Cardiovascular-related Causes Research Articles

Short- and long-term outcomes in critically ill patients with primary glomerular disease: a case‒control study.

Glomerular diseases, encompassing primary and secondary forms, pose significant morbidity and mortality risks. Despite their impact, little is known about critically ill patients with primary glomerulopathy admitted to the intensive care unit (ICU). We conducted a case‒control study of patients with primary glomerulopathy using the Medical Information Mart for Intensive Care IV database. Demographic, clinical, and outcome data were collected. Logistic regression and mediation analysis were performed to identify predictors of hospital and long-term mortality. Among 50,920 patients, 307 with primary glomerulopathy were included. Infectious and cardiovascular-related causes were the main reasons for ICU admission, with sepsis being diagnosed in more than half of the patients during their ICU stay. The hospital mortality rate was similar to that of the control group, with a long-term mortality rate of 29.0% three years post-ICU discharge. Reduced urine output and serum albumin were identified as independent predictors of hospital mortality, while serum albumin and the Charlson comorbidity index were significantly associated with long-term mortality. Notably, although acute kidney injury was frequent, it was not significantly associated with mortality. Additionally, reduced urine output mediates nearly 25% of the association between serum albumin and hospital mortality. Critically ill patients with primary glomerulopathy exhibit unique characteristics and outcomes. Although hospital mortality was comparable to that of the control group, long-term mortality remained high. The serum albumin concentration and Charlson Comorbidity Index score emerged as robust predictors of long-term mortality, highlighting the importance of comprehensive risk assessment in this population. The lack of an association between acute kidney injury and mortality suggests the need for further research to understand the complex interplay of factors influencing outcomes in this patient population.

Mean arterial pressure versus cardiac index for haemodynamic management and myocardial injury after hepatopancreatic surgery: A randomised controlled trial.

Myocardial injury after noncardiac surgery (MINS) frequently complicates the peri-operative period and is associated with increased mortality. We hypothesised that cardiac index (CI) based haemodynamic management reduces peri-operative high-sensitive troponin-T (hsTnT) elevation and MINS incidence in patients undergoing hepatic/pancreatic surgery compared to mean arterial pressure. A randomised controlled study. A single-centre study conducted in a university-affiliated tertiary hospital between June 2022 and March 2023. Ninety-one patients, who were ≥ 65 years old or ≥ 45 years old with a history of at least one cardiac risk factor were randomised to either mean arterial pressure (MAP) based ( n = 45) or CI-based ( n = 46) management groups, and completed the study. In group-MAP, patients received fluid boluses and/or a noradrenaline infusion to maintain MAP above the predefined threshold. In group-CI, patients received fluid boluses and/or dobutamine infusion to keep CI above the predefined threshold. When a low MAP was observed despite a normal CI, a noradrenaline infusion was started. The primary outcome was peri-operative hsTnT elevation. The secondary outcomes were MINS incidence and 90-day mortality. The median absolute troponin elevation was 4.3 ng l -1 (95% CI 3.4 to 6) for the CI-based group, and 9.4 ng l -1 (95% CI 7.7 to 12.7) for the MAP-based group (median difference: 5.1 ng l -1 , 95% CI 3 to 7; P < 0.001). MINS occurred in 8 (17.4%) patients in the CI-based group and 17 (37.8%) patients in the MAP-based group (relative risk: 0.46, 95% CI: 0.22 to 0.96; P = 0.029). Two patients in group-MAP died from cardiovascular-related causes. One patient in group-CI and two in group-MAP died from sepsis-related complications (for all-cause mortality: χ2 = 1.98, P = 0.16). MAP-AUC and CI-AUC values of the CI- and MAP-based groups were 147 vs. 179 min × mmHg ( P = 0.85) and 8.4 vs. 43.2 l m -2 min -1 × min ( P < 0.001), respectively. CI-based haemodynamic management assures sufficient flow and consequently is associated with less peri-operative hsTnT elevation and lower incidence of MINS compared to MAP. Clinicaltrials.gov identifier: NCT05391087.

A Research Agenda to Improve Outcomes in Patients with Chronic Obstructive Pulmonary Disease and Cardiovascular Disease: An Official American Thoracic Society Research Statement.

