5-year HR Research Articles

The relative impact of components of high residual risk on the long-term prognosis after AMI

BackgroundThe reduction in long-term mortality after acute myocardial infarction (AMI) is less pronounced than that of in-hospital mortality among patients with AMI complicated by heart failure (HF) and/or in those with a high residual thrombotic risk (HTR). AimTo investigate the relative prognostic significance of HTR and HF in AMI survivors. MethodsThis retrospective cohort study enrolled patients admitted for AMI in 2014–2015 in all Italian hospitals. HTR was defined as at least one of the following conditions: previous AMI, ischemic stroke or other vascular disease, type 2 diabetes, renal failure. Patients were classified into four categories: uncomplicated AMI; AMI with HTR; AMI with HF and AMI with both HTR and HF (HTR + HF). Cox proportional hazard model was used to evaluate the impact of HTR, HF and HTR + HF on the 5-year prognosis. A time-varying coefficient analysis was performed to estimate the 5-year trend of HR for major averse cardiac and cerebrovascular events (MACCE). Resultsa total of 174.869 AMI events were identified. The adjusted 5-year HR for MACCE was 1.74 (p < 0.0001) and 1.75 (p < 0.0001) in HTR and HF patients vs uncomplicated patients, respectively. The coexistence of HTR and HF furtherly increased the risk of MACCE (HR = 2.43, p < 0.0001) over the first 3 years after AMI. ConclusionEither HRT and HF confer an increased 5-year hazard of MACCE after AMI. The coexistence of HTR and HF doubled the overall 5-year risk of MACCE after AMI.

Prevalence and Outcomes of Cognitive Frailty Among Community-Dwelling Older Adults: A Systematic Review and Meta-Analysis.

To systematically review the available evidence regarding the prevalence and outcomes of cognitive frailty-a clinical syndrome characterized by the combination of physical frailty and cognitive impairment, without dementia-in community-dwelling older adults. The following databases were searched: PubMed, Web of Science, Embase, EBSCO, Cochrane Central Register of Controlled Trials, ProQuest, CNKI, Wanfang, VIP, and CBMdisc (inception to October 2, 2023). Twenty-four studies were included (N = 62,169) reporting a median prevalence of cognitive frailty among community-dwelling older adults of 12.2%. Frailty with cognitive impairment was independently associated with increased all-cause mortality (adjusted 8-year hazard ratio [HR] = 2.6, 95% confidence interval [CI] [2.05, 3.30]). There was evidence of increased risk of 3-year mortality for frailty (adjusted HR = 1.92, 95% CI [1.26, 2.93]) and prefrailty (adjusted HR = 1.79, 95% CI [1.33, 2.41]) with cognitive impairment. There was also evidence of increased risk of dementia for frailty (adjusted 24-month HR = 6.19, 95% CI [2.74, 13.99]; adjusted 4-year HR = 4.98, 95% CI [2.17, 11.41]) and prefrailty (adjusted 4-year HR = 5.21, 95% CI [2.95, 9.20]; adjusted 5-year HR = 14.5, 95% CI [1.68, 125.1]) with cognitive impairment. Activities of daily living (ADL) dependence was more frequent in individuals with cognitive impairment and frailty (adjusted 4-year odds ratio = 5.6, 95% CI [2.13, 14.72]). Of community-dwelling older adults, 12.2% have cognitive frailty as well as increased risk of all-cause mortality, dementia, and ADL dependence. Further studies on prevention and treatment of cognitive frailty is warranted. Health care providers should formulate specific interventions to decrease the impact of cognitive frailty. [Research in Gerontological Nursing, 17(4), 202-212.].

Comparing High- and Low-Model for End-Stage Liver Disease Living-Donor Liver Transplantation to Determine Clinical Efficacy: A Systematic Review and Meta-Analysis (CHALICE Study).

Various studies have demonstrated that low-Model for End-Stage Liver Disease (MELD) living-donor liver transplant (LDLT) recipients have better outcomes with improved patient survival than deceased-donor liver transplantation (DDLT) recipients. LDLT recipients gain the most from being transplanted at MELD <25-30; however, some existing data have outlined that LDLT may provide equivalent outcomes in high-MELD and low-MELD patients, although the term "high" MELD is arbitrarily defined in the literature and various cut-off scores are outlined between 20 and 30, although most commonly, the dividing threshold is 25. The aim of this meta-analysis was to compare LDLT in high-MELD with that in low-MELD recipients to determine patient survival and graft survival, as well as perioperative and postoperative complications. Following PROSPERO registration CRD-42021261501, a systematic database search was conducted for the published literature between 1990 and 2021 and yielded a total of 10 studies with 2183 LT recipients; 490 were HM-LDLT recipients and 1693 were LM-LDLT recipients. Both groups had comparable mortality at 1, 3 and 5 years post-transplant (5-year HR 1.19; 95% CI 0.79-1.79; p-value 0.40) and graft survival (HR 1.08; 95% CI 0.72, 1.63; p-value 0.71). No differences were observed in the rates of major morbidity, hepatic artery thrombosis, biliary complications, intra-abdominal bleeding, wound infection and rejection; however, the HM-LDLT group had higher risk for pulmonary infection, abdominal fluid collection and prolonged ICU stay. The high-MELD LDLT group had similar patient and graft survival and morbidities to the low-MELD LDLT group, despite being at higher risk for pulmonary infection, abdominal fluid collection and prolonged ICU stay. The data, primarily sourced from high-volume Asian centers, underscore the feasibility of living donations for liver allografts in high-MELD patients. Given the rising demand for liver allografts, it is sensible to incorporate these insights into U.S. transplant practices.

