Prognosis Of Nutrition And Metabolism Factors For Very Advanced Age Patiens With Non-valvular Atrial Fibrillation And Patients With Takayasu Arteritis

Section 1:Clinical manifestation and prognosis of very advanced age patients with non-valvular atrial fibrillationBackground and ObjectiveAtrial fibrillation(AF)is one of the most common arrhythmia in the elderly patients.Its incidence and prevalence increase with the advancing age.Previous studies have focused on the prevention of ischemic stroke in patients with AF.However,for elderly patients,especially the very advanced age patients with AF,the risk of death may exceed the risk of ischemic stroke.Making a comprehensive geriatric assessment of them is essential.In the present study,we enrolled very advanced age patients with non-valvular AF and explored the risk factors for their all-cause mortality.MethodsThe medical records of elderly patients(age ? 80)with non-valvular AF admitted to our hospital from January 2010 to December 2015 were retrospectively collected.The follow-up was conducted in October 2017 and November 2017.The primary endpoint was all-cause death.Clinical characteristics were compared between survival patients and died patients.Univariate and multivariate Cox regression analysis were performed to identify the risk factors of all-cause death.Survival curves of different anticoagulation status groups and different serum albumin level groups were plotted by Kaplan-Meier methods,and compared by the Log-rank test.Receiver-operating characteristic(ROC)curves were performed to evaluate the prediction performance of body mass index(BMI),estimated glomerular filtration rate(eGFR)and CHA2DS2-VASc score for all-cause death.ResultsA total of 487 elderly patients with AF were enrolled in the present study,with mean age of 82.0(80.0-84.0)years and 202(41.5%)were females.Of these patients,the median of CHA2DS2-VASc score was 4(3-5),and 97(19.9%)patients received oral anticoagulants.During a median follow-up of 27.0(13.0-42.0)months,there were 96(19.7%)patients died.Compared with the survivals,patients with death had more prevalence of coronary artery disease,myocardial infarction history,heart failure,anemia and hypoalbuminemia,higher CHA2DS2-VASc score,and lower eGFR(P all<0.05).The rate of anticoagulation therapy was significantly lower in patients with death(P all<0.05).Kaplan-Meier analysis showed that patients with anticoagulantion therapy had a lower rate of all-cause death than those without anticoagulation therapy(P<0.001).Patients with hypoalbuminemia had a higher rate of all-cause death than those without(P<0.001).Multivariate Cox regression analysis shows that BMI[hazard ratio(HR):0.942,95%confidence interval(CI):0.890-0.998,P=0.044],eGFR(HR:0.987,95%CI:0.976-0.999,P=0.029),CHA2DS2-VASc score(HR:1.174,95%CI:1.016-1.356,P=0.030),hypoalbuminemia(HR:1.940,95%CI:1.078-3.491,P=0.027),and anticoagulation status(HR:0.230,95%CI:0.093-0.573,P=0.002)were significantly associated with the incidence of all-cause death.The area under the ROC curve of BMI,eGFR and CHA2DS2-VASc score for all-cause death was 0.569(95%CI:0.505-0.633,P=0.040),0.595(95%CI:0.525-0.665,P=0.005)and 0.584(95%CI:0.520-0.648,P=0.012)respectively.ConclusionsThe prognosis of elderly patients with AF was affected by several factors.BMI,eGFR,CHA2DS2-VASc score,hypoalbuminemia and anticoagulation status were significantly associated with the incidence of all-cause death in very advanced age patients with AF.In order to improve the survival of elderly patients,it is necessary to making comprehensive assessments of these patients,which include anticoagulation,comorbidities,and nutritional status.Section 2:Nutrition status in very advanced age patients with atrial firbillation and its impact on clinical outcomesBackground and ObjectiveMalnutrition is a common status in elderly patients and associates with adverse outcomes.Comprehensive geriatric assessment of elderly patients with atrial fibrillation(AF)is recommended in some guidelines.However,studies about the nutrition status and its impact on clinical outcomes are limited.The present study aimed to assess the nutrition status among AF patients aged over 80 years and explore the impact of malnutrition status on patients' prognosis.MethodsNon-valvular AF patients(aged?80 years)admitted to our hospital from January 2010 to December 2015 were included in the present study.Malnutrition status was assessed by the Controlling Nutritional Status(CONUT),Prognostic Nutritional Index(PNI),and Geriatric Nutritional Risk