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• Severe OSAS is associated with increased comorbid burden and all-cause mortality. • The prognostic role of comorbidity remains poorly defined. • Age and comorbidity are crucial contributors to increased mortality in severe OSAS. • Clustering of comorbidities allows identify clinically meaningful phenotypes Obstructive sleep apnoea syndrome (OSAS) is a highly prevalent disorder. The prognostic role of comorbidity in patients with OSAS and their role for risk stratification remain poorly defined. We studied 1,592 patients with severe OSAS diagnosed by polysomnography. The primary outcome was all-cause mortality. The standardized mortality ratio (SMR) was estimated as the ratio of observed deaths to expected number of deaths in the general population. The expected numbers of deaths were derived using mortality rates from the general Apulian population. The association of comorbidities with all-cause mortality was assessed using multivariable Cox regression analysis. Finally, recursive-partitioning analysis was applied to identify the combinations of comorbidities that were most influential for mortality and to cluster the patients into risk groups according to individual comorbidities During 11,721 person-years of follow-up, 390 deaths (3.33 deaths/100 person-years) occurred. The median follow-up was 7 (4–10) years. The SMR was 1.47 (95% confidence intervals 1.33–1.63). Age, sex, obesity, cardiovascular diseases (CVD), moderate-to-severe chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD) and malignancy were independently associated with mortality risk. Recursive-partitioning analysis allowed distinguishing three clinical phenotypes differentially associated with mortality risk. The combination of CKD with CVDs or with moderate-to-severe COPD conferred the highest risk. Severe OSAS is associated with increased risk for all-cause death. Age and comorbidity are crucial predictors of mortality in patients with severe OSAS. Clustering patients according to comorbidities allows identifying clinically meaningful phenotypes. [ABSTRACT FROM AUTHOR]

Objective: We sought to determine sex differences in outcomes in patients with severe stroke who had been admitted to inpatient rehabilitation. Methods: We studied 1,316 patients aged 18 to 99 (mean 72) classified as case-mix groups 0108, 0109, and 0110 of the Medicare case-mix classification system. These groups encompass the most severe strokes. Three outcomes were analyzed: (1) 3-year mortality from admission to rehabilitation; (2) combined outcome of transfer to acute care or death within 90 days from admission to rehabilitation; (3) functional outcome, including proportional recovery in motor functioning and good functional outcome as defined by achievement of a Functional Independence Measure (FIM)-motor score ≥65 points at discharge. Multivariable regression analyses were used to assess sex-difference in each outcome between women and men. The covariates examined included age, marital status, comorbidities, time from stroke onset to rehabilitation admission <30 days, ischemic stroke, dysphagia, neglect, motor FIM score at admission, and cognitive FIM score at admission. Results: Kaplan-Meier estimated 3-year mortality rate was 20.7% in women and 22.0% in men. The crude hazard ratio (HR) of death for women compared with men was 0.94 (95% CI 0.74–1.20). After adjustment for significant covariates, the HR of 3-year mortality was 0.73 (95% CIs 0.56–0.96; p = 0.025). Comorbidity, including diabetes, anemia, coronary artery disease, atrial fibrillation, and chronic obstructive pulmonary disease, significantly increased mortality risk by 49–88%. The incidence of the combined outcome was 8.3% in women and 8.4% in men. The crude HR of the combined end-point for women compared with men was 1.05 (95% CI 0.72–1.53). After adjustment for significant covariates, the HR was 0.95 (95% CIs 0.65–1.40; p = 0.810). Likewise, no significant difference in proportional recovery or in the rate of achievement of a good functional outcome between women and men was observed. Conclusion: Among patients admitted to inpatient rehabilitation after severe stroke, women and men had comparable crude mortality rates at 3 years. After multivariable adjustment, however, women had lower mortality risk. No sex-differences in the risk of being transferred to acute care or dying within 90 days from admission to rehabilitation or in responsiveness to rehabilitation were observed. [ABSTRACT FROM AUTHOR]