Estimated Clinical Outcomes and Cost-effectiveness Associated With Provision of Addiction Treatment in US Primary Care Clinics

US primary care practitioners (PCPs) are the largest clinical workforce, but few provide addiction care. Primary care is a practical place to expand addiction services, including buprenorphine and harm reduction kits, yet the clinical outcomes and health care sector costs are unknown. To estimate the long-term clinical outcomes, costs, and cost-effectiveness of integrated buprenorphine and harm reduction kits in primary care for people who inject opioids. In this modeling study, the Reducing Infections Related to Drug Use Cost-Effectiveness (REDUCE) microsimulation model, which tracks serious injection-related infections, overdose, hospitalization, and death, was used to examine the following treatment strategies: (1) PCP services with external referral to addiction care (status quo), (2) PCP services plus onsite buprenorphine prescribing with referral to offsite harm reduction kits (BUP), and (3) PCP services plus onsite buprenorphine prescribing and harm reduction kits (BUP plus HR). Model inputs were derived from clinical trials and observational cohorts, and costs were discounted annually at 3%. The cost-effectiveness was evaluated over a lifetime from the modified health care sector perspective, and sensitivity analyses were performed to address uncertainty. Model simulation began January 1, 2021, and ran for the entire lifetime of the cohort. Life-years (LYs), hospitalizations, mortality from sequelae (overdose, severe skin and soft tissue infections, and endocarditis), costs, and incremental cost-effectiveness ratios (ICERs). The simulated cohort included 2.25 million people and reflected the age and gender of US persons who inject opioids. Status quo resulted in 6.56 discounted LYs at a discounted cost of $203 500 per person (95% credible interval, $203 000-$222 000). Each strategy extended discounted life expectancy: BUP by 0.16 years and BUP plus HR by 0.17 years. Compared with status quo, BUP plus HR reduced sequelae-related mortality by 33%. The mean discounted lifetime cost per person of BUP and BUP plus HR were more than that of the status quo strategy. The dominating strategy was BUP plus HR. Compared with status quo, BUP plus HR was cost-effective (ICER, $34 400 per LY). During a 5-year time horizon, BUP plus HR cost an individual PCP practice approximately $13 000. This modeling study of integrated addiction service in primary care found improved clinical outcomes and modestly increased costs. The integration of addiction service into primary care practices should be a health care system priority.

The Hypertension Paradox: Survival Benefit After ST-Elevation Myocardial Infarction in Patients With History of Hypertension. A Prospective Cohort- and Risk-Analysis.

BackgroundMortality after ST-elevation myocardial infarction (STEMI) is dependent from best-medical treatment after initial event.ObjectivesDetermining the impact of prescription of guideline-recommended therapy after STEMI in two cohorts, patients with and without history of arterial hypertension, on survival.Methods1,025 patients of the Cologne Infarction Model registry with invasively adjudicated STEMI were dichotomized according to their history of arterial hypertension. We recorded prescription rates and dosing of RAS-inhibitors, β-blockers and statins in all patients. The primary outcome was all-cause death. Mean follow-up was 2.5 years.ResultsMean age was 64 ± 13 years, 246 (25%) were women. 749 (76%) patients had a history of hypertension. All-cause mortality was 24.2%, 30-day and 1-year mortality was 11.3% and 16.6%, respectively. History of hypertension correlated with lower mortality (hazard ratio [HR], @30 days: 0.41 [0.27-0.62], @1 year: 0.37 [0.26-0.53]). After adjusting for age, sex, Killip-class, diabetes mellitus, body-mass index, kidney function and statin prescription at discharge 1-year mortality HR was 0.24 (0.12-0.48). At discharge, prescription rates for RAS-inhibitors, β-blockers and statins, as well as individual dosing and long-term persistence of RAS-inhibitors were higher in patients with history of hypertension. On the same lines, prescription rates for RAS-inhibitors, β-blockers and statins at discharge correlated significantly with lower mortality regardless of history of hypertension.ConclusionPatients with history of hypertension show higher penetration of guideline recommended drug therapy after STEMI, which may contribute to better survival. Better tolerance of β-blockers and RAS-inhibitors in patients with history of hypertension, not hypertension itself, likely explains these differences in prescription and dosing.