Background: Individuals with chronic obstructive pulmonary disease (COPD) are often at risk for or have comorbid cardiovascular disease and are likely to die of cardiovascular-related causes. Objectives: To prioritize a list of research topics related to the diagnosis and management of patients with COPD and comorbid cardiovascular diseases (heart failure, atherosclerotic vascular disease, and atrial fibrillation) by summarizing existing evidence and using consensus-based methods. Methods: A literature search was performed. References were reviewed by committee co-chairs. An international, multidisciplinary committee, including a patient advocate, met virtually to review evidence and identify research topics. A modified Delphi approach was used to prioritize topics in real time on the basis of their potential for advancing the field. Results: Gaps spanned the translational science spectrum from basic science to implementation: 1) disease mechanisms; 2) epidemiology; 3) subphenotyping; 4) diagnosis and management; 5) clinical trials; 6) care delivery; 7) medication access, adherence, and side effects; 8) risk factor mitigation; 9) cardiac and pulmonary rehabilitation; and 10) health equity. Seventeen experts participated, and quorum was achieved for all votes (>80%). Of 17 topics, ≥70% agreement was achieved for 12 topics after two rounds of voting. The range of summative Likert scores was -15 to 25. The highest priority was "Conduct pragmatic clinical trials with patient-centered outcomes that collect both pulmonary and cardiac data elements." Health equity was identified as an important topic that should be embedded within all research. Conclusions: We propose a prioritized research agenda with the purpose of stimulating high-impact research that will hopefully improve outcomes among people with COPD and cardiovascular disease.

Real-World Clinical Burden of Newly Diagnosed Heart failure in Thai Patients.

There are limited data on the burden of newly diagnosed patients with heart failure (HF) in Thailand. Thus, this study aimed to fully understand the hospitalization, rehospitalization, mortality rates, demographics and characteristics, and quality of care in these patients. A retrospective review of all eligible adult patients' medical records from 2018 and 2019 was conducted at five hospitals.The patients were newly diagnosed with HF, as indicated by the International Classification of Diseases (ICD)-10 code "I50." Descriptive statistics was used to investigate patients' hospital burden and clinical outcome data. There were 1134 patients newly diagnosed with HF, classified as HF with reduced ejection fraction (HFrEF), HF with preserved ejection fraction (HFpEF), and HF with mildly reduced ejection fraction (HFmrEF) (44.0, 40.0, and 16.0%, respectively). The male-to-female ratios in HFmrEF and HFpEF were similar. In contrast, the proportion of men with HFrEF was greater. The mean age of all patients was 66.0years. The hospitalization rate was 1.3. Rehospitalization rates for HF-related issues were 0.1, 0.2, 0.4, and 0.5 at 30days, 60days, 180days, and 1year, respectively. The percentage of deaths from all causes among these patients was 9.8%, while the percentage of deaths from cardiovascular-related causes was 8.5%. Only a small proportion of patients received a target dose of guideline-directed medical therapy (GDMT). The study revealed that the characteristics, hospitalization rate for HF, and in-hospital mortality rate among newly diagnosed patients with HF were higher compared to similar studies conducted in Thailand and other countries. Moreover, a high quality of care is needed to improve the morbidity and mortality associated with HF in Thailand.

Artificial Intelligence-Based Left Ventricular Ejection Fraction by Medical Students for Mortality and Readmission Prediction.

Point-of-care ultrasound has become a universal practice, employed by physicians across various disciplines, contributing to diagnostic processes and decision-making. To assess the association of reduced (<50%) left-ventricular ejection fraction (LVEF) based on prospective point-of-care ultrasound operated by medical students using an artificial intelligence (AI) tool and 1-year primary composite outcome, including mortality and readmission for cardiovascular-related causes. Eight trained medical students used a hand-held ultrasound device (HUD) equipped with an AI-based tool for automatic evaluation of the LVEF of non-selected patients hospitalized in a cardiology department from March 2019 through March 2020. The study included 82 patients (72 males aged 58.5 ± 16.8 years), of whom 34 (41.5%) were diagnosed with AI-based reduced LVEF. The rates of the composite outcome were higher among patients with reduced systolic function compared to those with preserved LVEF (41.2% vs. 16.7%, p = 0.014). Adjusting for pertinent variables, reduced LVEF independently predicted the composite outcome (HR 2.717, 95% CI 1.083-6.817, p = 0.033). As compared to those with LVEF ≥ 50%, patients with reduced LVEF had a longer length of stay and higher rates of the secondary composite outcome, including in-hospital death, advanced ventilatory support, shock, and acute decompensated heart failure. AI-based assessment of reduced systolic function in the hands of medical students, independently predicted 1-year mortality and cardiovascular-related readmission and was associated with unfavorable in-hospital outcomes. AI utilization by novice users may be an important tool for risk stratification for hospitalized patients.

Transplant Candidates of 70+ Years Have Superior Survival If Receiving Pre-Emptively a Living Donor Kidney.