Objective: To measure competition amongst providers and to examine whether a correlation exists with hospitals mortality for congestive heart failure (CHF), acute myocardial infarction (AMI), isolated-coronary artery bypass graft (CABG) or valve surgery.Design: Cross-sectional study based on publically available data from the National Outcome Evaluation Program (Edition 2016) of the Italian Agency for Regional Health Services.Setting and Participants: Patients discharged during 2015 for CHF or AMI, and between 2014 and 2015 for cardiac surgery (respectively, from 662, 395 and 91 hospitals).Main Outcome Measures: Risk-adjusted mortality rates at 30 days and measures of hospital competition for areas centred on hospital' location (fixed-radius 50-150 km, variable-radius to capture 10-30 hospitals and 6-10% of national volume). Competition was estimated as number of providers and Herfindahl-Hirschman Index (HHI).Results: Indicators of competitions varied by condition and were sensitive to method used for the area definition. Hospital mortality after AMI and valve surgery increased with competition in areas identified by the variable-radius method (higher rates for a greater number of hospitals or lower HHIs). In area with fixed radius of 100-150 km, competition reduced mortality after CABG procedures (lower rates for a greater number of hospitals or smaller HHIs). Neither the number of hospitals nor HHI correlated with outcomes in CHF.Conclusions: The measures of hospital competition changed according to definition of local market and results in mortality correlations varied among conditions. Understanding the relationship between hospital competition and outcomes is important to identify strategies to improve quality of care. [ABSTRACT FROM AUTHOR]

Background Obesity has been suggested to confer a survival benefit in acute heart failure. The concentrations of NT-proBNP may be reduced in patients with high body mass index (BMI). Objectives To investigate the relationship among BMI, NT-proBNP, and mortality risk in decompensated chronic heart failure (DCHF). Methods This was a retrospective study. We studied 1001 patients with DCHF. Hazard ratios (HR) were calculated with Cox regression analysis. Results During the 1-year follow-up, 295 patients died. Compared with normal-weight patients, the unadjusted HR for death were 1.02 (95% CIs 0.79–1.33; p = 0.862) for patients with a BMI of 25.0–29.9 kg/m 2 and 0.83 (95% CIs 0.61–1.12; p = 0.213) for patients with a BMI ≥ 30 kg/m 2 . NT-proBNP remained independently associated with mortality across the BMI categories. There was no statistically significant interaction between BMI and NT-proBNP levels for risk prediction. Conclusions Obesity was not associated with mortality risk. NT-proBNP remained an independent prognostic factor across the BMI categories. [ABSTRACT FROM AUTHOR]

Background Acute heart failure is a common cause of hospitalization among older patients. Optimized risk stratification might improve the outcome for this subgroup of patients. Natriuretic peptides have been used in the diagnosis of heart failure and in evaluating the prognosis of patients hospitalized for heart failure. However, their utility in the elderly is still controversial. Objective To evaluate long-term survival and prognostic factors for elderly patients hospitalized for acutely decompensated heart failure and evaluate the prognostic utility of NT-proBNP. Design Retrospective, multicenter cohort study. Setting Two Italian hospitals. Participants Two hundred seventy-nine patients, aged >75 years; hospitalized for decompensation of chronic, established heart failure. Methods Baseline clinical data were recorded at admission. The primary outcome was long-term mortality. Results In-hospital, 12-month and 5-year mortality were, respectively, 10%, 36%, and 77%. NT-proBNP, eGFR, hemoglobin, diabetes, systolic blood pressure, and moderate to severe tricuspid regurgitation were independently associated with long-term prognosis and were entered into a multivariate model, with a C-index of 0.765 for the determination of high-risk patients. The C-index for NT-proBNP to predict mortality at 2 and 12 months was 0.740 and 0.756, respectively. The optimal cutoff point for predicting mortality at 2 and 12 months was 8,444 pg/mL (hazard ratio 5.33) and 8,275 pg/mL (hazard ratio 6.03), respectively. Conclusion Elderly patients hospitalized for acutely decompensated heart failure had a poor long-term outcome, especially in the subgroup with reduced ejection fraction (EF). In addition to EF and comorbidities, NT-pro-BNP remained independently prognostic among elderly patients hospitalized with heart failure. [ABSTRACT FROM AUTHOR]