Early symptomatic benefit indicates long-term prognosis after transcatheter mitral valve edge-to-edge repair in functional and degenerative etiology

BackgroundMitral regurgitation (MR) is common in patients with heart failure and constitutes an independent risk factor for adverse prognosis besides NYHA-class. The predictive value of dyspnea reduction after transcatheter mitral valve repair (TMVr) on outcome has not been investigated up to now. Methods and resultsWe enrolled 627 consecutive patients (47.0% female, 57.4% functional MR; median follow-up 486 days[IQR 157/961]; survival status available in 96.8%; symptoms assessed in n = 556 at baseline / n = 406 at 1 month) treated with isolated percutaneous mitral valve edge-to-edge repair in our center from 06/2010–03/2018 (exclusion of combined forms of TMVr) in a monocentric retrospective analysis. Survival was 97.6% at discharge, 73.9% after 1, 54.5% after 3, 37.6% after 5 and 21.7% after 7-years. Before TMVr, NYHA-classes III/IV were found in 89.0%. Of these, 74.7% reported symptomatic relief (reduction in NYHA-class) one month after procedure (NYHA class recorded in 406 patients at 30 days). NYHA-classes III/IV were documented in 37.2% (p < 0.001) at 30 days and in 36.6% (p < 0.001) at 1 year without significant changes between the follow-ups. Dyspnea reduction was accompanied by significantly improved long-term survival (1 year, 89.1 vs 71.2%, p = 0.001, 2 years: 75.5 vs 58.7%, p = 0.039) and was identified as an independent predictor for lower mortality (1-year HR for increased mortality by missing symptomatic improvement 2.94 [95%CI 1.53–5.65], p = 0.001; long-term HR 1.95 [95%CI 1.29–2.94], p = 0.001) independently in both etiologies of MR. ConclusionTMVr by edge-to-edge therapy enables early and sustainable symptomatic improvement in nearly 75% of the symptomatic patients. The simple assessment of postinterventional changes in NYHA-class might serve as an independent predictor for mid- and long-term prognosis in both FMR and DMR.

Impact of anatomical liver resection for hepatocellular carcinoma: A systematic review and meta-analysis

Although several retrospective studies comparing anatomical liver resection (AR) and non-anatomical liver resection (NAR) for hepatocellular carcinoma (HCC) have been published, the efficacy of anatomic liver resection for HCC remains unclear. This study aimed to compare the oncologic and surgical outcomes of AR and NAR for HCC by performing meta-analysis of published studies. We systemically reviewed the MEDLINE, Embase, and Cochrane Library databases for propensity score matching (PSM) studies compared AR and NAR for HCC. The primary outcome was overall survival (OS) and recurrence free survival (RFS). Secondary outcomes were recurrence patterns and peri-operative outcomes. A total of 19 PSM studies were included. AR was superior to NAR in 3- and 5-year OS (3-year OS hazard ratio [HR]: 0.79, 95% confidence interval [CI]: 0.68-0.91, p = 0.001; 5-year OS HR: 0.83, 95% CI: 0.71-0.95, p = 0.009). AR showed a significantly better 1-, 3-, and 5-year RFS than NAR with low local recurrence rate, intra- and extra-hepatic recurrence (1-year RFS HR: 0.79, 95% CI: 0.69-0.90, p = 0.0005; 3-year RFS HR: 0.81, 95% CI: 0.75-0.87; p = 0.00001; 5-year RFS HR: 0.82, 95% CI: 0.76-0.88, p < 0.00001). In subgroup analyses about tumor with diameter less than 5cm and with microscopic cancer spread, RFS in AR group was significantly better than NAR. However, AR showed comparable 3- and 5-year RFS with NAR group in patients with cirrhotic liver. Also, post-operative overall complications including biliary leakage and hepatic failure were similar between two groups. Our meta-analysis revealed that AR showed better OS and RFS with low local recurrence than NAR especially patients with tumor diameter less than 5 cm and non-cirrhotic liver.

A systematic review and meta-analysis of the influence of STAS on the long-term prognosis of stage I lung adenocarcinoma.

