Background Many specific prognostic risk scores have been validated for myocardial infarction (MI), such as the Global Registry of Acute Coronary Events (GRACE) 2.0. Other general risk scores are used in intensive care units (ICUs), such as the Acute Physiologic and Chronic Health Evaluation (APACHE) II and the Simplified Acute Physiology Score (SAPS) II. Purpose Compare the ability of GRACE 2.0, APACHE II and SAPS II risk scores to estimate in-hospital, 3- and 12-month mortality after primary angioplasty (PA) for ST-segment elevation MI (STEMI). Methods Retrospective cohort of 427 consecutive STEMI patients (64 years [55–75]; 78% men) admitted to a general ICU between November-2013 and February-2017. We used Area under the Receiver Operating Characteristic (ROC) curve (AUC) analysis to asses performance of risk scores, and the Hosmer-Lemeshow (HL) goodness of fit test and the Standardized Mortality Ratio (SMR) to assess calibration. Results All risk scores were associated with in-hospital, 3- and 12-month mortality (P<0.001). SAPS II had the highest sensitivity for short-term mortality and the highest AUC for in-hospital, 3- and 12-month mortality (Figure). SAPS II had the highest calibration and the less underestimation of mortality in all follow-up periods analysed (Table). Performance of prognostic risk scores Youden index (J) Sensitivity (%) Specificity (%) AUC (95% CI) H-L (P value) SMR In-Hospital mortality (5.4%)   SAPS II 32 87.0 89.4 0.938 (0.887–0.988) 1.826 (0.969) 1.64   GRACE 2.0 150 86.9 83.7 0.922 (0.865–0.979) 8.111 (0.423) 1.77   APACHE II 17 82.6 93.8 0.896 (0.841–0.986) 11.941 (0.154) 1.92 3-month mortality (5.6%)   SAPS II 32 79.2 89.1 0.913 (0.854–0.973) 3.635 (0.821) 1.85   GRACE 2.0 150 79.1 85.4 0.902 (0.842–0.962) 5.149 (0.742) 2.0   APACHE II 17 79.1 93.8 0.882 (0.792–0.971) 9.244 (0.322) 2.0 12-month mortality (7.0%)   SAPS II 32 73.3 89.7 0.880 (0.809–0.951) 1.994 (0.960) 1.58   GRACE 2.0 150 76.7 84.1 0.878 (0.816–0.941) 4.073 (0.850) 2.31   APACHE II 17 70.0 92.4 0.824 (0.722–0.927) 7.464 (0.487) 2.14 AUC: Area under the curve; H-L: Hosmer-Lemeshow; SMR: Standardized Mortality Ratio. Area under the ROC curves (AUC) Conclusions SAPS II represents the best model to estimate mortality in this cohort of STEMI patients, with an appropriate calibration and less underestimation of mortality. Underestimation of mortality showed by all risk scores suggests the need of creating new risk prediction models that improve identification of high risk STEMI patients.

Background:In hospitalized patients elevated D-dimer concentration is associated with an increased risk of occurrence for VTE and mortality. D-dimer concentration may be used to identify medical patients at an elevated VTE risk, who might benefit from extended thromboprophylaxis following hospitalization for an acute illness. Methods: This is a post hoc sub-study of the Acute Medically Ill VTE Prevention with Extended Duration Betrixaban (APEX) trial. The aim was to evaluate the modulation of the treatment effect of betrixaban versus standard duration enoxaparin as a function of D-dimer concentrations, both as a discrete and continuous measurement.Results: There was no interaction between positive D-dimer levels and betrixaban efficacy (Pint=0.54). In D-dimer positive subjects (≥2x ULN), as determined by the central laboratory, extended duration betrixaban versus standard enoxaparin significantly reduced the risk of all VTE (OR=0.71; 95% CI: 0.55-0.90; p=0.005) and asymptomatic DVT (OR=0.68; 95% CI: 0.52-0.89; p=0.004). These results are consistent with previously published findings from the Magellan trial (Risk for VTE among D-dimer positive subjects, as measured by central lab: RR=0.71; 95% CI: 0.54-0.92; p<0.001). For every 0.25 μg/mL increase in Ddimer concentration, there was a 2% relative increase in the odds of experiencing a VTE (DVT, nonfatal PE, or VTE-related death) in both the betrixaban (p<0.001) and enoxaparin (p<0.001) treatment arms ( Figure), resulting in greater absolute reductions with extended betrixaban. Conclusions: Increased D-dimer concentration was associated with increased risk for VTE. While relative benefit of betrixaban over enoxaparin was consistent across D-dimer concentrations, greater absolute benefits were observed at high D-dimer concentrations.