Index(GNRI)scores.Patients were followed up during October 2017 and November 2017.The primary endpoints were composite events,including thromboembolic events and all-cause death.Survival curves of different nutrition status were plotted by Kaplan-Meier methods.Cox regression analyses were performed to identify the risk factors of composite outcomes.The net reclassification index(NRI)and integrated discrimination index(IDI)were calculated to determine whether the prediction model of composite outcomes would improve after adding the CONUT,PNI,and GNRI scores to the basic prediction model of composite events.ResultsThe median age of 461 elderly patients with AF was 82.0(80.0-84.0)years and there were 198(43.0%)females.A total of 303(65.7%)patients had malnutrition status.Malnutrition was present in 62.9%,5.0%,and 21.9%of patients according to the CONUT,PNI,and GNRI scores,respectively.During a median follow-up of 27.0(15.0-42.0)months,130(28.2%)patients had composite outcomes.Kaplan-Meier curves revealed that patients with moderate to severe malnutrition had the worst clinical outcomes(Log-rank P<0.001 for all scores).In the multivariate Cox regression analysis which included age,sex,the type of AF,commorbidities,high sensitive C reactive protein,N-terminal pro-B-type natriuretic peptide(NT-proBNP),eGFR,and anticoagulation therapy,moderated to severe malnutrition remained an independent predictor of composite events[hazard ratio(HR):2.051,95%confidence interval(CI):1.143-3.679,P=0.016 for CONUT score;HR:3.374,95%CI:1.898-5.998,P<0.001 for PNI score;HR:2.254,95%CI:1.381-3.679,P=0.001 for GNRI score]and all cause death(HR:3.688,95%CI:1.856-7.326,P<0.016 for CONUT score;HR:5.509,95%CI:2.887-10.514,P<0.001 for PNI score;HR:3.604,95%CI:2.094-6.204,P<0.001 for GNRI scor).The NRI and IDI analysis showed that adding the CONUT(NRI:0.582,95%CI:0.218-0.638,P=0.013;IDI:0.012,95%CI:0.001-0.042,P=0.020)or GNRI(NRI:0.779,95%CI:0.412-0.817,P<0.001;IDI:0.041,95%CI:0.013-0.138,P<0.001)score to the baseline prediction model of composite events significantly improved its performance.ConclusionsMalnutrition is a common status in elderly patients with non-valvular AF.Moderate to severe malnutrition is an independent predictor of adverse outcomes among patients of very advanced age with non-valvular AF.Screening for malnutrition could provide additional information regarding prognosis and risk stratification.Assessing malnutrition status and conducting proper intervention might improve the prognosis of them.Section 3:Nutrition status in Takayasu arteritis and its impact on clinical prognosisBackground and ObjectiveTakayasu arteritis(TAK)is a chronic non-specific vasculitis.Having progressive disease and severe commorbidities propose TAK patients to a higher mortality.Nutrition status and inflammation correlate with each other.Geriatric nutritional risk index(GNRI)is modified from nutritional risk index(NRI),replacing daily weight with ideal weight.In the present study,we assessed nutrition status of TAK patients by GNRI score and investigate relationship between nutrition status and disease activity and prognosis.MethodsThe medical records of TAK patients admitted to our hospital from January 2010 to December 2015 were retrospectively collected.All patients were followed up in August 2018 and September 2019.Nutrition status was assessed by GNRI score:normal(GNRI>98),mild malnutrition status(GNRI:92-98),moderate malnutrition status(GNRI:82-91)and severe malnutrition(GNRI<82).Kaplan-Meier method was used to plot the survival curves of different nutrition status.Cox regression analyses were performed to identify the risk factors of all-cause death.Receiver-operating characteristic(ROC)curves were performed to evaluate the prediction performance of GNRI score of survival.ResultsA total of 563 TAK patients were included in the study.The average of GNRI score was 105.4±10.2 and there were 126(22.4%)TAK patients identified as having malnutrition status.Compared with normal nutrition status,malnourished TAK patients were younger,having shorter disease duration,having more symptom of dyspnea,having higher rate of active disease,anemia and heart failure,having more involvement of pulmonary artery,subclavian artery,ascending aorta,innominate artery and external iliac artery(all P<0.05).GNRI score was negatively correlated with erythrocyte sedimentation rate(r=-0.220,P<0.001)and C-reactive protein(r=-0.241,P<0.001).During a median follow-up of 36.0(25.0-60.0)months,24 TAK patients died.Malnourished TAK patients had a lower rate of