Background: The number of kidney transplant recipients over 70 years of age is increasing but detailed data on patient and graft survival in the modern era of immune suppression are few. Methods: A single-center cohort of patients of 70 years and older (n = 349) at time of kidney transplantation from 2010-2020 were followed until January 2023. Results: The median age was 73 years with a median follow-up of 4.3 years. Fifty percent of recipients of a living donor kidney (LDK, n = 143) received their graft pre-emptively. Cumulative death-censored graft survival was excellent in the LDK group and reached 98% at 5 years vs. 85% in the deceased donor kidney (DDK) group. Primary non-function (38%) and rejection (43%) were the major causes of graft loss in the first year after DDK transplantation. Rejection-related graft loss was 4.6% during follow-up. Median recipient survival was superior in the subgroup of pre-emptively transplanted LDK patients compared to non-pre-emptively LDK transplanted patients (11.1 versus 6.2 years). Non-pre-emptively transplanted patients had a significantly increased incidence of infection (HR 3.81, 1.46-9.96) and cardiovascular-related causes of death (HR 3.35, 1.16-9.71). Pre-emptive transplantation was also associated with a significantly improved graft survival in the DDK recipients but this result was confounded by significantly better HLA matching and younger donor age in this group. Conclusions: Pre-emptive LDK transplantation in patients of 70 years or older confers superior graft and recipient survival.

The effect of primary healthcare on mortality: Evidence from Costa Rica

This paper uses the gradual implementation of a primary healthcare (PHC) intervention in Costa Rica to examine the long-term effect of PHC on mortality. Nine years after opening a primary care center, known as a Health Area, there was an associated 13% reduction in age-adjusted mortality rate in the assigned patient population. The effect was highest among adults over 65 years of age and for those with noncommunicable diseases, such as cardiovascular-related causes of death. We also show that as Health Areas opened, more individuals sought care at primary care clinics, while fewer sought care at emergency rooms; these changes may have partially mediated the effect of the intervention on mortality.

Cardiac power output is associated with cardiovascular related mortality in the ICU in post-cardiac arrest patients

AimAlthough brain injury is the main determinant of poor outcome following cardiac arrest (CA), cardiovascular failure is the leading cause of death within the first days after CA. However, it remains unclear which hemodynamic parameter is most suitable for its early recognition. We investigated the association of cardiac power output (CPO) with early mortality in intensive care unit (ICU) after CA and with mortality related to post-CA cardiovascular failure. MethodsRetrospective analysis of adult comatose survivors of CA admitted to the ICU of a University Hospital. Exclusion criteria were treatment with extracorporeal cardiopulmonary resuscitation, ECMO or intra-aortic balloon pump. We retrieved CA characteristics; we recorded mean arterial pressure, cardiac output, CPO (as derived parameter) and the vasoactive-inotropic score for the first 72 hours after ROSC, at intervals of 8 hours. ICU death was defined as related to post-CA cardiovascular failure when death occurred as a direct consequence of shock, secondary CA or fatal arrhythmia, or related to neurological injury if this led to withdrawal of life-sustaining therapy or brain death. ResultsAmong the 217 patients (median age 66 years, 65% male, 61.8% out-of-hospital CA), 142 (65.4%) died in ICU: 99 (69.7%) patients died from neurological injury and 43 (30.3%) from cardiovascular-related causes. Comparing the evolution over time of CPO between survivors and non-survivors, a statistically significant difference was found only at +8 hours after CA (p = 0.0042). In multivariable analysis, CPO at 8-hour was significantly associated with cardiovascular-related mortality (p = 0.007). ConclusionsIn post-CA patients, the 8-hour CPO is an independent factor associated with ICU cardiovascular-related mortality.

Incidence and predictors of cardiac arrhythmias in patients with systemic sclerosis

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Heart involvement in systemic sclerosis patients is frequent and represents a negative prognostic factor with around 25% of SSc patients dying from cardiovascular related causes. Cardiac arrhythmias represent 6% of the overall causes of death in SSc patients. Not only a plethora of conditions typical of the disease seem to favour the presence of an arrhythmic substrate such as microvascular disease or fibrosis but autoimmunity itself has been recognized as a pathogenic mechanism for cardiac arrhythmias. Purpose The aim of our study was to investigate the incidence of arrhythmias in patients with systemic sclerosis and identify potential predictors. Methods Prospective longitudinal study enrolling all consecutive patients with a diagnosis of SSc and no overt cardiac disease nor pulmonary hypertension. Echocardiographic parameters and GLS were obtained at baseline and at each follow up as well as 12 lead ECG. Presence of atrial fibrillation (AF), atrial tachycardia (AT), ventricular ectopic beats &amp;gt;1000/24 h (VEB), supraventricular ectopic beats (SVEB), bundle branch block (BBB) and atrioventricular block (AVB) was registered. Results 160 patients (144 females, 90%, mean age 59±14 years) were enrolled from June 2016 to December 2021. At enrolment, 11.3% of patients with SSc presented a previous history of supraventricular arrhythmia (5.6% supraventricular ectopic beats, 3.1% atrial fibrillation, 2.5% atrial flutter) and 5.6% a history of ventricular arrhythmia (5.0% ventricular ectopic beats, 0.6% ventricular tachycardia). After a median follow-up of 3.1 years (95% CI 1.4-4.8 years), five patients (3.1%) died of cardiovascular causes, of which three (1.8%) experienced a sudden cardiac death. During the same period, 16 patients (10%) presented a new diagnosis of supraventricular arrythmia (8.7% atrial fibrillation, 1.3% atrial flutter) and two patients (1.2%) a new diagnosis of ventricular tachycardia. PR interval significantly increased during the 3.1-year follow-up (154±27 vs. 178±32 ms; p=0.013), as well as corrected QT interval (420±23 vs. 436±19 ms; p=0.001). New diagnosis of complete right and left bundle branch block was made in 18 (11.2%) and two (1.2%) of all SSc patients. Diagnosis of pulmonary arterial hypertension was associated with a 4-fold and a 10-fold increased risk of supraventricular and ventricular arrhythmias, respectively (Figure 1). A diffuse SSc variant (p=0.049), indexed right (p=0.020) and left atrial volumes (p=0.035), and E/E’ ratios (p=0.016) were all associated with an increased risk of supraventricular arrhythmias. TAPSE (p=0.040), as well as right (p=0.030) global longitudinal strain were associated with an increased risk of ventricular arrhythmias. Conclusions Ssc patients are often by an arrhythmic profile with an increased risk of supraventricular and ventricular events as well as sudden cardiac death. A comprehensive cardiological work up may help in lowering the risk of arrhythmic complications.

