Cardiovascular-related Hospitalizations Research Articles

T-wave morphology descriptors in patients with bulimia nervosa

Bulimia nervosa (BN) is associated with increased risk of cardiovascular disease and arrhythmias. Some reports found abnormal electrocardiographic markers of arrhythmias in BN, while others did not. This study investigated novel parameters of T-wave morphology that were reported to be associated with adverse cardiovascular outcomes in other patient groups, among patients with BN under medical care. Thirty-five BN patients and 76 healthy controls were included. Total cosine R to T (TCRT) and T-wave Morphology Dispersion (TMD) parameters were computed according to accepted standards for an average beat and a random beat. Patients were followed for 11.1 ± 0.1years for the emergence of arrhythmias or events of sudden death. Twenty-five (71.4%) BN patients were hospitalized when enrolled, for a mean duration of 1.1 ± 0.2months. The rest were ambulatory patients. The BN group had lower blood pressure, more smokers, and used antidepressants, neuroleptic drugs and benzodiazepines more than controls did. Other demographic parameters were comparable between groups. TCRT and TMD parameters were statistically similar and within the normal ranges reported by other research groups. None of the BN patients had prolonged QTc interval or electrolyte abnormalities on inclusion. During the follow-up period, no clinical symptoms suggestive of arrhythmias were reported, and no cardiovascular-related hospitalizations or deaths occurred in either group. Medically treated BN patients have normal T-wave morphology parameters and hence, low risk for repolarization-associated malignant ventricular arrhythmias. The prognostic importance of these novel repolarization parameters remains to be explored among untreated patients, those who ingest emetic substances and patients with electrolyte imbalance. Level III.

Perinatal outcomes and long-term offspring cardiovascular morbidity of women with congenital heart disease

ObjectiveDue to advances in medical care available for patients with congenital heart disease, these patients now have a longer life span. As a result, the number of pregnancies of mothers with congenital heart disease has increased. The purpose of the current study was to evaluate perinatal outcomes of women with congenital heart disease and to examine long-term cardiovascular morbidity of offspring to mothers with congenital heart disease. Materials and methodsA population-based cohort analysis was performed including all singleton deliveries occurring between years 1991–2014 at Soroka University Medical Center. The primary exposure was defined as maternal congenital heart disease. Short-term perinatal outcomes as well as long-term cardiovascular related hospitalizations of the offspring up to the age of 18 years were compared between women with and without congenital heart disease. To compare perinatal outcomes between the two study groups, we conducted a Generalized Estimation Equation (GEE) model accounting for maternal age and multiple occurrence in the cohort, parity, fertility treatment, smoking and induction of labor. To compare cumulative long-term cardiovascular morbidity, we compared cardiovascular hospitalization incidence of offspring of mothers with and without congenital heart disease using Kaplan-Meier survival curve and Weibull regression analysis to control for maternal age, diabetes, smoking, hypertension, birth weight, and cesarean delivery. ResultsDuring the study period 243,313 deliveries met the inclusion criteria, of which 369 were of mothers with congenital heart disease. Maternal congenital heart disease was found to be an independent risk factor for low birth weight (adjusted OR = 1.5 CI 95 % 1.06–2.32, p=0.022) and cesarean delivery (adjusted OR = 1.4 CI 95 % 1.09–1.86, p = 0.008). Mothers with congenital heart disease also had higher risk for placental abruption, but it was not statistically significant (adjusted OR = 2.3 CI 95 % 0.87–6.16, p = 0.09). Long-term cardiovascular morbidity was comparable between the groups (Log rank p = 0.251; adjusted HR = 1.6 CI 95 % 0.62–4.42, p = 0.313). ConclusionIn conclusion, pregnancies of women with congenital heart disease are at an increased risk for adverse short-term perinatal outcomes, such as low birth weight and cesarean delivery. However, we did not find an increase in long-term cardiovascular morbidity among offspring of these women; still this association cannot be ruled out.

Major Outcomes With Personalized Dialysate TEMPerature (MyTEMP): Rationale and Design of a Pragmatic, Registry-Based, Cluster Randomized Controlled Trial.