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Background To assess the impact of comorbidities on long-term all-cause mortality in patients hospitalized with exacerbated signs/symptoms of previously chronic stable HF (AE-CHF). Methods 1119 patients admitted for AE-CHF and with NT-proBNP levels > 900 pg/mL were enrolled. Univariable and multivariable Cox analyses were performed to assess the association of age, gender, hypertension, diabetes, obesity, atrial fibrillation, coronary heart disease (CHD), chronic obstructive pulmonary disease, previous cerebrovascular accidents, chronic liver disease (CLD), thyroid disease, renal impairment (RI), and anemia with 3-year all-cause mortality. Results During the follow-up, 441 patients died and 126 underwent heart transplantation (HT) or ventricular assist device (VAD) implantation. 45.8% of the fatal events and 52.4% of HT/VAD implantations occurred within 180 days after admission. Increasing age (p = .012), obesity (p = .037), atrial fibrillation (p = .030), CHD (p = .015), CLD (p = .001), RI (p < .001), and anemia (p < .001) were independently associated with 3-year all-cause mortality. Most of the prognostic impact of CHD, took place within the first 180 days after admission. Male gender was associated with mortality beyond 180 days. Compared with normal weight, obesity was associated with better overall survival. Obese patients, however, had significantly lower NT-proBNP concentrations and less frequently presented with hypotension, hyponatremia, and severe left ventricular systolic dysfunction, despite a similar prevalence of severe dyspnea at admission. Conclusions Several comorbidities are associated with long-term risk of death in hospitalized patients with worsening HF, although the nature of this association does appear to be complex. Our data may help to raise awareness about the clinical relevance of comorbid conditions. [ABSTRACT FROM AUTHOR]

• The characteristics and outcomes of patients with heart failure (HF) admitted to inpatient cardiac rehabilitation (CR) are poorly defined. • This lack of knowledge may generate uncertainty about the role of inpatient CR. • Patients admitted to inpatient CR have a poor clinical and functional profile. • In patient CR is effective in improving functional capacity. • In patients with post-acute HF, inpatient CR is associated with improved long-term survival. To investigate the association of cardiac rehabilitation (CR) participation with all-cause mortality after a hospitalization for heart failure (HF) and to describe the characteristics and functional and clinical outcomes of HF patients undergoing inpatient CR. Multicenter cohort study. The association between CR participation and all-cause mortality from discharge from the acute care setting was assessed using Cox regression analysis adjusting for established prognostic factors. Six inpatient rehabilitation facilities. A total of 3219 patients with HF admitted to inpatient CR between January 2013 and December 2016. Of these patients, 1455 had been transferred directly from acute care hospitals after a hospitalization for HF (CR-group 1) and 1764 had been admitted from the community due to worsening functional disability or worsening clinical conditions (CR-group 2). Serving as a control group were 633 patients not referred to CR after a hospitalization for HF served as control group (non–CR group). Cardiac rehabilitation. Long-term mortality. Secondary outcomes were: (1) change in functional capacity, as assessed by change in 6-minute walking distance from admission to discharge; (2) clinical outcomes of the index inpatient rehabilitation admission, including in-hospital mortality and unplanned readmission to the acute care. Compared with the non–CR group, the adjusted hazard ratios of mortality at 1, 3, and 5 years for CR-group 1 patients were 0.82 (range, 0.68-0.97), 0.81 (range, 0.71-0.93), and 0.80 (range, 0.70-0.91). The 6-minute walking distance increased from 230-292 meters (P <.001), and 43.4% of the patients gained >50 m improvement. Overall, 2.5% of the patients died in hospital and 4.7% of the patients experienced unplanned readmissions to acute care, with significant differences between group 1 and group 2. Our data show that inpatient CR is effective in improving functional capacity and suggest that inpatient CR provided in the earliest period after a hospitalization for HF is associated with long-term improved survival. [ABSTRACT FROM AUTHOR]