survival than normal nutrition status patients(P=0.024).Cox regression analysis showed that moderate to severe malnutrition status[hazard ratio(HR):4.465,95%Confidence interval(CI):1.485-13.424,P=0.008],disease duration(HR:1.006,95%CI:1.000-1.006,P=0.038),the presence of heart failure(HR:21.176,95%CI:4.833-92.785,P<0.001)and coronary artery disease(HR:6.102,95%CI:2.260-16.474,P<0.001)were significant risk factors of all-cause death.ROC curve analysis showed that the optimal cut-off value of GNRI score of survival was 101.5[area under the curve(AUC):0.665,95%CI:0.546-0.785,P=0.007],with a sensitivity of 67.6%and specificity of 65.2%.ConclusionsMalnutrition is not rare in TAK.Malnourished TAK patients had more prevalence of active disease and worse clinical outcome.Moderate to severe malnutrition status,disease duration,the presence of coronary artery disease and heart failure were significant risk factors of all-cause death in TAK patients.The manifestation of malnutrition in TAK patients is not specific and can be easily overlooked.Screening nutrition status among TAK patients with active disease or heart failure may be beneficial to their survival.Section 4:Plasma fibroblast growth factor 23 in Takayasu arteritis and its relationship with left ventricular mass indexBackground and ObjectiveTakayasu arteritis(TAK)is a chronic non-specific vasculitis that primarily affects the aorta and its branches.Recent studies have indicated that heart involvement is not rare in TAK patients.Fibroblast growth factor(FGF23)is an endocrine hormone involved in the metabolism of calcium and phosphate.It can be induced by inflammation and plays an important role in the pathogenesis of cardiac abnormalities.In the present study,we measured the plasma FGF23 concentrations in TAK patients and investigated its relationship with disease activity and abnormal cardiac mass as evaluated by left ventricular mass index(LVMI).MethodsForty-seven patients diagnosed with TAK and 52 age-and gender-matched healthy controls were included in this observational study.Plasma FGF23 was detected by human enzyme-linked immunosorbent assay.According to the median of plasma FGF23,all TAK patients were divided into two groups:lower FGF23 group and higher FGF23 group.Clinical characteristics of different groups were compared.Multivariable liner regression analyses were performed to examine the association between FGF23 and left ventricular mass index(LVMI).ResultsThe mean age of TAK patients was 41.4± 15.5 years and female patients accounted for 87.2%.The median concentrations of plasma FGF23 was 121.8(84.5-168.8)RU/mL.TAK patients had higher plasma FGF23 concentrations than healthy controls[121.8(84.5-168.8)vs.86.7(70.5-101.1)RU/ml,P<0.001].Patients with higher FGF23 concentrations were more likely to be females(100.0%vs.75.0%,P=0.010),having more prevalence of heart failure(43.5%vs.12.5%,P=0.018),angiographic type V:non-angiographic type V(16:7 vs.8:16,P=0.013),having higher rate of receiving immunosuppressant(21.7%vs.0.0%,P=0.022),having larger left ventricular end diastolic diameter[54.0(47.0-58.0)vs.47.0(44.0-51.5)mm,P=0.017]and higher LVMI[126.3(81.1-177.7)vs.85.9(69.7-114.3)g/m2,P=0.041].Among patients without receiving glucocorticoid,no significant difference was observed between the plasma FGF23 concentrations of active disease and remission disease[132.6(85.7-323.2)vs.92.9(82.4-124.1)RU/mL,P=0.193].Age(?=-0.399,P=0.016)and the presence of angiographic type V(?=0.376,P=0.018)were identified to be significant determinants of plasma FGF23 concentrations in TAK patients.Spearman analysis showed that plasma FGF23 was correlated with LVMI(r=0.369,P=0.011).In the multivariate liner regression,plasma FGF23 was significantly associated with LVMI in TAK patients[?=0.402,95%confidence interval(CI):0.032-0.301,P=0.016],after adjusting for age,gender,disease duration,angiographic type(angiographic type V vs.non-angiographic type V),the presence of cardiovascular events and hypertension,and serum N-terminal pro-B-type natriuretic peptide.ConclusionsPlasma FGF23 was elevated in patients with TAK.Age and the presence of angiographic type V were significant determinants of plasma FGF23 concentrations in TAK patients.Plasma FGF23 was significantly associated with LVMI in TAK patients.FGF23 may participate in the development of abnormal cardiac mass in TAK patients,making it a potential marker for cardiac complication.Further studies should be taken to make sure whether plasma FGF23 can be used as a marker of disease activity among TAK patients.