Background:Small randomized trials demonstrated that a lower compared with higher dialysate temperature reduced the average drop in intradialytic blood pressure. Some observational studies demonstrated that a lower compared with higher dialysate temperature was associated with a lower risk of all-cause mortality and cardiovascular mortality. There is now the need for a large randomized trial that compares the effect of a low vs high dialysate temperature on major cardiovascular outcomes.Objective:The purpose of this study is to test the effect of outpatient hemodialysis centers randomized to (1) a personalized temperature-reduced dialysate protocol or (2) a standard-temperature dialysate protocol for 4 years on cardiovascular-related death and hospitalizations.Design:The design of the study is a pragmatic, registry-based, open-label, cluster randomized controlled trial.Setting:Hemodialysis centers in Ontario, Canada, were randomized on February 1, 2017, for a trial start date of April 3, 2017, and end date of March 31, 2021.Participants:In total, 84 hemodialysis centers will care for approximately 15 500 patients and provide over 4 million dialysis sessions over a 4-year follow-up.Intervention:Hemodialysis centers were randomized (1:1) to provide (1) a personalized temperature-reduced dialysate protocol or (2) a standard-temperature dialysate protocol of 36.5°C. For the personalized protocol, nurses set the dialysate temperature between 0.5°C and 0.9°C below the patient’s predialysis body temperature for each dialysis session, to a minimum dialysate temperature of 35.5°C.Primary outcome:A composite of cardiovascular-related death or major cardiovascular-related hospitalization (a hospital admission with myocardial infarction, congestive heart failure, or ischemic stroke) captured in Ontario health care administrative databases.Planned primary analysis:The primary analysis will follow an intent-to-treat approach. The hazard ratio of time-to-first event will be estimated from a Cox model. Within-center correlation will be considered using a robust sandwich estimator. Observation time will be censored on the trial end date or when patients die from a noncardiovascular event.Trial Registration:www.clinicaltrials.gov; identifier: NCT02628366.

173: Long inter-pregnancy interval and later paediatric cardiovascular health of the offspring

Recent evidence suggest that long inter-pregnancy interval (IPI; defined as a time interval between a live birth and estimated time of conception of a subsequent pregnancy of over 60 months) poses a risk for adverse short-term perinatal outcome. We aimed to study the effect of short (< 6 months) and long IPIs on long-term cardiovascular health of the offspring. A population-based cohort study was performed in which all singleton live births in parturients with at least one previous birth were included. Deliveries occurred between the years 1991-2014 at a single regional tertiary medical center. Hospitalizations of the offspring up to the age of 18 years involving cardiovascular diseases were evaluated according to a predefined set of related ICD codes. Outcomes were evaluated according to IPI length. Intermediate interval, between 6 (short) and 60 (long) months was considered the reference. Kaplan-Meier survival curves were used to compare the cumulative morbidity incidence between the groups, and Cox hazards regression models, to control for confounders. During the study period 144,397 deliveries met the inclusion criteria. Of them, 13.1% (n=18,947) occurred in women with short IPIs, 79.0% (n=114,012) in women with intermediate IPIs, and 7.9% (n=11,438) in women with long IPIs. Total hospitalizations of the offspring, involving cardiovascular morbidity, were comparable between the groups (Table). The Kaplan-Meier survival curves demonstrated similar cumulative incidences of cardiovascular morbidity in all groups (Figure). In the Cox regression models, controlled for maternal age, diabetes mellitus and hypertensive disorders of pregnancy, prematurity, and birthweight, short and long IPI did not appear as independent risk factors for later pediatric cardiovascular related hospitalizations in the offspring (adjusted HR 0.96, 95%CI 0.79-1.20; and adjusted HR 1.06, 95%CI 0.82-1.40, respectively). Extreme IPIs do not appear to impact on long-term cardiovascular health of the offspring.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Schumann resonance and cardiovascular hospital admission in the area of Granada, Spain: An event coincidence analysis approach

