvious pallor in the physical examination, were the key data to identify anaemia as a cause ofAngina in the case presented.
Abstract: Ischaemic heart disease is the leading cause of mortality and morbidity and one of the primary causes of morbidity in Spain. The variability in the clinical presentation of this condition at both primary care and emergency services level requires a careful history and a thorough physical examination. In the case presented, the main symptoms of angina and dyspnea reported in the anamnesis, and the obvious pallor in the physical examination, were the key data to identify anaemia as a cause of angina.
1 citations
08 Dec 2020
TL;DR: The study showed that in patients with STEMI undergoing primary PCI, hemoglobin level had a significant association with post procedural low TIMI flow and no-reflow, emphasizing the need for randomized control trials to evaluate the importance of pre-simultaneous blood transfusion in patientsWith anemia undergoing PPCI.
Abstract: Background: Anemia is a predictor of no reflow with high rate morbidity and mortality particularly in patients with heart failure. Objectives: The aim of this study was to investigate the relation between hemoglobin level and no-reflowing in patients with myocardial infarction undergoing primary PCI. Methods: In this retrospective cross sectional study, all patients with ST elevation myocardial infarction (STEMI) undergoing coronary angiography from 2016 till 2018 were included. According to post procedural TIMI flow, the patients were divided into two groups: patients with TIMI flow III and those with TIMI flow less than III. Patients’ demographic and laboratory data such as hemoglobin, hematocrit, platelets count, white blood cells, serum creatinine level and troponin were collected. To compare the quantitative variables chi square test and to compare qualitative variables t-test were applied by SPSS software version 19. Results: In this study 1200 patients with acute ST elevation myocardial infarction (STEMI) treated with primary PCI were included. The mean Hemoglobin level in normal TIMI group and low TIMI group were 14.15 ± 1.49 and 13.66 ± 1.69, respectively (P < 0.001). Our results also showed a significant lower RBC count (P < 0.001), lower HCT level (P < 0 .001) and lower RDW (P < 0.001) in those patients with lower TIMI flow. Based on the multivariate regression analysis lower hemoglobin has a significant association with lower TIMI flow and no-reflow (OR = 0.747, CI = 0.618 - 0.888, P < 0.001). Conclusions: Our study showed that in patients with STEMI undergoing primary PCI, hemoglobin level had a significant association with post procedural low TIMI flow and no-reflow. Our results emphasize the need for randomized control trials to evaluate the importance of pre-simultaneous blood transfusion in patients with anemia undergoing PPCI.
References
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TL;DR: Across the entire spectrum of ACS and in general clinical practice, this model provides excellent ability to assess the risk for death and can be used as a simple nomogram to estimate risk in individual patients.
Abstract: Background Management of acute coronary syndromes (ACS) should be guided by an estimate of patient risk. Objective To develop a simple model to assess the risk for in-hospital mortality for the entire spectrum of ACS treated in general clinical practice. Methods A multivariable logistic regression model was developed using 11 389 patients (including 509 in-hospital deaths) with ACS with and without ST-segment elevation enrolled in the Global Registry of Acute Coronary Events (GRACE) from April 1, 1999, through March 31, 2001. Validation data sets included a subsequent cohort of 3972 patients enrolled in GRACE and 12 142 in the Global Use of Strategies to Open Occluded Coronary Arteries IIb (GUSTO-IIb) trial. Results The following 8 independent risk factors accounted for 89.9% of the prognostic information: age (odds ratio [OR], 1.7 per 10 years), Killip class (OR, 2.0 per class), systolic blood pressure (OR, 1.4 per 20-mm Hg decrease), ST-segment deviation (OR, 2.4), cardiac arrest during presentation (OR, 4.3), serum creatinine level (OR, 1.2 per 1-mg/dL [88.4-µmol/L] increase), positive initial cardiac enzyme findings (OR, 1.6), and heart rate (OR, 1.3 per 30-beat/min increase). The discrimination ability of the simplified model was excellent with c statistics of 0.83 in the derived database, 0.84 in the confirmation GRACE data set, and 0.79 in the GUSTO-IIb database. Conclusions Across the entire spectrum of ACS and in general clinical practice, this model provides excellent ability to assess the risk for death and can be used as a simple nomogram to estimate risk in individual patients.
2,053 citations
TL;DR: The c statistic, or area under the receiver operating characteristic (ROC) curve, achieved popularity in diagnostic testing, in which the test characteristics of sensitivity and specificity are relevant to discriminating diseased versus nondiseased patients, may not be optimal in assessing models that predict future risk or stratify individuals into risk categories.