Background Gender-based differences in mortality of patients with ST-segment elevation myocardial infarction (STEMI) have been reported. However, controversy exists about the impact of female gender on mortality after correcting for baseline risk differences. Purpose Assess gender-based mortality in a cohort of STEMI patients following primary angioplasty. Methods Retrospective cohort of 427 consecutive STEMI patients (64 years [55–75]; 78% men) admitted to a general ICU between November-2013 and February-2017. We used Kaplan-Meier and Cox regression models for survival analysis. The Clinical Frailty Scale (CFS) was used to assess frailty. Results Women were older and had a higher GRACE 2.0 and frailty (CFS≥4). Women had lower creatine-phosphokinase and albumin levels and higher B-natriuretic peptide levels, despite the lack of gender-based differences in left ventricular ejection fraction (LVEF) and MI size and location. One-year mortality rate was higher in women, most often from cardiogenic shock during admission and at 30-day follow-up (Table). After Cox regression analysis, women had a 2.23-fold higher risk of one-year mortality compared with men (Figure), independently of age, frailty, GRACE 2.0, LVEF and inotropic agents requirements. Baseline characteristics Women (n=93) Men (n=334) P value One-year mortality, n (%) 15 (16.1) 15 (4.5) <0.001 Cardiogenic shock, n (%) 10 (62.5) 6 (37.5) <0.001 Age (years) 70.8 [51.2–80.3] 61.9 [54.2–71.8] <0.001 Hypertension, n (%) 54 (58.1) 149 (44.6) 0.022 GRACE 2.0 129 [104.5–156] 112 [94–139] 0.001 Clinical Frailty Scale≥4, n (%) 28 (30.1) 32 (9.6) <0.001 MI location (anterior), n (%) 42 (45.2) 152 (45.5) 0.953 Creatin-phosphokinase (UI/L) 1040 [300.5–2134] 1517 [620.5–2852.8] 0.004 High-sensitivity troponin I (pg/mL) 4003 [62.1–48526.6] 9070 [65.8–65893] 0.473 Left ventricular ejection fraction (%) 52 [40–60] 55 [45–60] 0.465 B-natriuretic peptide (pg/mL) 241.1 [99.9–896.9] 103.6 [28.3–259.2] <0.001 Albumin (g/L) 36.1 [34.3–38.5] 38.4 [35.6–40.5] <0.001 Inotropic agents, n (%) 14 (15.1) 26 (7.8) 0.033 Kaplan-Meier and Cox survival curves. Conclusions Female gender is an independent predictor of one-year mortality in STEMI patients, regardless of age, clinical severity and frailty. A potential myocardial disfunction probably mediated by an increased frailty, may play a role in the high mortality rate among women after STEMI.