The study of bio-effects of Schumann resonances is a very complex issue. There is a need to identify mechanisms and pathways that explain how Extremely Low Frequency magnetic fields affect biology or human health. This particular study tries to identify statistical associations between ELF magnetic fields in the province of Granada (Spain) and cardiovascular related hospital admission in the same province for the period April, 1st 2013 to March, 31st 2014. Research is developed under an epidemiological approach based on an Event Coincidence Analysis statistical method. Clustered events, statistically significant (ECA shuffle-surrogate test p = .01 and p < .01), were found for the minimum values of the first and the third Schuman resonances frequency on east-west and north-south directions, and for the amplitude parameter of the second resonance and the total signal energy in the north-south direction. Empirical measurements of SR parameters were recorded at the Sierra Nevada Mountain in Granada province (Spain). Results show a clear coincidence of the events for the minima amplitudes of Shuman resonances and energy in the north-south orientation and the number of the cardiovascular related hospital admissions. Further research is needed with longer temporal series and a new approach based on gender seems to be also interesting for future studies.

Tafamidis: A First-in-Class Transthyretin Stabilizer for Transthyretin Amyloid Cardiomyopathy.

Objective: To review the pharmacology, efficacy, and safety of the selective transthyretin inhibitor tafamidis for transthyretin amyloid cardiomyopathy (ATTR-CM). Data Sources: A PubMed (1966 to October 2019) and ClinicalTrials. gov search was conducted using the keywords tafamidis, Fx-1006A, Vyndaqel, and Vyndamax. Additional articles were identified from references. Study Selection and Data Extraction: We included English-language clinical studies evaluating the pharmacology, efficacy, or safety of tafamidis in humans for ATTR-CM. Data Synthesis: Tafamidis binds to the thyroxine-binding sites of the transthyretin tetramer and inhibits its dissociation into monomers, which is the rate-limiting step in the amyloidogenic process. Treatment with tafamidis was significantly associated with a significant reduction in mortality, lowered cardiovascular-related hospitalizations, less functional decline, and improved transthyretin stabilization compared with placebo. Additionally, tafamidis was found to have fewer adverse events, with no difference found compared with placebo. Relevance to Patient Care and Clinical Practice: Historically, symptomatic management for ATTR-CM was the only option, and the treatment of the underlying disease was limited to liver or heart transplantation. Tafamidis is the first medication approved for the treatment of ATTR-CM and the only medication that showed a reduction in all-cause mortality and cardiovascular-related hospitalizations in patients with amyloidosis. However, the role of tafamidis in patients with the New York Heart Association class III/IV heart failure or mutated transthyretin remains unclear. Conclusion: Tafamidis is an effective and safe oral medication for the treatment of the cardiomyopathy of transthyretin-mediated amyloidosis in adults to reduce cardiovascular mortality and cardiovascular-related hospitalization.

PIN29 PUBLIC HEALTH AND ECONOMIC IMPACT OF VACCINATION OF SENIORS WITH A HIGH DOSE TRIVALENT INFLUENZA VACCINE IN BRAZILIAN PRIVATE HEALTH CARE SYSTEM

Older adults are particularly vulnerable to influenza and are susceptible to serious complications after an influenza infection, which frequently lead to hospitalizations. Standard-dose influenza vaccines have proven to be beneficial to older patients, however presenting suboptimal efficacy due to immunosenescence. A large randomized controlled trial (FIM12) and several real world studies have shown trivalent influenza vaccine high dose (TIV-HD) to be more effective than standard dose trivalent influenza vaccine (TIV-SD) in terms of reducing influenza cases and hospitalizations, including serious cardio-respiratory events, in the elderly population. In 2018, TIV-HD has been licensed in Brazil. The objective is to assess the impact of switching from TIV-SD to TIV-HD for adults aged ≥65 years in Brazilian private health care system. A flexible age structured decision tree model was used and two classes of events were considered: cases of laboratory confirmed influenza, and hospitalizations due to conditions known to be related to influenza. Three alternative definitions of hospitalization were provided: influenza/pneumonia, any respiratory illness, or all serious cardiorespiratory events. The model was populated with clinical data from FIM12 and demographic and economic inputs appropriate to the Brazilian private setting. Switching from TIV-SD to TIV-HD for adults aged ≥65 years in Brazilian private sector was estimated to lead to an incremental annual reduction from 10,000 to 20,000 influenza-related hospitalization (where 14,000 were respiratory-related hospitalization and 6,000 were cardiovascular-related hospitalization), from 900 to 1800 influenza-related deaths, and 11,000 influenza-related general practitioner visits, corresponding to avoided costs from USD111 million (BRL454M) to USD219 million (BRL890M), depending on the hospitalization definition. Hospitalization avoided costs represented 99% of the total avoided costs. Switching to TIV-HD would significantly reduce the burden of influenza especially by reducing hospitalizations that represent the most important source of cost for private market.

