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The CHA2DS2-VASc score incorporates several comorbidities which have prognostic implications in COVID-19. We assessed whether a modified score (M-R2CHA2DS2-VASc), which includes pre-admission kidney function and male sex, could be used to classify mortality risk among people hospitalized with COVID-19. This retrospective study included adults admitted for COVID-19 between March and December 2020. Pre-admission glomerular filtration rate (GFR) was calculated based on serum creatinine and used for scoring M-R2CHA2DS2-VASc. Participants were categorized according to the M-R2CHA2DS2-VASc categories as 0–1 (low), 2–3 (intermediate), or ≥ 4 (high), and according to initial COVID-19 severity score. The primary outcome was 30-day mortality rates. Secondary outcomes were mortality rates over time, and rates of mechanical ventilation, hemodynamic support, and renal replacement therapy. Eight hundred hospitalizations met the study criteria. Participants were 55% males, average age was 65.2 ± 17 years. There were similar proportions of subjects across the M-R2CHA2DS2-VASc categories. 30-day mortality was higher in those in higher M-R2CHA2DS2-VASc category and with severe or critical COVID-19 at admission. Subjects in the low, intermediate, and high M-R2CHA2DS2-VASc categories had 30-day mortality rates of 4.7%, 17% and 31%, respectively (p < 0.001). Higher category was also associated with increased need for mechanical ventilation and renal replacement therapy. All-cause 90-day mortality remained significantly associated with M-R2CHA2DS2-VASc. The M-R2CHA2DS2-VASc score is associated with 30-day mortality rates among patients hospitalized with COVID-19, and adds predictive value when combined with initial COVID-19 severity. [ABSTRACT FROM AUTHOR]

Brain atrophy (BA) is often found in neuroimaging of hemodialysis patients, representing parenchymal cerebral damage. Likely contributing factors to BA are age, chronic hypertension, diabetes mellitus and other cardiovascular risk factors of atherosclerosis that are also common among hemodialysis patients. BA may also occur due to focal ischemia and hypoperfusion during hemodialysis. However, data on optimal blood pressure (BP) in these patients are limited. The goal of this study was to determine whether the prevalence and severity of BA would be higher among hemodialysis patients with lower BP. A blinded neuroradiologist graded BA of all hemodialysis patients who underwent brain non‐contrast computerized tomography (CT) from 2015 to 2017 in our institution. Age‐ and sex‐matched patients with normal kidney function who underwent brain CT during the same period and technique served as the control group. A total of 280 patients were included in this retrospective study, with average BP of 140/70 mmHg among hemodialysis patients and 142/75 mmHg in the control group. BA was more common in dialysis patients and its severity increased with age and traditional cardiovascular risk factors. We observed a significant negative correlation between diastolic BP (DBP) at dialysis initiation and BA. Average DBP decreased with increasing severity of BA. These findings were observed in both hemodialysis and non‐CKD patients. BA was associated with lower DBP, which may induce cerebral hypoperfusion and ischemia. This finding should discourage over‐treatment of hypertension among hemodialysis patients. [ABSTRACT FROM AUTHOR]

Aims  Asses the added value of quantitative evaluation of tricuspid regurgitation (TR), the proper cut-off value for severe TR and 'torrential TR' based on outcome data. The added value of quantitative evaluation of TR, and the cut-off values associated with increased mortality are unknown. Methods and results In patients with all-cause TR assessed both qualitatively and quantitatively by proximal iso-velocity surface area method, long-term and 1-year outcome analysis was conducted. Thresholds for excess mortality were assessed using spline curves, receiver-operating characteristic curves, and minimum P- value analysis. The study involved 676 patients with all-cause TR (age 73.9 ± 14 years, male 45%, ejection fraction 52.9 ± 14%). Effective regurgitant orifice (ERO) was strongly associated with decreased survival in unadjusted [hazard ratio (HR) 2.38 (1.79–3.01), P  < 0.0001 per 0.1 cm2 increment] and adjusted [2.6 (1.25–5.0), P  = 0.01] analyses. Quantitative grading was superior to qualitative grading in prediction of outcome (P  < 0.01). The optimal cut-off value for the best separation in survival between groups of patients with severe vs. lesser degree of TR was 0.35 cm2 [ P  < 0.0001, HR =2.0 (1.5–2.7)]. ERO negatively impacted survival, even when including only the subgroup of patients with severe TR [HR 1.5 (1.01–2.3); P  = 0.04]. The optimal threshold corresponding for the best separation for survival between groups of patients with severe vs. 'torrential' TR was 0.7 cm2 [ P  = 0.005, HR =2.6 (1.2–5.1)]. Conclusion  TR can be severe and even 'torrential' and is associated with excess mortality. Quantitative assessment of TR by ERO measurement is a powerful independent predictor of outcome, superior to standard qualitative assessment. The optimal cut-off above which mortality is increased is 0.35 cm2, similar albeit slightly lower than suggested in recent guidelines. Torrential TR >0.7 cm2 is associated with poorer survival compared to patients with severe TR (ERO > 0.4 cm2 and <0.7 cm2). [ABSTRACT FROM AUTHOR]