Improving the residual risk of renal and cardiovascular outcomes in diabetic kidney disease: A review of pathophysiology, mechanisms, and evidence from recent trials.

Based on global estimates, almost 10% of adults have diabetes, of whom 40% are estimated to also have chronic kidney disease (CKD). Almost 2 decades ago, treatments targeting the renin‐angiotensin system (RAS) were shown to slow the progression of kidney disease. More recently, studies have reported the additive benefits of antihyperglycaemic sodium‐glucose co‐transporter‐2 inhibitors in combination with RAS inhibitors on both CKD progression and cardiovascular outcomes. However, these recent data also showed that patients continue to progress to kidney failure or die from kidney‐ or cardiovascular‐related causes. Therefore, new agents are needed to address this continuing risk. Overactivation of the mineralocorticoid (MR) receptor contributes to kidney inflammation and fibrosis, suggesting that it is an appropriate treatment target in patients with diabetes and CKD. Novel, selective non‐steroidal MR antagonists are being studied in these patients, and the results of two large recently completed clinical trials have shown that one such treatment, finerenone, significantly reduces CKD progression and cardiovascular events compared with standard of care. This review summarizes the pathogenic mechanisms of CKD in type 2 diabetes and examines the potential benefit of novel disease‐modifying agents that target inflammatory and fibrotic factors in these patients.

Impact of serum albumin level and variability on short-term cardiovascular-related and all-cause mortality in patients on maintenance hemodialysis.

Studies have shown that low serum albumin (Salb) levels are associated with a high risk of mortality among patients on maintenance hemodialysis (MHD); however, the impact of Salb variability on short-term cardiovascular mortality remains unclear. Herein, we investigated the association between Salb levels and Salb variability on short-term all-cause and cardiovascular-related mortality in patients on MHD.Eligible patients on MHD at Chongqing General Hospital between June 2017 and June 2020 were recruited in this study. Patients were grouped by Salb levels (normal Salb, ≥3.8 g/dL; low Salb, 3.4–3.8 g/dL; and lower Salb, 2–3.4 g/dL) and Salb variability (decreased, >5% loss; increased, >5% gain; and steady, 5% loss to 5% gain). Associations between Salb levels, Salb variability, and all-cause and cardiovascular-related mortality were analyzed using Cox regression models. A survival analysis was performed using the Kaplan–Meier analysis.We enrolled a total of 181 patients on MHD with an average age of 65 years (interquartile range [IQR], 53–75 years). The mean Salb level was 3.8 ± 0.6 g/dL (IQR 2.9–4.4 g/dL), and the median Salb variability was 2.6% per year (IQR, −4.1 to 6.5). Fifty-two (29%) patients died, including 31 (17%) patients who died due to cardiovascular-related causes. Compared with the other groups, the lower Salb group had higher all-cause mortality (P < .01). Cox regression analyses revealed that lower Salb levels and decreased Salb variability were independently associated with all-cause mortality (hazard ratio [HR] = 1.95, 95% confidence interval [CI] 1.103–3.452; HR = 2.245, 95% CI 1.084–4.650), whereas increased Salb variability was independently associated with cardiovascular-related mortality (HR = 2.919, 95% CI 1.178–7.234; P < .05).Lower Salb levels were an independent predictor of all-cause mortality in patients on MHD. Increased Salb variability was strongly associated with cardiovascular-related mortality in the same population, especially in the short-term and in patients with normal Salb levels. Significantly elevated Salb variability should be evaluated to reduce cardiovascular-related mortality.

Hospitalizations among adults with chronic kidney disease in the United States: A cohort study.