Background Malnutrition and sarcopenia are common features of frailty. Prevalence of frailty among ST-segment elevation myocardial infarction (STEMI) patients is higher in women than men. Purpose Assess gender-based differences in the impact of nutritional risk index (NRI) and frailty in one-year mortality rate among STEMI patients following primary angioplasty (PA). Methods Cohort of 321 consecutive patients (64 years [54–75]; 22.4% women) admitted to a general ICU after PA for STEMI. NRI was calculated as 1.519 × serum albumin (g/L) + 41.7 × (actual body weight [kg]/ideal weight [kg]). Vulnerable and moderate to severe NRI patients were those with Clinical Frailty Scale (CFS)≥4 and NRI&lt;97.5, respectively. We used Kaplan-Meier survival model. Results Baseline and mortality variables of 4 groups (NRI-/CFS-; NRI+/CFS-; NRI+/CFS- and NRI+/CFS+) are depicted in the Table. Prevalence of malnutrition, frailty or both were significantly greater in women (34.3%, 10% y 21.4%, respectively) than in men (28.9%, 2.8% y 6.0%, respectively; P&lt;0.001). Women had greater mortality rate (20.8% vs. 5.2%: OR 4.78, 95% CI, 2.15–10.60, P&lt;0.001), mainly from cardiogenic shock (P=0.003). Combination of malnutrition and frailty significantly decreased cumulative one-year survival in women (46.7% vs. 73.3% in men, P&lt;0.001) Conclusion Among STEMI patients undergoing PA, the prevalence of malnutrition and frailty are significantly higher in women than in men. NRI and frailty had an independent and complementary prognostic impact in women with STEMI. Kaplan-Meier and Cox survival curves Funding Acknowledgement Type of funding source: None

Background Frailty is characterized by decline in physiologic reserve and function leading to increased vulnerability. Sarcopenia, one of its features, has been associated with cardiac dysfunction. Purpose Assess frailty-based mortality in ST-segment elevation myocardial infarction (STEMI) patients following primary angioplasty. Methods Retrospective cohort of 427 consecutive STEMI patients (64 years [55–75]; 78% men) admitted to a general ICU between November-2013 and February-2017. We assessed frailty with the Clinical Frailty Scale (CFS). We used Kaplan-Meier and Cox regression models for survival analysis, stratified by CFS score categories (Figure). For clinical relevance, patients were dichotomized in robust (CFS 1–3) and vulnerable (CFS ≥4). Results Vulnerable patients were older, had more comorbidities and a higher GRACE 2.0. They had lower CK and albumin levels and higher BNP levels, despite the lack of frailty-based differences in LVEF and MI size and location. One-year mortality rate was higher in vulnerable patients (Table). After Cox regression analysis, vulnerable patients (CFS ≥4) showed a 3.37-fold higher risk of one-year mortality than robust ones (95% CI, 1.59–7.15; P=0.002), independently of age, gender, GRACE 2.0 or LVEF. Baseline characteristics Vulnerable (CFS ≥4) Robust (CFS 1–3) P value (n=60) (n=367) One-year mortality, n (%) 15 (25) 14 (4.1) <0.001 Age (years) 78 [67–85] 61 [54–72] <0.001 Gender (women), n (%) 28 (46.7) 65 (17.7) <0.001 Hypertension, n (%) 47 (78.3) 156 (42.5) <0.001 Diabetes mellitus, n (%) 31 (51.7) 79 (21.5) <0.001 GRACE 2.0 150 [129–170.8] 112 [93–136] <0.001 Left ventricular ejection fraction (%) 52 [40–60] 55 [45–60] 0.151 MI location (anterior), n (%) 26 (43.3) 168 (45.8) 0.781 Creatin-phosphokinase (UI/L) 921 [286.8–2072] 1496 [607–2786] 0.011 High-sensitivity troponin I (pg/mL) 3699.5 [38–47968.1] 8789.8 [65.8–61970] 0.537 B-natriuretic peptide (pg/mL) 267.9 [117.3–901.6] 104.3 [29.5–268.7] <0.001 Albumin (g/L) 34.9 [32.8–37.4] 38.4 [35.7–40.4] <0.001 Kaplan-Meier and Cox survival curves. Conclusions Frailty is an independent predictor of one-year mortality in STEMI patients, independently of age, clinical severity and ventricular function. Frailty assessment should be routinely included in the clinical examination and decision-making process of STEMI patients.