Background: Chest-pain patients with no evidence of acute coronary syndrome might still be at risk for adverse outcomes. Adding renal function to the classic scoring of CHADS and CHA 2 DS 2 VASC may improve risk stratification of chest-pain patients discharged from internal medicine wards after acute coronary syndrome (ACS) rule-out., Methods: We accessed medical records of patients admitted to internal medicine wards during 2010-2016 and discharged following ACS rule-out. A R 2 CHA 2 DS 2 -VASc score model that included higher scores as kidney function deteriorated was calculated and compared to CHADS and CHA 2 DS 2 VASC scores. The primary endpoint was the composite of 30-day ACS and mortality. One-year ACS and 1-year mortality were the secondary endpoints. The study included 12,449 patients, stratified into three risk groups according to their R 2 CHA 2 DS 2 -VASc score., Results: Participants were stratified into 3 groups according to R 2 CHA 2 DS 2 -VASc score. R 2 CHA 2 DS 2 -VASc score predicted better the composite outcome of ACS and 30-day and 1-year mortality after discharge (OR: 4, 95%, CI 2.3-7, p < 0.01 and OR: 13.3, 95% CI 7.8-22.7, p < 0.01, respectively). Receiver operating characteristic curve analysis showed better risk stratification of the R 2 CHA 2 DS 2 -VASc compared with both CHADS and CHA 2 DS 2 VASC score., Conclusions: The R 2 CHA 2 DS 2 -VASc score is a better predictor of short- and long-term cardiovascular morbidity and mortality after hospital discharge., (Copyright © 2020. Published by Elsevier Ltd.)

Aims: Asses the added value of quantitative evaluation of tricuspid regurgitation (TR), the proper cut-off value for severe TR and 'torrential TR' based on outcome data. The added value of quantitative evaluation of TR, and the cut-off values associated with increased mortality are unknown., Methods and Results: In patients with all-cause TR assessed both qualitatively and quantitatively by proximal iso-velocity surface area method, long-term and 1-year outcome analysis was conducted. Thresholds for excess mortality were assessed using spline curves, receiver-operating characteristic curves, and minimum P-value analysis. The study involved 676 patients with all-cause TR (age 73.9 ± 14 years, male 45%, ejection fraction 52.9 ± 14%). Effective regurgitant orifice (ERO) was strongly associated with decreased survival in unadjusted [hazard ratio (HR) 2.38 (1.79-3.01), P < 0.0001 per 0.1 cm2 increment] and adjusted [2.6 (1.25-5.0), P = 0.01] analyses. Quantitative grading was superior to qualitative grading in prediction of outcome (P < 0.01). The optimal cut-off value for the best separation in survival between groups of patients with severe vs. lesser degree of TR was 0.35 cm2 [P < 0.0001, HR =2.0 (1.5-2.7)]. ERO negatively impacted survival, even when including only the subgroup of patients with severe TR [HR 1.5 (1.01-2.3); P = 0.04]. The optimal threshold corresponding for the best separation for survival between groups of patients with severe vs. 'torrential' TR was 0.7 cm2 [P = 0.005, HR =2.6 (1.2-5.1)]., Conclusion: TR can be severe and even 'torrential' and is associated with excess mortality. Quantitative assessment of TR by ERO measurement is a powerful independent predictor of outcome, superior to standard qualitative assessment. The optimal cut-off above which mortality is increased is 0.35 cm2, similar albeit slightly lower than suggested in recent guidelines. Torrential TR >0.7 cm2 is associated with poorer survival compared to patients with severe TR (ERO > 0.4 cm2 and <0.7 cm2)., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.)

Background: Chest-pain patients deemed safe for discharge from internal medicine wards might still be at risk for adverse outcomes., Hypothesis: CHA 2 DS 2 -VASc score improves risk stratification of low-risk chest-pain patients discharged after acute coronary syndrome (ACS) rule-out., Methods: We accessed medical records of patients who were admitted to internal medicine wards at a single medical center during 2010-2016 and discharged following an ACS rule-out. Patients were classified according to CHA 2 DS 2 -VASc score: 0-1 (low), 2-3 (intermediate), >3 (high). Primary endpoint was occurrence of ACS at 1 year; 30-day and 1-year all-cause mortality (ACM) were secondary outcomes., Results: Of 12 449 patients, 7057 (57%) had low, 3781 (30%) intermediate, and 1611 (13%) high CHA 2 DS 2 -VASc scores. Compared with a low score, intermediate and high scores were associated with significantly increased risk for 1-year ACS during the first year (OR: 2.89, 95% CI: 1.91-4.37, P < 0.01 and OR: 4.84, 95% CI: 3.02-7.74, P < 0.01, respectively). Each 1-point increase in CHA 2 DS 2 -VASc was associated with a 37% increased risk for 1-year ACS. A higher CHA 2 DS 2 -VASc score was associated with significantly higher 30-day ACM. Hazard ratios for 30-day ACM were 1.9 (95% CI: 1.1-3.4, P = 0.03) and 4.4 (95% CI: 2.4-7.9, P < 0.01) for intermediate and high CHA 2 DS 2 -VASc scores, respectively, compared with a low score. Each 1-point increase in CHA 2 DS 2 -VASc score was associated with 43% increased risk for 30-day mortality., Conclusions: High CHA 2 DS 2 -VASc score (>3) was associated with adverse outcomes among chest-pain patients discharged from internal medicine wards following ACS rule-out., (© 2018 Wiley Periodicals, Inc.)