Age-specific seasonal associations between acute exposure to PM2.5 sources and cardiorespiratory hospital admissions in California

Numerous studies have explored the relationships between short-term exposure to fine particulate matter (PM2.5) and morbidity. However, few studies have investigated which PM2.5 sources and constituents contribute to the health associations, and even fewer studies are available which explored age or seasonal effect modification for the associations between PM2.5 sources and health. We explored age-specific associations between short-term exposure to PM2.5 chemical constituents and its sources, and hospital admissions in California. We linked hospital admission data (n = 1,679,094) with PM2.5 chemical constituents and source apportionment data for eight sites in California for the period of 2002–2009. Site-specific source apportionment was conducted using Positive Matrix Factorization, and five PM2.5 sources were commonly identified in most sites (biomass burning, soil, secondary ammonium nitrate, secondary ammonium sulfate, and vehicular emissions). Age-stratified Poisson time-series regression was conducted for each site, and the health risk estimates were combined to generate overall age-specific associations with cardiovascular- and respiratory-related hospital admissions. We further conducted seasonal interaction models to assess seasonal effect modification. An interquartile range increase in PM2.5 vehicular emissions was associated with increased risk of cardiovascular-related hospital admission at lag 0 (1.32% [95% confidence interval (CI): 0.16, 2.49]) for elderly people (≥65 years old). Exposure to PM2.5 vehicular emissions increased the risk of respiratory-related hospitalizations at lag 2 (3.58% [95% CI: 0.90, 6.33]) for children (0–18 years old). Risk estimates of PM2.5 total mass, vehicular emissions, and its related constituents (e.g., iron) for respiratory admissions were higher in the warm season among children. Heterogeneous seasonal estimates were not observed for other age groups. Our results suggest that short-term exposures to several PM2.5 sources and their related constituents are more harmful than exposures to other pollutants, particularly for children in summer. Identifying toxic sources is important for developing effective interventions and protecting susceptible populations.

Long-term risk for maternal cardiovascular morbidities in twin pregnancies complicated with gestational diabetes mellitus – a retrospective cohort study†

Background Gestational diabetes mellitus (GDM) results in an increased risk for maternal and neonatal complications in singletons. In twin pregnancies, however, scarce data exist regarding its implications. Objective To investigate whether a diagnosis of GDM in twin gestation poses a risk for subsequent maternal long-term cardiovascular morbidity. Study design A population-based cohort study was conducted, comparing the incidence of cardiovascular morbidity within a group of women with and without a diagnosis of GDM who delivered twins in a tertiary medical center, between the years 1991 and 2014. Mothers with pregestational diabetes mellitus, triplet or higher-order multiples, patients lacking prenatal care, patients with known cardiovascular morbidities prior to or during the current pregnancy and fetal malformations or/and chromosomal abnormalities were excluded. Kaplan–Meier’s survival curve was used to estimate the cumulative incidence of cardiovascular-related hospitalizations, and a Cox proportional hazards model was used to estimate the adjusted HRs for cardiovascular morbidity. Results Of 4256 twin deliveries that met the inclusion criteria, 336 (7.9%) occurred in patients that were diagnosed with GDM. During a follow-up period of more than 10 years, with a median of 3431 (0–9172) days in total, patients with GDM had higher rates of simple cardiovascular events as compared to women without diagnosis of GDM (incidence = 7, 2.1%. OR = 2.7, 95% confidence interval (CI) 1.17–6.12, p = .03). Total cardiovascular hospitalizations were comparable between the groups. There was no difference between the two groups in the rate of complex cardiovascular events, noninvasive or invasive cardiac diagnostic procedures. In a Cox proportional hazards model, which is adjusted for maternal age, ethnicity, hypertensive disorders, and fertility treatments, GDM in twin pregnancies was not found to be associated with long-term cardiovascular morbidity (adjusted HR 1.41, 95% CI 0.77–2.58, p = .26). Conclusions While GDM during twin pregnancy might be associated with long-term maternal simple cardiovascular events, the complex, as well as the total morbidities, are comparable to patients without GDM.

