Circulating Total Bilirubin and Long-Term Prognosis in Patients With Previous Myocardial Infarction

Combined Risk Stratification With Patient Characteristics and Biomarkers in Patients Treated With the Impella for Cardiogenic Shock

BACKGROUND

In patients with cardiogenic shock (CS), a percutaneous microaxial ventricular assist device (Impella, Abiomed, Danvers, MA) is a choice for temporary mechanical circulatory support. Given the high morbidity and mortality in this patient population, early risk stratification is relevant when making treatment decisions.

METHODS

Using nationwide registry data between February 2020 and December 2022 in Japan, we included a total of 4122 patients with cardiogenic shock treated with the Impella devices. Using logistic regression analysis, we incorporated patient characteristics and biomarkers to develop a risk-stratifying model for in-hospital mortality. The model was also tested if applicable to composite outcomes of in-hospital death and major complications.

RESULTS

Of the 4122 patients with cardiogenic shock, the Impella was indicated for acute myocardial infarction in 2575 (62.5%). Multivariable analysis identified 4 patient characteristics (age, body mass index, out-of-hospital cardiac arrest, and blood pressure) and 6 biomarkers (lactate, lactate dehydrogenase, creatinine, total bilirubin, albumin, and creatinine kinase) with cutoff values as factors significantly associated with in-hospital mortality. We developed a risk-stratifying model using the 10 variables, which was predictive of in-hospital death (area under the curve, 0.711; P<0.001). Adding biomarkers to patient characteristics significantly improved the diagnostic accuracy (area under the curve, from 0.649 to 0.711; P<0.001). This risk score was also predictive of death and major complications (area under the curve, 0.680; P<0.001).

CONCLUSIONS

In patients with cardiogenic shock treated with the Impella devices, our risk-stratifying system, consisting of 4 patient characteristics and 6 biomarkers, strongly correlated with in-hospital mortality, potentially facilitating clinical decision-making.

A cross-sectional observational study of the association between biochemistry profiles and the risk of age-related macular degeneration

This study aimed to explore the relationship between biochemical profiles and the risk of age-related macular degeneration (AMD) through a cross-sectional observational analysis. We examined data of U. S. population from the 2005-2008 National Health and Nutrition Examination Survey (NHANES) database. Student's t-test, multivariable logistic regression, Pearson's correlation, restricted cubic spline (RCS) model, and linear regression were applied to analyze the underlying relationship between biochemical profiles and the AMD risk, through comparing data between the non-AMD and AMD subgroups. Multivariable logistic regression, adjusted for age and demographic factors, showed no significant associations between the AMD risk and the levets of specific biochemical parameters (P > 0.05). Pearson's correlation revealed a positive linear relationship between age and total bilirubin, uric acid in the non-AMD subgroup (P < 0.05), but no such liner association was found in the AMD subgroup (P > 0.05). The RCS model confirmed no non-linear relationships presented between these variables in the AMD subgroup. In addition, without age adjustment, significant associations were found between total bilirubin, uric acid, and the AMD presence (P < 0.05). Biochemical profiles, after adjusting for age, did not significantly influence the AMD risk. However, total bilirubin and uric acid might potentially be related to the AMD presence. Our findings suggest a need for further research to clarify the role of these biomarkers in AMD development.

Biomarkers for Risk Stratification in Patients With Type A Acute Aortic Dissection

Type A acute aortic dissection (AAD) is a fatal disease and thus, accurate and objective risk stratification is essential. In this study, we evaluated the prognostic value of readily available and assessable biomarkers in patients with type A AAD. This was a retrospective, multicenter, observational study. A total of 703 patients with type A AAD diagnosed using contrast-enhanced computed tomography were included. Therapeutic strategies were left to the physician's discretion in a real-world clinical setting. The prognostic value for in-hospital mortality was examined in 15 circulating biomarkers on admission, which are routinely available in clinical practice. Of the 703 patients, 126 (17.9%) died during the hospitalization. Of the 15 biomarkers, the multivariable analysis identified positive cardiac troponin, a low total bilirubin (T-Bil) level, and increased levels of brain natriuretic peptide (BNP) and lactate dehydrogenase (LDH) as significant predictors of in-hospital death. The receiver operating characteristics curve analysis showed that these 4 biomarkers had an independent additive prognostic value. With the cut-off values of T-Bil, BNP, and LDH, in combination with positive troponin, the increase in the number of positive biomarkers was progressively associated with higher in-hospital mortality from 1.3% to 9.8%, 20.5%, 36.4%, and 75.0% (p <0.001). In conclusion, in patients with type A AAD, positive cardiac troponin, a low T-Bil level, and increased levels of BNP and LDH on admission were related to higher in-hospital mortality, with an incremental prognostic value, suggesting that the readily available and assessable biomarkers can aid in decision-making in therapeutic strategies.

Total Bilirubin Yields Prognostic Information Following a Myocardial Infarction in the Elderly

Total bilirubin consists of an unconjugated form, solubilized by its binding to albumin, and a conjugated form representing a minor part of the circulating bilirubin. As total bilirubin in physiological concentrations is a powerful antioxidant, its concentration gradient may reflect the health status of an individual, and serve as a prognostic indicator of outcome in primary and secondary cardiovascular disease prevention. The aim of this study was to assess the association between total bilirubin and incident cardiovascular events following a myocardial infarction. Total bilirubin in serum was measured at baseline 2-8 weeks after hospitalization for an MI in 881 patients, aged 70 to 82 years, included in the OMEMI (Omega-3 Fatty acids in Elderly with Myocardial Infarction) study, where patients were followed-up for up to 2 years. The first major adverse clinical event (MACE) was the primary endpoint and consisted of nonfatal MI, unscheduled coronary revascularization, stroke, hospitalization for heart failure or all-cause death. As total bilirubin was non-normally distributed, log-transformed values and quartiles of bilirubin were analyzed using Cox regression models. The median (Q1, and Q3) baseline concentration of bilirubin was 11 (9, and 14) µmol/L, and higher log-transformed concentrations were associated with male sex, lower New York Heart Association (NYHA) class and non-smoking. MACE occurred in 177 (20.1%) patients during the follow-up. Higher concentrations of bilirubin were associated with a lower risk of MACE: HR 0.67 (95%CI 0.47-0.97) per log-unit increase, p = 0.032. Patients in the lowest quartile of bilirubin (<9 µmol/L) had the highest risk with HR 1.61 (95%CI 1.19-2.18), p = 0.002, compared to quartiles 2-4. This association remained significant even after adjusting for age, sex, body mass index (BMI), smoking status, NYHA class and treatment allocation: HR 1.52 (1.21-2.09), p = 0.009. Low concentrations of bilirubin (<9 µmol/L) are associated with increased nonfatal cardiovascular events or death in elderly patients with a recent myocardial infarction.