Adults with chronic kidney disease (CKD) are hospitalized more frequently than those without CKD, but the magnitude of this excess morbidity and the factors associated with hospitalizations are not well known. Data from 3,939 participants enrolled in the Chronic Renal Insufficiency Cohort (CRIC) Study between 2003 and 2008 at 7 clinical centers in the United States were used to estimate primary causes of hospitalizations, hospitalization rates, and baseline participant factors associated with all-cause, cardiovascular, and non-cardiovascular hospitalizations during a median follow up of 9.6 years. Multivariable-adjusted Poisson regression was used to identify factors associated with hospitalization rates, including demographics, blood pressure, estimated glomerular filtration rate (eGFR), and proteinuria. Hospitalization rates in CRIC were compared with rates in the Nationwide Inpatient Sample (NIS) from 2012. Of the 3,939 CRIC participants, 45.1% were female, and 41.9% identified as non-Hispanic black, with a mean age of 57.7 years, and the mean eGFR is 44.9 ml/min/1.73m2. CRIC participants had an unadjusted overall hospitalization rate of 35.0 per 100 person-years (PY) [95% CI: 34.3 to 35.6] and 11.1 per 100 PY [95% CI: 10.8 to 11.5] for cardiovascular-related causes. All-cause, non-cardiovascular, and cardiovascular hospitalizations were associated with older age (≥65 versus 45 to 64 years), more proteinuria (≥150 to <500 versus <150 mg/g), higher systolic blood pressure (≥140 versus 120 to <130 mmHg), diabetes (versus no diabetes), and lower eGFR (<60 versus ≥60 ml/min/1.73m2). Non-Hispanic black (versus non-Hispanic white) race/ethnicity was associated with higher risk for cardiovascular hospitalization [rate ratio (RR) 1.25, 95% CI: 1.16 to 1.35, p-value < 0.001], while risk among females was lower [RR 0.89, 95% CI: 0.83 to 0.96, p-value = 0.002]. Rates of cardiovascular hospitalizations were higher among those with ≥500 mg/g of proteinuria irrespective of eGFR. The most common causes of hospitalization were related to cardiovascular (31.8%), genitourinary (8.7%), digestive (8.3%), endocrine, nutritional or metabolic (8.3%), and respiratory (6.7%) causes. Hospitalization rates were higher in CRIC than the NIS, except for non-cardiovascular hospitalizations among individuals aged >65 years. Limitations of the study include possible misclassification by diagnostic codes, residual confounding, and potential bias from healthy volunteer effect due to its observational nature. In this study, we observed that adults with CKD had a higher hospitalization rate than the general population that is hospitalized, and even moderate reductions in kidney function were associated with elevated rates of hospitalization. Causes of hospitalization were predominantly related to cardiovascular disease, but other causes contributed, particularly, genitourinary, digestive, and endocrine, nutritional, and metabolic illnesses. High levels of proteinuria were observed to have the largest association with hospitalizations across a wide range of kidney function levels.

Trends in Cardiovascular Mortality Among a Cohort of Children and Young Adults Starting Dialysis in 1995 to 2015

Survival of patients receiving dialysis has improved during the last 2 decades. However, few studies have examined temporal trends in the attributed causes of death (especially cardiovascular-related) in young populations. To determine temporal trends and risk of cause-specific mortality (ie, cardiovascular and infectious) for children and young adults receiving dialysis. This retrospective cohort study examined the records of children and young adults (aged <30 years) starting dialysis between 1995 and 2015 according to the United States Renal Data System database. Analyses were performed between June 2019 and June 2020. Fine-Gray models were used to examine trends in risk of different cardiovascular-related deaths. Models were adjusted for age, sex, race, neighborhood income, cause of end-stage kidney disease, insurance type, and comorbidities. Analyses were performed separately for children (ie, age <18 years) and young adults (between ages 18 and 30 years). Follow-up was censored at death or administratively, and transplantation was treated as a competing event. Calendar year. Cardiovascular cause-specific mortality. A total of 80 189 individuals (median [interquartile range] age, 24 [19-28] years; 36 259 [45.2%] female, 29 508 [36.8%] Black, and 15 516 [19.3%] Hispanic white) started dialysis and 16 179 experienced death during a median (interquartile range) of 14.3 (14.0-14.7) years of follow-up. Overall, 40.2% of deaths were from cardiovascular-related causes (6505 of 16 179 patients). In adjusted analysis, risk of cardiovascular-related death was stable initially but became statistically significantly lower after 2006 (vs 1995) in those starting dialysis as either children (subhazard ratio [SHR], 0.74; 95% CI, 0.55-1.00) or adults (SHR, 0.90; 95% CI, 0.83-0.98). Risk of sudden cardiac death improved steadily for all age groups, but to a greater degree in children (SHR, 0.31; 95% CI, 0.20-0.47) vs young adults (SHR, 0.64; 95% CI, 0.56-0.73) comparing 2015 vs 1995. Risk of stroke became statistically significantly lower around 2010 (vs 1995) for children (SHR, 0.40; 95% CI, 0.18-0.88) and young adults (SHR, 0.76; 95% CI, 0.59-0.99). In this study, the risk of cardiovascular-related death declined for children and young adults starting dialysis during the last 2 decades, but trends differed depending on age at dialysis initiation and the specific cause of death. Additional studies are needed to improve risk of cardiovascular disease in young populations.