Tachycardiomyopathy in Patients without Underlying Structural Heart Disease.

Tachycardiomyopathy (TCM) is an underestimated cause of reversible left ventricle dysfunction. The aim of this study was to identify the predictors of recurrence and incidence of major cardiovascular events in TCM patients without underlying structural heart disease (pure TCM). The prospective, observational study enrolled all consecutive pure TCM patients. The diagnosis was suspected in patients admitted for heart failure (HF) with a reduced ejection fraction and concomitant persistent arrhythmia. Pure TCM was confirmed after the clinical and echocardiographic recovery during follow-up. From 107 pure TCM patients (9% of all HF admission, the median follow-up 22.6 months), 17 recurred, 51 were hospitalized for cardiovascular reasons, two suffered from thromboembolic events and one died. The diagnosis of obstructive sleep apnoea syndrome (OSAS, hazard ratio (HR) 5.44), brain natriuretic peptide on admission (HR 1.01 for each pg/mL) and the heart rate at discharge (HR 1.05 for each bpm) were all independent predictors of TCM recurrence. The left ventricular ejection fraction at discharge (HR 0.96 for each%) and the heart rate at discharge (HR 1.02 for each bpm) resulted as independent predictors of cardiovascular-related hospitalization. Pure TCM is more common than previously thought and associated with a good long-term survival but recurrences and hospitalizations are frequent. Reversing OSAS and controlling the heart rate could prevent TCM-related complications.

Multiple antihypertensive use and risk of mortality in residents of aged care services: a prospective cohort study.

The objective of this study is to investigate the association between multiple antihypertensive use and mortality in residents with diagnosed hypertension, and whether dementia and frailty modify this association. This is a two-year prospective cohort study of 239 residents with diagnosed hypertension receiving antihypertensive therapy across six residential aged care services in South Australia. Data were obtained from electronic medical records, medication charts and validated assessments. The primary outcome was all-cause mortality and the secondary outcome was cardiovascular-related hospitalizations. Inverse probability weighted Cox models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for all-cause mortality. Covariates included age, sex, dementia severity, frailty status, Charlson's comorbidity index and cardiovascular comorbidities. The study sample (mean age of 88.1 ± 6.3years; 79% female) included 70 (29.3%) residents using one antihypertensive and 169 (70.7%) residents using multiple antihypertensives. The crude incidence rates for death were higher in residents using multiple antihypertensives compared with residents using monotherapy (251 and 173/1000 person-years, respectively). After weighting, residents who used multiple antihypertensives had a greater risk of mortality compared with monotherapy (HR 1.40, 95%CI 1.03-1.92). After stratifying by dementia diagnosis and frailty status, the risk only remained significant in residents with diagnosed dementia (HR 1.91, 95%CI 1.20-3.04) and who were most frail (HR 2.52, 95%CI 1.13-5.64). Rate of cardiovascular-related hospitalizations did not differ among residents using multiple compared to monotherapy (rate ratio 0.73, 95%CI 0.32-1.67). Multiple antihypertensive use is associated with an increased risk of mortality in residents with diagnosed hypertension, particularly in residents with dementia and among those who are most frail.

Association of Rising Violent Crime With Blood Pressure and Cardiovascular Risk: Longitudinal Evidence From Chicago, 2014-2016.