Abstract: The c statistic, or area under the receiver operating characteristic (ROC) curve, achieved popularity in diagnostic testing, in which the test characteristics of sensitivity and specificity are relevant to discriminating diseased versus nondiseased patients. The c statistic, however, may not be optimal in assessing models that predict future risk or stratify individuals into risk categories. In this setting, calibration is as important to the accurate assessment of risk. For example, a biomarker with an odds ratio of 3 may have little effect on the c statistic, yet an increased level could shift estimated 10-year cardiovascular risk for an individual patient from 8% to 24%, which would lead to different treatment recommendations under current Adult Treatment Panel III guidelines. Accepted risk factors such as lipids, hypertension, and smoking have only marginal impact on the c statistic individually yet lead to more accurate reclassification of large proportions of patients into higher-risk or lower-risk categories. Perfectly calibrated models for complex disease can, in fact, only achieve values for the c statistic well below the theoretical maximum of 1. Use of the c statistic for model selection could thus naively eliminate established risk factors from cardiovascular risk prediction scores. As novel risk factors are discovered, sole reliance on the c statistic to evaluate their utility as risk predictors thus seems ill-advised.
1,815 citations
TL;DR: The c statistic, or area under the receiver operating characteristic (ROC) curve, achieved popularity in diagnostic testing, in which the test characteristics of sensitivity and specificity are relevant to discriminating diseased versus nondiseased patients, may not be optimal in assessing models that predict future risk or stratify individuals into risk categories.
Abstract: I am pleased that Pepe et al agree that the C-statistic is not a relevant measure of clinical value despite its use as such in the clinical literature They remain, however, interested in sensitivity and specificity It is true that in the high-density lipoprotein example the sensitivity, or probability of inclusion in the highest risk group among cases, improves in the model with high-density lipoprotein, whereas the specificity, or probability of inclusion in the lowest risk group among controls, declines The model with high-density lipoprotein …
1,077 citations
TL;DR: Blood transfusion in the setting of acute coronary syndromes is associated with higher mortality, and this relationship persists after adjustment for other predictive factors and timing of events.
Abstract: ContextIt is unclear if blood transfusion in anemic patients with acute coronary
syndromes is associated with improved survival.ObjectiveTo determine the association between blood transfusion and mortality
among patients with acute coronary syndromes who develop bleeding, anemia,
or both during their hospital course.Design, Setting, and PatientsWe analyzed 24 112 enrollees in 3 large international trials of
patients with acute coronary syndromes (the GUSTO IIb, PURSUIT, and PARAGON
B trials). Patients were grouped according to whether they received a blood
transfusion during the hospitalization. The association between transfusion
and outcome was assessed using Cox proportional hazards modeling that incorporated
transfusion as a time-dependent covariate and the propensity to receive blood,
and a landmark analysis.Main Outcome MeasureThirty-day mortality.ResultsOf the patients included, 2401 (10.0%) underwent at least 1 blood transfusion
during their hospitalization. Patients who underwent transfusion were older
and had more comorbid illness at presentation and also had a significantly
higher unadjusted rate of 30-day death (8.00% vs 3.08%; P<.001), myocardial infarction (MI) (25.16% vs 8.16%; P<.001), and death/MI (29.24% vs 10.02%; P<.001)
compared with patients who did not undergo transfusion. Using Cox proportional
hazards modeling that incorporated transfusion as a time-dependent covariate,
transfusion was associated with an increased hazard for 30-day death (adjusted
hazard ratio [HR], 3.94; 95% confidence interval [CI], 3.26-4.75) and 30-day
death/MI (HR, 2.92; 95% CI, 2.55-3.35). In the landmark analysis that included
procedures and bleeding events, transfusion was associated with a trend toward
increased mortality. The predicted probability of 30-day death was higher
with transfusion at nadir hematocrit values above 25%.ConclusionsBlood transfusion in the setting of acute coronary syndromes is associated
with higher mortality, and this relationship persists after adjustment for
other predictive factors and timing of events. Given the limitations of post
hoc analysis of clinical trials data, a randomized trial of transfusion strategies
is warranted to resolve the disparity in results between our study and other
observational studies. We suggest caution regarding the routine use of blood
transfusion to maintain arbitrary hematocrit levels in stable patients with
ischemic heart disease.
979 citations
"Impact of Anemia on In-Hospital, On..." refers background in this paper
...In addition, the need for blood transfusion due to anemia in the setting of ACS is associated with higher short-term mortality.(10) Furthermore, a low baseline hemoglobin level in ACS patients has been found to be an independent predictor of the risk of in-hospital major bleeding and risk of death and myocardial infarction at 30 days....
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649 citations