Characteristics and outcome of a first acute myocardial infarction in patients with ankylosing spondylitis

ObjectivesTo study clinical characteristics, mortality, and secondary prevention, after a first incident acute myocardial infarction (AMI) in patients with ankylosing spondylitis (AS) compared with the general population.MethodsIn total, 292 subjects with AS and a first AMI between Jan 2006 and Dec 2014 were identified using the Swedish national patient register. Each subject was matched with up to 5 general population comparators per AS-patient (n = 1276). Follow-up started at the date of admission for AMI and extended until death or 365 days of follow-up. Cox regression was used to assess mortality in two time intervals: days 0–30 and days 31–365. For a subgroup with available data, clinical presentation at admission, course, treatment for AMI, and secondary prevention were compared.ResultsDuring the 365-day follow-up, 56/292 (19%) AS patients and 184/1276 (14%) comparators died. There were no difference in mortality due to cardiovascular-related causes, although the overall mortality day 31–365 was increased among patients with AS compared with comparators (HR [95% CI] = 2.0 [1.3;3.0]). At admission, AS patients had a higher prevalence of cardiovascular comorbidities compared with comparators. At discharge, patients with AS were less often prescribed lipid-lowering drugs and non-aspirin antiplatelet therapy.ConclusionsPatients with AS tend to have a higher comorbidity burden at admission for first AMI. The mortality after a first AMI due to cardiovascular-related causes does not seem to be elevated, despite an increased overall mortality during days 31–365 among patients with AS compared with the general population.Key Points• The all-cause mortality after a first AMI was higher in patients with AS.• Mortality after a first AMI due to CVD-related causes does not seem to be elevated for patients with AS.• In patients with AS suffering a first AMI, more attention should be given to other comorbidities causing an excess in mortality.

Disease assimilation: The mortality impacts of fine particulate matter on immigrants to Canada.

Immigrants make up 20% of the Canadian population; however, little is known about the mortality impacts of fine particulate matter (PM2.5) air pollution on immigrants compared with non-immigrants, or about how impacts may change with duration in Canada. This study used the 2001 Canadian Census Health and Environment Cohort, a longitudinal cohort of 3.5 million individuals, of which 764,000 were classified as immigrants (foreign-born). Postal codes from annual income tax files were used to account for mobility among respondents and to assign annual PM2.5 concentrations from 1998 to 2016. Exposures were estimated as a three-year moving average prior to the follow-up year. Cox survival models were used to determine hazard ratios (HRs) for cause-specific mortality, comparing the Canadian and foreign-born populations, with further stratification by year of immigration grouped into 10-year cohorts. Differences in urban-rural settlement patterns resulted in greater exposure to PM2.5 for immigrants compared with non-immigrants (mean = 9.3 vs. 7.5 μg/m3), with higher exposures among more recent immigrants. In fully adjusted models, immigrants had higher HRs per 10 μg/m3 increase in PM2.5 concentration compared with Canadian-born individuals for cardiovascular mortality (HR [95% confidence interval] = 1.22 [1.12 to 1.34] vs. 1.12 [1.07 to 1.18]) and cerebrovascular mortality (HR = 1.25 [1.03 to 1.52] vs. 1.03 [0.93 to 1.15]), respectively. However, tests for differences between the two groups were not significant when Cochran's Q test was used. No significant associations were found for respiratory outcomes, except for lung cancer in non-immigrants (HR = 1.10 [1.02 to 1.18]). When stratified by year of immigration, differences in HRs across varied by cause of death. In Canada, PM2.5 is an equal-opportunity risk factor, with immigrants experiencing similar if not higher mortality risks compared with non-immigrants for cardiovascular-related causes of death. Some notable differences also existed with cerebrovascular and lung cancer deaths. Continued reductions in air pollution, particularly in urban areas, will improve the health of the Canadian population as a whole.

3D echocardiographic global longitudinal strain can identify patients with mildly-to-moderately reduced ejection fraction at higher cardiovascular risk.