The purpose of this study was to examine the longitudinal association between rising violent crime and elevated blood pressure (BP). We analyzed 217,816 BP measurements from 17,783 adults during a temporal surge in violent crime in Chicago (2014-2016). Serial observations were abstracted from the electronic health record at an academic medical center and paired to the City of Chicago Police Data Portal. The violent crime rate (VCR) was calculated as the number of violent crimes per 1,000 population per year for each census tract. Longitudinal multilevel regression models were implemented to assess elevated BP (systolic BP ≥ 140 mm Hg or diastolic BP ≥ 90 mm Hg) as a function of the VCR, adjusting for patient characteristics, neighborhood characteristics, and time effects. Secondary dependent measures included elevated heart rate, obesity, missed outpatient appointments, all-cause hospital admissions, and cardiovascular hospital admissions. At baseline, the median VCR was 41.3 (interquartile range: 15.2-66.8), with a maximum rise in VCR of 59.1 over the 3-year surge period. A 20-unit rise in the VCR was associated with 3% higher adjusted odds of having elevated BP (95% confidence interval [CI]: 1.01-1.06), 8% higher adjusted odds of missing an outpatient appointment (95% CI: 1.03-1.13), and 6% higher adjusted odds of having a cardiovascular-related hospital admission (95% CI: 1.01-1.12); associations were not significant for elevated heart rate and obesity. Rising violent crime was associated with increased BP during a temporal crime surge.

Efficacy and Safety of Tafamidis Doses in the Tafamidis in Transthyretin Cardiomyopathy Clinical Trial (ATTR-ACT)

Introduction Tafamidis was shown to be an effective treatment for transthyretin amyloid cardiomyopathy (ATTR-CM) in the Tafamidis in Transthyretin Cardiomyopathy Clinical Trial (ATTR-ACT). Hypothesis While ATTR-ACT was not designed for a definitive assessment by dose, further analysis may assist determination of the optimal dose. Methods In ATTR-ACT, adult patients with ATTR-CM (variant or wild-type) were randomized (2:1:2) to tafamidis 80 mg, tafamidis 20 mg, or placebo for 30 months, with pooled tafamidis (80mg and 20mg) compared with placebo. In this analysis, tafamidis 80 mg and 20 mg are presented separately. Efficacy outcomes included the hierarchical combination of all-cause mortality and frequency of cardiovascular-related hospitalisations, all-cause mortality, and change in NT-proBNP. Results The combination of all-cause mortality and cardiovascular-related hospitalizations over 30 months vs placebo was significantly reduced with both tafamidis 80 mg (P=0.003) and 20 mg (P=0.005). All-cause mortality was significantly reduced with tafamidis 80 mg (Cox-proportional hazard model [95% CI], 0.690 [0.487, 0.979], P=0.0378), and there was a trend towards reduction with tafamidis 20 mg (0.715 [0.450-1.137], P=0.1564), compared with placebo. The increase in NT-proBNP was reduced with tafamidis 80 mg, compared with both 20 mg (P=0.0468) and placebo (P Conclusions Tafamidis 80 mg and tafamidis 20 mg effectively reduced the combination of mortality and cardiovascular-related hospitalizations. Given the lack of dose-related safety concerns, and the NT-proBNP and survival data, tafamidis 80 mg is the preferred dose.

Tafamidis Reduced the Decline in Health-Related Quality of Life in the Tafamidis in Transthyretin Cardiomyopathy Clinical Trial (ATTR-ACT)

Introduction In the Tafamidis in Transthyretin Cardiomyopathy Clinical Trial (ATTR-ACT), tafamidis reduced all-cause mortality and cardiovascular-related hospitalizations in patients with transthyretin amyloid cardiomyopathy (ATTR-CM). ATTR-CM is associated with a significant burden of disease and tafamidis reduced the decline in health-related quality of life (as assessed by the Kansas City Cardiomyopathy Questionnaire-Overall Summary [KCCQ-OS] score). Hypothesis Analysis of the changes in KCCQ-OS domains in patients with ATTR-CM over 30 months, together with the impact of tafamidis on these changes, will provide new data on the progression of disease and the efficacy of tafamidis. Methods In ATTR-ACT, 441 adult patients with ATTR-CM (variant or wild-type) were randomized (2:1:2) to tafamidis 80 mg, tafamidis 20 mg, or placebo for 30 months, with pooled tafamidis (80mg and 20mg) compared with placebo. Change from baseline in the four KCCQ-OS domain scores were pre-specified exploratory endpoints and analyzed using a mixed model, repeated measures ANCOVA. The KCCQ is a 23-item self-administered questionnaire in which scores range from 0 to 100, with higher scores reflecting better health status. Results Tafamidis significantly reduced the decline in the KCCQ-OS and all four of its domains (P Conclusions Treatment with tafamidis effectively reduced the decline in all components of the KCCQ-OS, providing further insight into its efficacy in health-related quality of life in patients with ATTR-CM.