BackgroundThe appearance of airway dissemination often indicates poor prognosis of lung cancer. However, the relationship between airway dissemination and early lung adenocarcinoma is not clear. Therefore, this study uses meta-analysis to study the long-term prognosis of patients with early lung adenocarcinoma.MethodsA computer search of the PubMed, EMbase, Web of Science, and other databases was conducted, and the search time limit was from the establishment of the database to December 30, 2020. Data strictly in accordance with the inclusion and exclusion criteria was extracted and the quality of the included literature was evaluated. Two reviewers then independently screened the literature and evaluated the risk of bias.ResultsA total of 11 studies were included, comprised of 5,097 patients with early lung adenocarcinoma. The results of the meta-analysis showed that among patients with stage I lung adenocarcinoma, the 5-year recurrence-free survival (RFS) and overall survival (OS) of STAS-positive patients was lower than those of the STAS-negative group, and the difference was statistically significant. In the control study, the 5-year RFS was HR =1.95, 95% CI (1.58–2.31) P<0.01, and the 5-year OS was OR =2.04, 95% CI (1.60–2.48) P<0.01, and in STAS-positive patients, sublobectomy had a worse long-term prognosis than lobectomy. While the 5-year RFS HR of the lobectomy group was 1.82, 95% CI (1.43–2.22), and the 5-year RFS HR of the sublobectomy group was 6.92, 95% CI (1.64–12.18) P<0.01, the prognosis of the STAS-positive high-expression group and the low-expression group was worse. The 5-year RFS HR of the low-expression STAS group was 2.93, 95% CI (0.21–6.07), and in the high expression group this was 8.20, 95% CI (0.55–15.85) P<0.05.DiscussionSTAS is an independent risk factor for the poor prognosis of stage I lung adenocarcinoma and a high expression of STAS results in a higher 5-year recurrence rate. When STAS is positive, the sublobectomy method should be carefully selected. However, our research has certain limitations, such as literature selection and publication bias. At the same time, the depth of literature analysis needs to be further improved.

Mortality rates and risk factors after low-trauma hip fracture in the largest university center in Romania.

Data on mortality after low-trauma hip fracture in Romania is scarce and comes from a single-hospital study. Our aim was to calculate mortality rates and risk factors in all patients admitted for low-trauma hip fracture in the largest university medical center of Romania. We retrospectively analyzed the charts of all patients (>40 years old) admitted for hip fracture in a 12-month period in hospitals with an Orthopedic Department in Bucharest, Romania, and surrounding Ilfov County and calculated the crude in-hospital, 30-day, and 1-year mortality rates after low-trauma hip fractures. A number of potential clinical risk factors for mortality were evaluated. We analyzed 2742 low-trauma hip fractures. The in-hospital, 30-day, and 1-year all-cause mortality rates were 4.26% (n=117), 9.59% (n=263), and 29.72% (n=815) respectively. Four hundred and fifty (16.41%) fractures were managed conservatively with a 1-year mortality HR of 3.05 (p<0.001) compared to surgically treated fractures. The 1-year mortality rate in conservatively treated fractures was 56.44% compared to 24.47% in surgically treated fractures. Age, male sex, length of stay in hospital, day of surgery, post-surgical complications, and late surgery were significantly associated (p<0.001) with mortality after hip fracture. The lowest 1-year mortality rate was in surgically treated patients with a length of stay in hospital between 6 and 10 days. We found a high mortality rate at 30 days and 1 year after low-trauma hip fracture. The high mortality rates can be attributable, in part, to the high number of conservatively treated fractures.

Meta-analysis and meta-regression of outcomes for adult living donor liver transplantation versus deceased donor liver transplantation.

Prior single center or registry studies have shown that living donor liver transplantation (LDLT) decreases waitlist mortality and offers superior patient survival over deceased donor liver transplantation (DDLT). The aim of this study was to compare outcomes for adult LDLT and DDLT via systematic review. A meta-analysis was conducted to examine patient survival and graft survival, MELD, waiting time, technical complications, and postoperative infections. Out of 8600 abstracts, 19 international studies comparing adult LDLT and DDLT published between 1/2005 and 12/2017 were included. U.S. outcomes were analyzed using registry data. Overall, 4571 LDLT and 66,826 DDLT patients were examined. LDLT was associated with lower mortality at 1, 3, and 5years posttransplant (5-year HR 0.87 [95% CI 0.81-0.93], p<.0001), similar graft survival, lower MELD at transplant (p<.04), shorter waiting time (p<.0001), and lower risk of rejection (p=.02), with a higher risk of biliary complications (OR 2.14, p<.0001). No differences were observed in rates of hepatic artery thrombosis. In meta-regression analysis, MELD difference was significantly associated with posttransplant survival (R2 0.56, p=.02). In conclusion, LDLT is associated with improved patient survival, less waiting time, and lower MELD at LT, despite posing a higher risk of biliary complications that did not affect survival posttransplant.

Effectiveness of adjuvant FOLFOX vs 5FU/LV in adults over age 65 with stage II and III colon cancer using a novel hybrid approach.

