Qi Guo

Early identification of patients with breast cancer who are at increased risk of treatment-related myocardial injury may support individualized cardiovascular surveillance. This retrospective study included 551 patients treated at Sun Yat-sen Memorial Hospital between January 2014 and December 2021. All patients had chest computed tomography data and at least three high-sensitivity cardiac troponin T (hs-cTnT) measurements. Early myocardial injury was defined as hs-cTnT > 14 ng/L within 6 months after treatment. Patients were randomly divided into training (n = 366) and validation (n = 185) cohorts. Candidate predictors were identified using univariable Cox regression and least absolute shrinkage and selection operator regression. A multivariable Cox model was then used to construct the nomogram. Baseline hs-cTnT, high-density lipoprotein cholesterol, thoracic aortic calcification score, and anti-human epidermal growth factor receptor 2 therapy were retained as independent predictors. In the validation cohort, the nomogram showed good discrimination, with an area under the receiver operating characteristic curve of 0.901 and a concordance index of 0.882. Calibration curves indicated agreement between predicted and observed risks. Decision curve analysis suggested clinical utility, while risk stratification identified distinct groups in both cohorts (p < 0.001). This thoracic aortic calcification-based nomogram may support the identification of patients at high risk of early myocardial injury after anticancer therapy.

Background: Retrieving an implanted leadless pacemaker is a challenging component of its management. However, there are no dedicated tools specifically designed for retrieving the Micra leadless pacemaker. Given the lack of commercial retrieval systems, there is an urgent need to document and validate alternative interventional strategies to manage complications associated with device malfunction or migration. Case summary: In this series, we present cases involving increased capture threshold, device embolization into the right pulmonary artery, and broken tines following Micra implantation. We successfully completed four retrieval procedures using a coordinated approach with existing devices, including the Micra transcatheter pacing system, coronary angiography catheter, and endovascular snare system. Discussion: Notably, these cases exhibited different characteristics during the retrieval of the Micra leadless pacemaker, which may assist colleagues in dealing with such scenarios. Our experience demonstrates that a strategy combining the Micra delivery catheter with an endovascular snare system, without the need for a steerable sheath, was sufficient and effective for successful Micra retrieval.

Background: Current guidelines lack instruction on fluid administration for patients with critically ill heart failure (HF) in the intensive care unit. Objectives: This study aims to compare the risk of mortality and acute kidney injury (AKI) outcomes among unlimited intake, restrictive intake, and negative balance. Design: Retrospective cohort study. Methods: A total of 3267 patients with HF not receiving renal replacement therapy were included from the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database and were grouped into restrictive fluid intake (the first 24-h fluid intake from 1500 to 2000 mL), negative fluid balance management (the first 24-h net output >1000 mL), and unlimited fluid control groups. The primary endpoint was 28-day mortality, and the secondary endpoints were morbidity of 48-h AKI, 7-day AKI, and AKI progression from 48 h to 7 days. The odds ratio (OR) and the 95% confidence interval (CI) were estimated by multivariable logistic regression, and mediation analyses were performed. Results: Negative fluid balance, not restrictive fluid intake, was correlated to a lower risk of 28-day mortality (OR: 0.750 (0.570–0.987), p = 0.040), 48-h AKI (OR: 0.207 (0.169–0.255), p < 0.001), and 7-day AKI (OR: 0.261 (0.207–0.330), p < 0.001) but was correlated to a higher risk of AKI progression (OR: 2.284 (1.835–2.843), p < 0.001) compared to unlimited fluid control after multivariable adjustment. The 24-h net output mediated AKI incidence and progression. Conclusion: Negative fluid balance was related to lower risk of 28-day mortality, 48-h AKI, and 7-day AKI but a higher risk of AKI progression, which requires further clinical trials for validation.