Exercise-based cardiac rehabilitation for stable angina: systematic review and meta-analysis

ObjectiveA systematic review was undertaken to assess the effects of exercise-based cardiac rehabilitation (CR) for patients with stable angina.MethodsDatabases (Cochrane Central Register of Controlled Trials, MEDLINE, Embase and CINAHL) were...

Effectiveness of cinacalcet treatment for secondary hyperparathyroidism on hospitalization: Results from the MBD-5D study.

ObjectivesTo elucidate the effect of cinacalcet use on all-cause and cause-specific hospitalization outcomes using a prospective cohort of maintenance hemodialysis patients.MethodsWe used data from a prospective cohort of Japanese hemodialysis patients with secondary hyperparathyroidism and examined baseline characteristics as well as longitudinal changes. All patients were cinacalcet-naïve at study enrollment. Further, we used a marginal structural model to account for time-varying confounders on cinacalcet initiation and hospitalization outcomes, and an Andersen-Gill–type recurrent event model to account for any recurring events of hospitalization in the outcome analysis using the weighted dataset.ResultsAmong the 3,276 patients, cinacalcet treatment was initiated in 1,384 patients during the entire follow-up. Cinacalcet users were slightly younger, included more patients with chronic glomerulonephritis and fewer patients with diabetes, were more likely to have a history of parathyroidectomy, and were more often used receiving vitamin D receptor activator, phosphate binders, and iron supplements. The overall hospitalization analysis yielded a hazard ratio (HR) of 0.97 (95% confidence interval [CI]: 0.80, 1.18). A trend toward a mild protective association was observed for cardiovascular-related hospitalizations (HR: 0.85; 95% CI: 0.64, 1.14). In the subgroup analysis, a protective association was seen due to cinacalcet use for infection-related hospitalizations in the lowest intact parathyroid hormone group (HR: 0.36; 95% CI: 0.14, 0.95).ConclusionsCinacalcet initiation in patients on maintenance hemodialysis had no effect on all-cause and cause-specific hospitalizations. Although the overall association was statistically not significant, cinacalcet may have a protective association on cardiovascular-related hospitalization in all patients and infection-related hospitalization in patient with low intact parathyroid hormone.

PCV13 RISK OF CARDIOVASCULAR OUTCOMES AND ANTIHYPERTENSIVE TRIPLE COMBINATION THERAPY AMONG PATIENTS ENROLLED IN A MEDICARE ADVANTAGE PLAN (MAP)

To evaluate the risk of cardiovascular specific hospitalizations with different types of antihypertensive triple combination therapy among patients enrolled in a MAP. A retrospective cohort study was conducted among older adult patients with hypertension enrolled in Texas MAP between January 2014 and December 2016. Antihypertensive combination therapy users were classified into single pill triple combination group, fixed dose dual combination plus a third agent group, and free triple combination group. The primary outcome of interest was time to first cardiovascular related hospitalization. Descriptive statistics with patient characteristics were examined. Group differences were assessed using chi-square tests for binary variables and student’s t-tests for continuous variables. Cox proportional hazards model was performed to assess the association between type of combination therapy and risk of cardiovascular specific hospitalization adjusting for potential confounders including demographic variables, adherence, CMS risk score and several comorbidities. A total of 10,836 triple combination users were identified with 336 (3.10%) patients in the single pill triple combination group, 470 (4.34%) patients in the fixed dose dual combination plus a third agent group and 10,030 (92.56%) patients in the free triple combination group. The risk of CVD hospitalization for the fixed dose dual combination plus a third agent group was significantly higher than the single pill triple combination group (HR: 3.82, 95%CI: 1.80-8.12). In addition, the risk of CVD hospitalization for the free triple combination therapy group was significantly higher than the single pill triple combination group (HR: 3.65, 95% CI: 1.43-9.31). Male patients, higher CMS risk score, and comorbidities such as depression, diabetes, heart failure, and neuropathy were significantly associated with an increased risk of CVD hospitalization. Single pill triple combination therapy was significantly associated with a lower risk of CVD hospitalizations in comparison to other types of triple combination therapy.