Severely reduced left ventricular (LV) ejection fraction (EF) derived from 2D echocardiographic (2DE) images is associated with increased mortality and used to guide therapeutic choices. Global longitudinal strain (GLS) is more sensitive than LVEF to detect abnormal LV function, and accordingly may help identify patients with mildly-to-moderately reduced LVEF who are at a similarly high cardiovascular (CV) risk. We hypothesized that 3D echocardiographic (3DE) measurements of EF and GLS, which are more reliable and reproducible, may have even better predictive value than the 2DE indices, and compared their ability to identify such patients. We retrospectively studied 104 inpatients with 2DE-derived LVEF of 30-50% who underwent transthoracic echocardiography during 2006-2010 period, had good quality images, and were followed-up through 2016. Both 2DE and 3DE images were analyzed to measure LVEF and GLS. Kaplan-Meier survival curves were generated for two subgroups defined by the median of each parameter as the cutoff. Of the 104 patients, 32 died of CV related causes. Cox regression revealed that 3D GLS was the only variable associated with CV mortality. Kaplan-Meier curves showed that 2D LVEF, 2D GLS and 3D EF were unable to differentiate patients at higher CV mortality risk, but 3D GLS was the only parameter to do so. Because 3D GLS is able to identify patients with mildly-to-moderately reduced LVEF who are at higher CV mortality risk, its incorporation into clinical decisions may improve survival of those who would benefit from therapeutic interventions not indicated according to the current guidelines.

Prevalence and pattern of cardiovascular-related causes of out-of-hospital deaths in Lagos, Nigeria

In developed countries 50% - 75% of deaths from cardiovascular-diseases occurs out-of-hospital. In Nigeria where patronage of orthodox health facilities is low, the impact of cardiovascular-related diseases on out-of-hospital mortality has been sparsely studied. To determine the prevalence and pattern of cardiovascular-related causes of out-of-hospital deaths in Lagos, Nigeria. A 5-year retrospective review of all autopsied medical decedents brought-in-dead (BID) to a Nigerian tertiary health facility to identify cardiovascular-related causes of death. A total of 90 cardiovascular-related deaths out of 176 medical BID cases were identified, giving a prevalence of 51.1%. Mean age was 65.2 ± 15.6 years. Male: Female ratio was 1.4: 1, the females were older (68.29 ± 14.89) vs (61.63 ± 15.55) years. Age group > 60 years accounted for 63.3% of deaths. Commonest primary diseases were hypertensive heart disease (48.9%) and cerebrovascular accident (24.4%). Myocardial infarction occurred in 8.9%. Heart failure, cerebral dysfunction and unspecified circulatory collapse were the causes of death in 54.4%, 23.3% and 14.4% respectively. Cardiovascular-related diseases are major contributors to out-of-hospital medical deaths occurring chiefly in those >60 years. Hypertensive heart disease and heart failure are the greatest contributors to this cardiovascular-related disease mortality.

Long-term mortality after blood pressure-lowering and lipid-lowering treatment in patients with hypertension in the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) Legacy study: 16-year follow-up results of a randomised factorial trial

In patients with hypertension, the long-term cardiovascular and all-cause mortality effects of different blood pressure-lowering regimens and lipid-lowering treatment are not well documented, particularly in clinical trial settings. The Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT) Legacy Study reports mortality outcomes after 16 years of follow-up of the UK participants in the original ASCOT trial. ASCOT was a multicentre randomised trial with a 2 × 2 factorial design. UK-based patients with hypertension were followed up for all-cause and cardiovascular mortality for a median of 15·7 years (IQR 9·7-16·4 years). At baseline, all patients enrolled into the blood pressure-lowering arm (BPLA) of ASCOT were randomly assigned to receive either amlodipine-based or atenolol-based blood pressure-lowering treatment. Of these patients, those who had total cholesterol of 6·5 mmol/L or lower and no previous lipid-lowering treatment underwent further randomisation to receive either atorvastatin or placebo as part of the lipid-lowering arm (LLA) of ASCOT. The remaining patients formed the non-LLA group. A team of two physicians independently adjudicated all causes of death. Of 8580 UK-based patients in ASCOT, 3282 (38·3%) died, including 1640 (38·4%) of 4275 assigned to atenolol-based treatment and 1642 (38·1%) of 4305 assigned to amlodipine-based treatment. 1768 of the 4605 patients in the LLA died, including 903 (39·5%) of 2288 assigned placebo and 865 (37·3%) of 2317 assigned atorvastatin. Of all deaths, 1210 (36·9%) were from cardiovascular-related causes. Among patients in the BPLA, there was no overall difference in all-cause mortality between treatments (adjusted hazard ratio [HR] 0·90, 95% CI 0·81-1·01, p=0·0776]), although significantly fewer deaths from stroke (adjusted HR 0·71, 0·53-0·97, p=0·0305) occurred in the amlodipine-based treatment group than in the atenolol-based treatment group. There was no interaction between treatment allocation in the BPLA and in the LLA. However, in the 3975 patients in the non-LLA group, there were fewer cardiovascular deaths (adjusted HR 0·79, 0·67-0·93, p=0·0046) among those assigned to amlodipine-based treatment compared with atenolol-based treatment (p=0·022 for the test for interaction between the two blood pressure treatments and allocation to LLA or not). In the LLA, significantly fewer cardiovascular deaths (HR 0·85, 0·72-0·99, p=0·0395) occurred among patients assigned to statin than among those assigned placebo. Our findings show the long-term beneficial effects on mortality of antihypertensive treatment with a calcium channel blocker-based treatment regimen and lipid-lowering with a statin: patients on amlodipine-based treatment had fewer stroke deaths and patients on atorvastatin had fewer cardiovascular deaths more than 10 years after trial closure. Overall, the ASCOT Legacy study supports the notion that interventions for blood pressure and cholesterol are associated with long-term benefits on cardiovascular outcomes. Pfizer.