Objectives We aimed to develop an effective tool for predicting severe acute kidney injury (AKI) in patients admitted to the cardiac surgery recovery unit (CSRU). Design A retrospective cohort study. Setting Data were extracted from the Medical Information Mart for Intensive Care (MIMIC)-III database, consisting of critically ill participants between 2001 and 2012 in the USA. Participants A total of 6271 patients admitted to the CSRU were enrolled from the MIMIC-III database. Primary and secondary outcome Stages 2–3 AKI. Result As identified by least absolute shrinkage and selection operator (LASSO) and logistic regression, risk factors for AKI included age, sex, weight, respiratory rate, systolic blood pressure, diastolic blood pressure, central venous pressure, urine output, partial pressure of oxygen, sedative use, furosemide use, atrial fibrillation, congestive heart failure and left heart catheterisation, all of which were used to establish a clinical score. The areas under the receiver operating characteristic curve of the model were 0.779 (95% CI: 0.766 to 0.793) for the primary cohort and 0.778 (95% CI: 0.757 to 0.799) for the validation cohort. The calibration curves showed good agreement between the predictions and observations. Decision curve analysis demonstrated that the model could achieve a net benefit. Conclusion A clinical score built by using LASSO regression and logistic regression to screen multiple clinical risk factors was established to estimate the probability of severe AKI in CSRU patients. This may be an intuitive and practical tool for severe AKI prediction in the CSRU.

Background: To explore the potential heterogeneity of acute kidney injury (AKI) and evaluate the prognostic differences among AKI subphenotypes in critically ill patients with cardiovascular diseases. Methods: Data were extracted from the Medical Information Mart for Intensive Care (MIMIC)-III database. Latent class analysis (LCA) was used to explore the potential subphenotypes of AKI in critically ill patients with cardiovascular diseases. The number of classes was identified by the Bayesian information criterion and entropy. The differences in prognostic ability among the AKI subphenotypes were evaluated by logistic regression analysis. Result: A total of 7738 AKI patients were enrolled in this study. Using LCA, AKI patients were divided into 4 heterogeneous subphenotypes, which were obviously different from the Kidney Disease: Improving Global Outcomes (KDIGO) stages. Interestingly, class 3 classified by LCA was dominated by stage 2, while the mortality rate in class 3 was significantly different from that in class 1 (15.2% vs. 1.6%, p < 0.05). After further adjustment, the mortality rate in class 3 remained higher than that in class 1, with an odds ratio of 12.31 (95% confidence interval, 8.96–16.89). Conclusions: LCA was feasible for AKI classification in critically ill patients with cardiovascular disease, and 4 distinct subphenotypes of AKI patients with different prognoses were identified. Our results highlighted the potential heterogeneity of AKI patients, which is worthy of further investigation.

Background: Given the traditional acceptance of higher central venous pressure (CVP) levels, clinicians ignore the incidence of acute kidney injury (AKI). The objective of this study was to assess whether elevated CVP is associated with increased AKI in critically ill patients with multiple comorbidities.Methods: This was a retrospective observational cohort study using data collected from the Medical Information Mart for Intensive Care (MIMIC)-III open-source clinical database (version 1.4). Critically ill adult patients with CVP and serum creatinine measurement records were included. Linear and multivariable logistic regression were performed to determine the association between elevated CVP and AKI.Results: A total of 11,135 patients were enrolled in our study. Critically ill patients in higher quartiles of mean CVP presented greater KDIGO AKI severity stages at 2 and 7 days. Linear regression showed that the CVP quartile was positively correlated with the incidence of AKI within 2 (R² = 0.991,P = 0.004) and 7 days (R² = 0.990,P = 0.005). Furthermore, patients in the highest quartile of mean CVP exhibited an increased risk of AKI at 7 days than those in the lowest quartile of mean CVP with an odds ratio of 2.80 (95% confidence interval: 2.32–3.37) after adjusting for demographics, treatments and comorbidities. The adjusted odds of AKI were 1.10 (95% confidence interval: 1.08–1.12) per 1 mmHg increase in mean CVP.Conclusions: Elevated CVP is associated with an increased risk of AKI in critically ill patients with multiple comorbidities. The optimal CVP should be personalized and maintained at a low level to avoid AKI in critical care settings.