Treatment of Hyperthyroidism Decreases but Does Not Completely Abolish the Increased Risk of Cardiovascular-Related Hospitalization

Treatment of Hyperthyroidism Decreases but Does Not Completely Abolish the Increased Risk of Cardiovascular-Related Hospitalization

Pre-dialysis acute care hospitalizations and clinical outcomes in dialysis patients.

BackgroundPatients with chronic kidney disease (CKD), a precursor of end stage renal disease (ESRD), face an increasing burden of hospitalizations. Although mortality on dialysis is highest during the first year, the impact of pre-dialysis acute hospitalizations on clinical outcomes in dialysis patients remains unknown.MethodsWe evaluated 170,897 adult patients who initiated dialysis between 1/1/2010 and 12/31/2014 with linked Medicare claims from the United States Renal Data System. Using logistic regression models, we examined the association of 2-year pre-dialysis hospitalization on the primary outcome of 1-year all-cause mortality. Secondary outcomes included 90-day mortality, type of initial dialysis modality and type of vascular access at hemodialysis initiation.ResultsMean age was 72.7 ± 11.0 years. In the study sample, 76.0% of patients had at least one pre-dialysis hospitalization. Compared to patients with no pre-dialysis hospitalization, the adjusted 1-year mortality was higher with pre-dialysis cardiovascular related hospitalization (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.57–1.68), infection related hospitalization (OR, 1.51; CI, 1.45–1.57), both cardiovascular and infection hospitalization (OR, 1.91; CI, 1.83–1.99), and neither-cardiovascular nor-infection hospitalization (OR, 1.23; CI, 1.19–1.27). Additionally, the adjusted odds of hemodialysis vs. peritoneal dialysis as the initial dialysis modality were higher, whereas adjusted odds to initiate hemodialysis with an arteriovenous access vs. central venous catheter were lower in patients with any type of hospitalization.ConclusionPre-dialysis hospitalization is an independent predictor of 1-year mortality in dialysis patients. Reducing the risk of pre-dialysis hospitalization may provide opportunities to improve quality of care in ESRD.

Long-term cardiovascular hospitalizations of small for gestational age (SGA) offspring born to women with and without gestational diabetes mellitus (GDM)

Objective: To assess whether delivery of small for gestational age (SGA) neonates to mothers with gestational diabetes mellitus (GDM) increases the risk of long-term cardiovascular offspring hospitalizations compared to SGA neonates born to mothers without GDM. Study design: This is a population-based retrospective cohort study. The study group was SGA offspring born to mothers with GDM (n = 259), while the control group was SGA offspring born to mothers without GDM (n = 9053). The main factor evaluated was offspring cardiovascular hospitalizations up to the age of 18 years. Kaplan-Meier survival curve was used to estimate cumulative incidence of cardiovascular hospitalizations. A Cox proportional hazards model was used to estimate the adjusted hazard ratios (HR) for cardiovascular hospitalizations. Results: SGA children born to mothers with GDM had significantly higher rates of cardiovascular-related hospitalizations (1.9% vs. 0.7%, p = .026). A Kaplan-Meier survival curve demonstrated that SGA children born to GDM mothers had a higher cumulative incidence of cardiovascular hospitalizations (log-rank p = .037). The Cox regression model, while controlling for confounders, demonstrated that delivery of SGA neonates to mothers with GDM is independently associated with long-term cardiovascular offspring hospitalizations (adjusted HR =2.6; 95% CI 1.02–6.55 p = .045). Conclusion: Delivery of SGA neonates born to mothers with GDM is independently associated with long-term cardiovascular offspring hospitalizations.