Estimates of cancer therapy effects can differ in clinical trials and clinical practice, partly due to underrepresentation of certain patient subgroups in trials. We utilize a hybrid approach, combining clinical trial and real-world data, to estimate the comparative effectiveness of two adjuvant chemotherapy regimens for colon cancer. We identified patients aged 66 and older enrolled in the Multicenter International Study of Oxaliplatin/5FU-LV in the Adjuvant Treatment of Colon Cancer. Similar patients were identified in the Surveillance, Epidemiology, and End Results (SEER)-Medicare database, initiating adjuvant chemotherapy with either 5-fluorouracil (5FU) alone or in combination with oxaliplatin (FOLFOX). We used logistic regression to estimate the likelihood of trial enrollment as a function of age, sex, and substage. Using inverse odds of sampling weights (IOSW), we compared 5-year mortality in patients randomized to FOLFOX vs 5FU using weighted Cox proportional hazards regression, the Nelson-Aalen estimator for cumulative hazards, and bootstrapping for 95% confidence intervals (CIs). There were 690 trial participants and 3834 SEER-Medicare patients. The SEER-Medicare population was older and had a higher proportion of stage IIIB and IIIC patients than the trial. After controlling for differences between populations, the IOSW 5-year HR was 1.21 (0.89, 1.65), slightly farther from the null than the trial estimate (HR = 1.14, 95%CI: 0.87, 1.49). This study supports mounting evidence of little to no incremental reduction in 5-year mortality for FOLFOX vs 5FU in older adults with stage II-III colon cancer, emphasizing the importance of combining clinical trial and real-world data to support such conclusions.

Diabetes-Related Effectiveness and Cost of Liraglutide or Insulin in German Patients with Type 2 Diabetes: A 5-Year Retrospective Claims Analysis.

IntroductionLiraglutide is a glucagon-like peptide-1 analogue used to treat type 2 diabetes mellitus (T2DM). To date, limited long-term data (> 2 years) exist comparing real-world diabetes-related effectiveness and costs for liraglutide versus insulin treatment.MethodsThis retrospective claims data analysis covered the period from 1 January 2010 to 31 December 2017 and included continuously insured patients with T2DM who initiated insulin or liraglutide and had 3.5 or 5 years’ follow-up data, identified using the German AOK PLUS dataset. Propensity score matching (PSM) was used to adjust for patient characteristics.ResultsAfter PSM, there were 825 and 436 patients in the liraglutide and insulin groups at 3.5 and 5 years’ follow-up, respectively. Baseline characteristics were similar between compared cohorts. The respective change from baseline to follow-up in mean glycated haemoglobin for liraglutide and insulin patients was − 0.88% and − 0.81% (p > 0.100) after 3.5 years and − 1.15%/ − 1.02% (p > 0.100) after 5 years. Mean respective changes in body mass index (kg/m2) were − 1.21/+ 1.14 (p < 0.001) after 3.5 years and − 1.29/+ 1.13 after 5 years (p < 0.001). Liraglutide- versus insulin-treated patients were less likely to have an early T2DM-related hospitalisation (3.5-year hazard ratio [HR]: 0.414 [95% confidence interval (CI) 0.263–0.651]; 5-year HR: 0.448 [95% CI 0.286–0.701]). At 5 years’ follow-up, there was no statistically significant difference in total direct costs between treatment groups (cost ratio: 1.069 [95% CI 0.98–1.13]; p > 0.100).ConclusionThe clinical effectiveness of liraglutide is maintained long term (up to 5 years). Liraglutide treatment is not associated with higher total direct healthcare costs.Electronic Supplementary MaterialThe online version of this article (10.1007/s13300-020-00903-0) contains supplementary material, which is available to authorized users.

Postoperative statin treatment may be associated with improved mortality in patients with myocardial injury after noncardiac surgery

Myocardial injury after noncardiac surgery (MINS) is recently accepted as a strong predictor of mortality, regardless of symptoms. However, anticoagulation is the only established treatment. This study aimed to evaluate the association between statin treatment and mortality after MINS. From January 2010 to June 2019, a total of 5,267 adult patients who were discharged after the occurrence of MINS were enrolled. The patients were divided into two groups according to statin prescription at discharge. The outcomes were 1-year and overall mortalities. Of the total 5,109 patients, 1,331 (26.1%) patients were in the statin group and 3,778 (73.9%) patients were in the no statin group. The 1-year and overall mortalities were significantly lower in the statin group compared with the no statin group (6.1% vs. 13.3%; hazard ratio [HR], 0.55; 95% confidence interval [CI], 0.41–0.74; p < 0.001 for 1-year mortality and 15.0% vs. 25.0%; HR, 0.62; 95% CI, 0.51–0.76; p < 0.001 for overall mortality). Analyses after inverse probability treatment weighting showed similar results (HR, 0.61; 95% CI, 0.50–0.74; p < 0.001 for 1-year mortality and HR, 0.70; 95% CI, 0.54–0.90; p = 0.006 for overall mortality), and the mortalities did not differ according to the dose of statin. Our results suggest that statin treatment may be associated with improved survival after MINS. A trial is needed to confirm this finding and establish causality.