Background: This study aimed to develop and validate a nomogram for individually predicting coronary artery calcium (CAC) progression. Methods: The Multi-Ethnic Study of Atherosclerosis (MESA) cohort with 5486 participants (47.3% male, mean [SD] age 61.9 [10.2] years) were included, who were randomly assigned into the training set, or the internal validation set at a 7:3 ratio. A separate cohort of 2447 participants (44.6% male, a mean [SD] age of 40.4 [3.5] years) from the Coronary Artery Risk Development in Young Adults (CARDIA) study served as the external validation set. Baseline clinical characteristics, findings on physical examination, and laboratory profiles were assessed. CAC progression was the primary outcome measure. A nomogram was established based on the least absolute shrinkage and selection operator (LASSO)-derived Cox regression model. The discrimination and calibration ability of this nomogram was evaluated by Hosmer–Lemeshow test and calibration curves in the training and validation cohorts. Findings: Sixty-one features were reduced to 10, which were age, male gender, smoking status, waist circumference, systolic blood pressure, fasting glucose, lipid abnormalities, antihypertensive medication, and glucose-lowering medication and lipid-lowering medication use. The nomogram model showed a good discrimination in the training set (C-statistics: 0.682; 95% CI, 0.665-0.699), and application in the validation sets also gave good discrimination (C-statistics for the internal validation: 0.664; 95% CI, 0.638-0.690; for the external validation: 0.750; 95% CI, 0.729-0.771), which was better than the Framingham Risk Score model (C-statistics: 0.677; 95% CI, 0.663-0.691 vs. 0.658; 95% CI, 0.644-0.672, P<0.001). Calibration test yielded a high consistency between prediction and observation. Decision curve analysis demonstrated the clinical usefulness of the nomogram for predicting the risk of CAC progression. Interpretation: This study presents a nomogram that may be used to facilitate individualized prediction of CAC progression and should help better focus on primary prevention of cardiovascular disease in clinical practice. Funding: This work was supported by grants from National Natural Science Foundation of China (NSFC) [82170457, 81900379, 81870315, 81970683], Guangdong Basic and Applied Basic Research Foundation [2020A1515110313], and Yat-sen Start-up Foundation [YXQH202014]. The MESA study was supported by contracts N01-HC-95159 through N01-HC-95167 from the National Heart, Lung, and Blood Institute (NHLBI). The CARDIA study is conducted and supported by the NHLBI in collaboration with the University of Alabama at Birmingham (grants HHSN268201800005I and HHSN268201800007I), Northwestern University (grant HHSN268201800003I), University of Minnesota (grant HHSN268201800006I), and Kaiser Foundation Research Institute (grant HHSN268201800004I), of the United States. The authors report no conflicts of interest. (9) Clinical trial registration number: The CARDIA trial was registered at clinicaltrials.gov as NCT00005130. The MESA trial was registered at clinicaltrials.gov as NCT00005487. Declaration of Interest: The authors report no conflicts of interest. Ethical Approval: All participants provided informed consent and the study protocol was approved by the Institutional Review Boards at each participating institution.

Background: Invasive blood pressure (IBP) measurement is common in the intensive care unit, although its association with in-hospital mortality in critically ill patients with hypertension is poorly understood.Methods and Results: A total of 11,732 critically ill patients with hypertension from the eICU-Collaborative Research Database (eICU-CRD) were enrolled. Patients were divided into 2 groups according to whether they received IBP. The primary outcome in this study was in-hospital mortality. Propensity score matching (PSM) and inverse probability of treatment weighing (IPTW) models were used to balance the confounding covariates. Multivariable logistic regression was used to evaluate the association between IBP measurement and hospital mortality. The IBP group had a higher in-hospital mortality rate than the no IBP group in the primary cohort [238 (8.7%) vs. 581 (6.5%), p < 0.001]. In the PSM cohort, the IBP group had a lower in-hospital mortality rate than the no IBP group [187 (8.0%) vs. 241 (10.3%), p = 0.006]. IBP measurement was associated with lower in-hospital mortality in the PSM cohort (odds ratio, 0.73, 95% confidence interval, 0.59–0.92) and in the IPTW cohort (odds ratio, 0.81, 95% confidence interval, 0.67–0.99). Sensitivity analyses showed similar results in the subgroups with high body mass index and no sepsis.Conclusions: In conclusion, IBP measurement was associated with lower in-hospital mortality in critically ill patients with hypertension, highlighting the importance of IBP measurement in the intensive care unit.

Background: Low minimum heart rate (MHR) is common in critically ill myocardial infarction (MI) patients. However, the association between MHR and the mortality of critically ill MI patients remains unclear. Methods: In this retrospective cohort study, a total of 2,031 critically ill MI patients were enrolled from the Medical Information Mart for Intensive Care (MIMIC)-III database. Patients were divided into a low MHR group [MHR Results: MI patients in the low MHR group had higher 30-day and 1-year mortality than those in the high MHR group (20.59% vs. 10.91%, Pvs. 19.31%, PConclusions: MHR under 60 bpm may be associated with a higher risk for both 30-day and 1-year mortality in critically ill MI patients. These findings highlight the possibility of MHR as an early risk indicator and potential therapeutic target for mortality in critically ill MI patients, which warrants further investigation.