©2012 Wiley Periodicals Inc. Amino-terminal pro-B-type natriuretic peptide (NT-proBNP) has been associated with prognosis in heart failure. The aim of this study was to assess whether NT-proBNP enhances risk prediction in acute decompensated heart failure (ADHF). The authors enrolled 453 patients hospitalized for ADHF. The primary outcome was 12-month mortality. Two separate multivariable predictive models were built by using standard variables-only and NT-proBNP concentrations. The models were internally validated using the bootstrapping method. Twelve-month mortality was 28.3%. There was no statistical evidence of overfit. Compared with the standard variables-only model, the NT-proBNP model had a better predictive performance as judged by the Nagelkerke R2 (0.410 vs 0.374) and the Brier score (0.136 vs 0.141), which are measures of overall performance; the Akaike Information Criterion (399.2 vs 415.0), which is a tool for model selection; and the C index (0.844 vs 0.831), which is a measure of the discriminative ability. Both models were well calibrated, as judged by the Hosmer-Lemeshow chi-square test. Both models predicted 12-month mortality significantly better than the Enhanced Feedback for Effective Cardiology Treatment risk score. In conclusion, the NT-proBNP model improved risk prediction compared with the standard variables-only model. [ABSTRACT FROM AUTHOR]

Abstract: Background: Accurate identification of renal dysfunction (RD) is crucial to risk stratification in chronic heart failure (CHF). Patients with CHF are at special risk of having RD despite normal serum creatinine (SCr), owing to a decreased Cr generation. At low levels of SCr, the equations estimating renal function are less accurate. This study was aimed to assess and compare the prognostic value of formulas estimating renal function in CHF patients with normal SCr. Methods: We studied 462 patients with systolic CHF and normal SCr. Creatinine clearance was estimated by the Cockcroft–Gault (eCrCl) and glomerular filtration rate by the 4-variable MDRD equation (eGFR); eCrCl normalized for body-surface area (eCrClBSA) was calculated. The primary outcome was all-cause mortality at 2years. Results: Seventy five patients died. At multivariate Cox regression analysis, only eCrClBSA was significantly associated with mortality (p =0.006); eGFR (p =0.24), eCrCl (p =0.09) and BUN (p =0.14) were not statistically significant predictors. The patients in the lowest eCrClBSA quartile had an adjusted 2.1-fold (CI: 1.06–4.1) increased risk of mortality, compared with those in the referent quartile. Two-year survival was 70.4% in the lowest eCrClBSA quartile and 89.7% in the referent quartile. Other independent predictors of mortality were ischemic etiology (RR: 2.16 [CI: 1.3–3.5], p =0.0017), NYHA III/IV class (RR: 2.45 [CI: 1.51–3.97], p =0.0003), LVEF <0.25 (RR: 3.38 [CI: 1.69–6.75], p =0.014), and anemia (RR: 1.86 [CI: 1.16–2.99], p =0.009). Conclusions: A sizeable proportion of CHF patients have prognostically significant RD despite normal SCr. Such patients represent a high-risk subgroup and can more accurately be identified by the CG formula corrected for BSA than the MDRD. [Copyright &y& Elsevier]

Background: reduced renal excretory function (REF) is increasingly being appreciated as a potent prognostic factor in chronic heart failure (CHF). The Cockroft-Gault (CG) and the simplified Modification of Diet in Renal Disease (MDRD) equations have been recommended to estimate REF. However, limitations for both formulas have been reported in the elderly. Their prognostic performance in older CHF patients has not been investigated. Objectives: to assess the factors independently associated with all-cause mortality and compare the prognostic value of formulas estimating REF in CHF patients aged ⩾70 years. Design: a longitudinal study with a median follow-up of 859 days. The end-point was all-cause mortality. Setting: Division of Cardiology and Cardiac Rehabilitation. Subjects: two hundred and sixty-six patients aged ⩾70 years with systolic CHF. Methods: REF was estimated using the CG (eCrClCG) and the MDRD (eGFRMDRD) formulas. Cox proportional hazards model was used to assess the factors independently associated with mortality and compare the prognostic value of estimating formulas. Receiver-operating characteristic (ROC) curve analysis was also performed. Results: Kaplan-Meier estimates of the rates of death at 1 and 2 years were 85% and 73%, respectively At multivariate analysis, eCrClCG <50 mL/min (P = 0.005), anaemia (P = 0.012), non-prescription of beta-blockers (P = 0.006) and left ventricular ejection fraction (P 0.03) were the only independent predictors of mortality. On ROC analysis, the eCrClCG was significantly more accurate than the eGFRMDRD. Conclusions: among CHF patients aged ⩾70 years, reduced REF is the most powerful independent predictor of survival. The excess in risk conferred by reduced REF is better appraised by means of the CG than the MDRD equation. [ABSTRACT FROM AUTHOR]