Clinical and economic impact of multipoint left ventricular pacing: A comparative analysis from the Italian registry on multipoint pacing in cardiac resynchronization therapy (IRON-MPP).

Early evidence suggests that multipoint left ventricular pacing (MPP) may improve response to cardiac resynchronization therapy (CRT). It is unknown whether this benefit is sustained and cost-effective. We used real-world data to evaluate long-term impact of MPP-ON clinical status, heart failure hospitalizations (HFH) and costs. The Italian registry on multipoint left ventricular pacing is a prospective, multicenter registry of patients implanted with MPP-enabled CRT devices. For this analysis, clinical and echocardiographic data were collected through 24 months and compared between patients with (MPP-ON) or without (MPP-OFF) early MPP activation at implant. The total cost of each HFH was estimated with national Italian reimbursement rates. The study included 190 MPP-OFF and 128 MPP-ON patients with similar baseline characteristics. At 1 and 2 years, the MPP-ON group had lower rates of HFH vs MPP-OFF (1-year hazard ratio [HR]: 0.14, P = .0014; 2-year HR: 0.38, P = .009). The finding persisted in a subgroup of patients with consistent MPP activation through follow-up (1-year HR: 0.19; P = .0061; 2-year HR: 0.39, P = .022). Total HFH per-patient costs were lower in the MPP-ON vs the MPP-OFF group at 1 year (€101 ± 50 vs €698 ± 195, P < .001) and 2 years (€366 ± 149 vs €801 ± 203, P = .038). More MPP-ON patients had ≥5% improvement in ejection fraction (76.8% vs 65.4%, P = .025) and clinical composite score (66.7% vs 47.5%, P = .01). In this multicenter clinical study, early MPP activation was associated with a significant reduction in cumulative HFH and related costs after 1 and 2 years of follow-up.

518 Optimal Duration of Dual Antiplatelet Therapy After Coronary Stent Implantation: A Population-Based Retrospective Cohort Study

Studies have shown non-inferiority of short-term vs 12-month dual antiplatelet therapy (DAPT) following PCI with stents. Others have shown better ischemic outcomes with extended DAPT (>12-months) at the expense of bleeding. To investigate associations between DAPT (aspirin+clopidogrel) duration following PCI and ischemic and bleeding outcomes under real-world conditions. Patients ≥65 years who had a PCI with stent in WA hospitals between 2003-2008 and survived 1-year (1-year landmark) and 2-years (2-year landmark) following discharge were identified from linked hospital admissions data. Associations between DAPT duration (from Pharmaceutical Benefits Scheme data) and 1- and 3-year outcomes of all-cause death, ACS, coronary artery revascularisation, stroke and major bleeding admissions, and composite (MACCE) were assessed using adjusted Cox regression models. There were 6678 patients with mean age 74.5 years and 67% males. 1-year landmark analysis showed a non-significant decreasing trend for MACCE with increasing DAPT duration. Risk of MACCE was lowest for 9-12 month DAPT (1-year HR 0.93, 95% CI 0.66-1.32 and 3-year HR 0.89, 95% CI 0.72-1.11) compared to 0-3 months DAPT. 3-year major bleeding for 9-12 months DAPT was not significantly different to 0-3 months (HR 0.74, 95% CI 0.39-1.42). Results were similar for 2-year landmark with no significant differences between 12-18 or 18-24 months DAPT vs 0-6 months for MACCE and major bleeding outcomes. DAPT duration of 6 months or less following PCI may be adequate to balance outcomes of MACCE and major bleeding in the era of bare metal and 1st/2nd generation drug eluting stents.

P6395Elevated serum uric acid is associated with a greater inflammatory response and with short- and long-term mortality in patients with ST-segment elevation myocardial infarction undergoing primary percu