Causes of Death in Patients with Aortic Aneurysmal Disease (1987-2014)

Introduction: This study examined the cause of death of patients with aortic aneurysms treated for this disease between 1987 and 2014 to understand the current natural history of this condition. Methods: This study results from analysis of a prospectively maintained data base of patients treated by the author. Data points were obtained from practice records and supplemented by data made available through CHeRL (Centre for electronic Health Record Linkage). Six hundred and twenty two patients were treated consecutively between 1987 and 2014. At closure of the study in 2014, 402 patients had died and date of death was available. Cause of death was available by ICD (International Classification of Diseases) 9 or 10 in 89% of patients. Method of treatment of aneurysmal disease was available in all patients. Ethics approval for this study was obtained from the Centre for Health Research, Cancer Institute, New South Wales Department of Health. Statistical analysis was conducted by comparison of mean ±95% conference interval. Where appropriate contingency table analysis was constructed. Statistical significance was accepted at P < 0.05. Results: Mean age at presentation was 75.6 years (95%C.I. 74.8 - 76.3). Mean age at death was 81 years (95%C.I. 80.2 - 81.7). Predicted age at death based on Australian Bureau of Statistics life tables was 86.25 years (95%C.I. 85.8 - 86.8). Between 1987 and 1999, mean age at presentation was 74.5 years (95%C.I. 73.3 - 75, n = 304, Females = 78). Between 2000 and 2014, mean age at presentation was 75.3 years (95%C.I. 74.1 - 75, n = 318, females = 54). The difference for females presenting 1987 to 1999 compared 2000 to 2014 was significant, p < 0.01. Death was due to the following causes unknown 11%, cardiovascular disease 27.7%, pulmonary related disease 9.7% and aortic related disease 20.6%. Patients died of aortic related causes significantly earlier (within 2 years) compared to patients with other causes of death (5 to 8 years) due to presentation with ruptured aortic aneurysm. Cardiovascular related causes of death, malignancy and pulmonary related causes of death accounted for the majority of deaths post-treatment. There was no significant difference in length of survival among patients dying from these causes. Conclusion: Patients with successfully treated aneurysmal disease can expect to survive 5 - 8 years post-treatment. Presentation with aortic aneurysm rupture results in significantly shortened life expectancy. Patients presenting in the ninth decade of life and with less than 5 years life expectancy may not benefit from elective repair of aortic aneurysm.

An oxidative stress biomarker, urinary 8-hydroxy-2′-deoxyguanosine, predicts cardiovascular-related death after steroid therapy for patients with active cardiac sarcoidosis

BackgroundWe investigated whether urinary 8-hydroxy-2′-deoxyguanosine (U-8-OHdG), a marker of oxidative DNA damage, is a prognosticator of cardiovascular-related death in patients with cardiac sarcoidosis (CS). Methods and resultsIn this prospective study, 30 consecutive patients were divided into the active CS (n=20) and non-active CS (n=10) groups, based on abnormal isotope accumulation in the heart on 18F-fluorodeoxyglucose positron-emission tomography/computed tomography (18F-FDG PET/CT) imaging. Nineteen patients in the active CS group underwent corticosteroid therapy. Before corticosteroid therapy initiation, U-8-OHdG, brain natriuretic peptide (BNP), other biomarkers, and indices of cardiac function were measured. Patients were followed-up for a median of 48months. The primary endpoint was the incidence of cardiovascular-related death.During the follow-up period, in the corticosteroid-treated active CS group, 7 of 19 patients experienced cardiovascular-related death. By contrast, in the non-active CS group, 1 of 10 patients died from cardiovascular-related causes. Univariate and multivariate analyses showed that U-8-OHdG and BNP were independent predictors for cardiovascular-related death. The cut-off values for predicting cardiovascular death in corticosteroid-treated patients with active CS were 19.1ng/mg·Cr and 209pg/mL for U-8-OHdG and BNP, respectively. Patients with a U-8-OHdG concentration ≥19.1ng/mg·Cr or a BNP concentration ≥209pg/mL had a significantly higher cardiovascular-related death risk, but U-8-OHdG had better predictive value compared with BNP. ConclusionThese findings suggested that U-8-OHdG was a powerful predictor of cardiovascular-related death in patients with CS, suggesting that active CS patients with elevated U-8-OHdG levels might be resistant to corticosteroid therapy.