Abstract Introduction Elevated serum uric acid (eSUA) has been identified as independent risk factors for cardiovascular diseases, including coronary artery disease, and it has been associated with increased mortality in the general population. However, whether eSUA is associated with adverse outcomes in the setting of ST-segment elevation myocardial infarction (STEMI) is still controversial. Although the mechanisms of this possible relationship is similarly unsettled it has been suggested that eSUA could trigger oxidative stress and inflammatory response. Aim This study sought to investigate the association between eSUA with short- and long-term mortality and with inflammatory response in patients with STEMI treated with primary percutaneous coronary intervention (pPCI). Methods We prospectively enrolled all STEMI patients undergoing pPCI in our hospital between 2005 and 2017. Blood samples were collected on admission and at 24 and 48 hours after pPCI: SUA and the inflammatory biomarkers C-reactive protein (CRP), neutrophil count and neutrophil to lymphocytes ratio (NLR) were parameter of interest. NLR was obtained by dividing the total count of neutrophil by the total count of lymphocyte. eSUA was defined as &gt;6.8 mg/dl. Cumulative 30-days and 1-year mortalities were estimated using the Kaplan-Meyer analysis and compared with the long-rank test. Landmark analysis was set at 365 days. Multivariable analyses were performed by Cox proportional hazard models. Results Out of the dataset of 2959 STEMI patients treated with pPCI, we analyzed 2369 patients who had SUA data. Overall age was 63 (p25-p75: 54–73) years, men were 2295 (75.5%), anterior MI 1390 (45.8%). eSUA was present in 563 patients (23.8%). 30-day mortality was 5.8% (n=31) among patients with eSUA and 2% (n=34) among patient with normal SUA level (p&lt;0.001); 1-year mortality was 8.5% (n=46) vs 4% (n=70), respectively (p&lt;0.001). Landmark analysis is shown in Figure 1. At multivariable analyses eSUA was an independent predictor after adjusting for age, female gender, BMI, diabetes, previous MI, serum creatinine, Hb, acute glycemia, Killip class &gt;2 (30-day mortality HR 1.196, 95% CI 1.006–1.321, p=0.042; 1-year mortality HR 1.178, 95% CI 1.052–1.320, p=0.005). On admission CRP was higher in the group with eSUA as compared with the group with normal SUA levels (respectively, 1.27 [0.57–3.37] mg/dl vs 0.72 [0.30–1.8] mg/dl, p&lt;0.001). On admission neutrophil count and NLR did not differ among the groups (respectively, p=0.205 and p=0.399), but eSUA patients presented higher values in neutrophil count and NLR at 24 hours (respectively, p=0.020 and p&lt;0.001) and at 48 hours (p=0.018 and both p&lt;0.001). Figure 1 Conclusions Elevated serum uric acid is associated with higher short- and long-term mortality and with a greater inflammatory response after reperfusion in patients with STEMI treated with primary PCI.

Abstract P2-07-04: Prognostic value of residual cancer burden (RCB), neo-bioscore and neoadjuvant response index (NRI) to evaluate response to neoadjuvant trastuzumab-based therapy in HER2-positive breast cancer (BC)

Abstract Intro Pathological complete response (pCR) to neoadjuvant systemic therapy is associated with favorable long-term outcome. As pCR is not an optimal surrogate marker for outcome, other tools were developed to predict long-term outcome more accurately, including the RCB4, NRI3, and Neo-Bioscore5. We evaluated the prognostic value of these tools in a cohort of patients with HER2+ BC with the aim of selecting a group of patients with residual disease but a similar long-term outcome as patients achieving pCR. Methods We included all patients with stage II-III HER2+ BC who were treated with trastuzumab-based neoadjuvant therapy and surgery in the Netherlands Cancer Institute between November 2004 and December 2016. Patients were identified from the institutes' tumor registry and data was collected from the patients' records. To assess RCB scores surgical specimens (breast and axilla tissue) of patients without pCR were retrospectively reviewed. NRI and Neo-Bioscore were calculated based on original pathology reports. Primary endpoint was recurrence-free interval (RFI), defined as time since diagnosis of BC till locoregional or distant recurrence or death from BC, whatever came first. Cox proportional models were used with transformations of RCB, NRI, and Neo-Bioscore. In addition, we evaluated at which cut-off point the NRI could select patients with a similar good prognosis as patients who achieved a pCR, defined by the same lower bound of the 95%CI of the 5-year RFI estimate for the pCR-group. Results 283 women were included, 149 (53%) with HER2+/ER+ BC. 28% received dual HER2-blockade. Median follow-up was 66 months (range 11-148). 157 patients (55%) achieved a pCR in breast and axilla; predicted 5-year RFI for this group was 91% (95%CI 86-96), HR no-pCR vs pCR 2.19, 95%CI 1.07-4.47. Table 1 shows the predicted 5-year RFI and HR for RCB classes. The HR of an RFI event increases gradually for lower NRI values compared to NRI of 1 and gets more steep near NRI values of 0. Patients with a NRI of ≥0.80-0.99 have a 5-year RFI estimate of 90% (95%CI 86-96), HR 1.1 (95%CI 0.6-1.9) compared to patients with NRI of 1 (which is pCR). Table 2 shows the predicted 5-year RFI and HR for the Neo-Bioscore. Table 1RCB classes, estimated 5-year RFI and HRRCBn% 5-year RFI95% CIHR95% CI016392.688.397.111113990.385.295.61.330.672.6526278.469.488.53.181.427.1131135.316.476.113.605.3034.81 Table 2Neo-Bioscore classes, predicted 5-year RFI and HRNeo-Bioscoren% 5-year RFI95% CIHR95% CI01998.795.510011115392.486.099.36.100.9240.5229384.977.493.012.670.76210.4037289.983.896.58.200.62108.2041974.962.989.222.331.76283.445329.410.384.095.206.271446.64610.601.00406.2619.558442.21 Conclusions We show that in a HER2+ BC cohort the RCB and NRI are able to identify a subgroup of patients with limited residual disease after neoadjuvant therapy with similar good prognosis as patients with pCR and therefore may not benefit from additional adjuvant therapy. References 1 Cortazar Lancet 2014 2 FDA Regist 2014 3 Rodenhuis Ann Oncol 2010 4 Symmans JCO 2007 5 Jeruss JCO 2008 6 Mittendorf JAMA Oncol 2016 Citation Format: Steenbruggen TG, van Seijen M, Janssen LM, van Ramshorst MS, van Werkhoven E, Lips EH, Vrancken-Peeters M-JT, Horlings HM, Wesseling J, Sonke GS. Prognostic value of residual cancer burden (RCB), neo-bioscore and neoadjuvant response index (NRI) to evaluate response to neoadjuvant trastuzumab-based therapy in HER2-positive breast cancer (BC) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-07-04.

Absence of chest pain and long-term mortality in patients with acute myocardial infarction

ObjectiveChest pain is the predominant symptom in patients with acute myocardial infarction (AMI). A lack of chest pain in patients with AMI is associated with higher in-hospital mortality, but whether...

Impact of Frailty on Outcomes After Primary and Revision Total Hip Arthroplasty

BackgroundFrailty and disability from arthritis are closely intertwined and little is known about the impact of frailty on total hip arthroplasty (THA) outcomes. We hypothesized that higher preoperative frailty is associated with more adverse events following THA. MethodsAll patients (≥50 years) undergoing unilateral primary or revision THA at a single institution from 2005 through 2016 were included. We analyzed the association of frailty (measured by a frailty deficit index) with postoperative outcomes in hospital, within 90 days, and within 1 year using multivariable logistic and Cox regression, adjusting for age. ResultsAmong 8640 patients undergoing THA (6502 primary and 2138 revisions; median age 68 years), 22.7%, 32.9%, and 44.4% were classified as frail, vulnerable, and nonfrail, respectively. Frail patients tended to be female, older, sicker (American Society of Anesthesiologists ≥3), and received general anesthesia more frequently. Relative to nonfrail patients, frail patients had significantly increased odds of wound complications/hematoma (odds ratio 2.01) and reoperation (odds ratio 2.74) while in hospital, and increased risks for mortality (1-year hazards ratio [HR] 5.65), infection (1-year HR 3.63), dislocation (1-year HR 2.10), wound complications/hematoma (1-year HR 2.61), and reoperation (1-year HR 2.22) within 90 days and 1 year. Frailty was also associated with >5.5-fold increased mortality risk 1 year following THA. No significant associations with aseptic loosening, periprosthetic fracture, or heterotopic ossification were observed. ConclusionA higher preoperative frailty index is associated with increased mortality and perioperative complications following primary and revision THA. The proposed frailty deficit index provides clinically important information for healthcare providers to use when counseling patients prior to decision for surgery.

The Paradoxical Relationship Between Donor Distance and Survival After Heart Transplantation

Concerns over prolonged allograft ischemia have limited the widespread adoption of long-distance organ procurement in heart transplantation (HT). We sought to assess whether donor distance from the center of transplantation independently affects mortality. We queried the United Network for Organ Sharing (UNOS) database for adults undergoing isolated HT from 2005 to 2012. Risk-adjusted Cox proportional hazards models were constructed for the primary outcomes of 30-day and 1-year mortality, and the independent impact of donor distance from transplantation center at the time of procurement was assessed. We included 14,588 heart transplant recipients. The mean distance from location of the donor heart to transplantation center was 184.4 ± 214.6 miles; 1,214 HTs (8.3%) occurred at the same location as the donor heart. Ischemic times were inversely related to the distance from the site of donor procurement to recipient transplantation. After risk adjustment, longer donor distances (in miles) were associated with a significantly lower risk of mortality at both 30 days (hazard ratio [HR] 0.9993, 95% confidence interval [CI]: 0.9988 to 0.9998, p<0.01) and 1 year (HR 0.9994, 95% CI: 0.9989 to 0.9999, p= 0.015). Risk-adjusted hazards for mortality were significantly reduced in recipients receiving hearts from more than 25 miles away. The hazard reduction was greatest in recipients receiving donor hearts from more than 500 miles away (1-year HR0.64, p < 0.01; 30-day HR 0.47, p < 0.01). Longer distances between donor location and center of heart transplantation are associated with a reduced hazard for survival at 30 days and 1 year, despite greater ischemic times. Future studies are necessary to elucidate the protective factors surrounding long-distance heart donation.