Crude All-cause Mortality Research Articles

Early Mortality Associated with Inpatient versus Outpatient Hemodialysis Initiation in a Large Cohort of US Veterans with Incident End-Stage Renal Disease

Background: Mortality in the immediate post-hemodialysis transition period is extremely high. Many end-stage renal disease (ESRD) patients in the US start dialysis in an inpatient setting, but the characteristics of patients starting dialysis as inpatients, and the association of inpatient hemodialysis transition with mortality remain unclear. Methods: We examined 48,261 US veterans who transitioned to hemodialysis between October 2007 and September 2011. Associations of inpatient hemodialysis starting with all-cause mortality were examined in Cox proportional hazard models, with adjustments for demographics, comorbidities, vascular access type, pre-dialysis nephrology care and medication use, and last pre-ESRD estimated glomerular filtration rate and hemoglobin. Results: A total of 22,338 (46.3%) patients received the first hemodialysis treatment in an inpatient setting. Inpatient hemodialysis transition was associated with older age, presence of a tunneled catheter, higher comorbidity burden, and lack of pre-dialysis nephrology care. A total of 8,674 patients died (mortality rate 405/1,000 patient-years, 95% CI 397-413) during the first 6 months after transition to hemodialysis. The starting of inpatient vs. outpatient hemodialysis was associated with significantly higher crude all-cause mortality, but this association was attenuated after multivariable adjustments. Conclusions: Transition to hemodialysis in an inpatient setting is more common in older and sicker individuals, and in patients without pre-dialysis nephrology care and those who used a catheter for vascular access. Future studies are needed to determine if a higher proportion of patients could start hemodialysis treatment in outpatient clinics, through interventions targeting modifiable risk factors such as timely vascular access placement or earlier nephrology referrals.

GENDER DIFFERENCES IN CAUSE OF DEATH FOLLOWING PERCUTANEOUS CORONARY INTERVENTION

Women have higher rates of crude all-cause mortality after PCI. Whether there are gender differences in cause-specific mortality remains unclear. We assessed trends in cause-specific 5-year mortality after index PCI performed at a single center between 1991 and 2012. Cause of death was determined

Isavuconazole treatment for mucormycosis: a single-arm open-label trial and case-control analysis

Mucormycosis is an uncommon invasive fungal disease with high mortality and few treatment options. Isavuconazole is a triazole active in vitro and in animal models against moulds of the order Mucorales. We assessed the efficacy and safety of isavuconazole for treatment of mucormycosis and compared its efficacy with amphotericin B in a matched case-control analysis. In a single-arm open-label trial (VITAL study), adult patients (≥18 years) with invasive fungal disease caused by rare fungi, including mucormycosis, were recruited from 34 centres worldwide. Patients were given isavuconazole 200 mg (as its intravenous or oral water-soluble prodrug, isavuconazonium sulfate) three times daily for six doses, followed by 200 mg/day until invasive fungal disease resolution, failure, or for 180 days or more. The primary endpoint was independent data review committee-determined overall response-ie, complete or partial response (treatment success) or stable or progressive disease (treatment failure)-according to prespecified criteria. Mucormycosis cases treated with isavuconazole as primary treatment were matched with controls from the FungiScope Registry, recruited from 17 centres worldwide, who received primary amphotericin B-based treatment, and were analysed for day-42 all-cause mortality. VITAL is registered with ClinicalTrials.gov, number NCT00634049. FungiScope is registered with ClinicalTrials.gov, number NCT01731353. Within the VITAL study, from April 22, 2008, to June 21, 2013, 37 patients with mucormycosis received isavuconazole for a median of 84 days (IQR 19-179, range 2-882). By day 42, four patients (11%) had a partial response, 16 (43%) had stable invasive fungal disease, one (3%) had invasive fungal disease progression, three (8%) had missing assessments, and 13 (35%) had died. 35 patients (95%) had adverse events (28 [76%] serious). Day-42 crude all-cause mortality in seven (33%) of 21 primary-treatment isavuconazole cases was similar to 13 (39%) of 33 amphotericin B-treated matched controls (weighted all-cause mortality: 33% vs 41%; p=0·595). Isavuconazole showed activity against mucormycosis with efficacy similar to amphotericin B. Isavuconazole can be used for treatment of mucormycosis and is well tolerated. Astellas Pharma Global Development, Basilea Pharmaceutica International.

OUTCOMES FOLLOWING TRANSCATHETER AORTIC VALVE IMPLANTATION (TAVI) IN ONTARIO (2007-2013)

The Cardiac Care Network of Ontario (CCN) works to plan, coordinate, implement and evaluate adult cardiovascular care in Ontario, and is responsible for maintaining the CCN Cardiac Registry. Transcatheter Aortic Valve Implantation (TAVI) is a transcatheter procedure to replace diseased aortic valves, without the need for open heart surgery. Ten (10) hospitals in Ontario provide TAVI procedures. All 10 hospitals enter data in the CCN Cardiac Registry. All TAVI procedures in the CCN Cardiac Registry between January 2007 and November 2013 were analyzed. Patient characteristics and procedural details were obtained from the CCN Cardiac Registry. Data from the CCN Cardiac Registry was linked to the Canadian Institute for Health Information Discharge Abstract Database (CIHI-DAD) and the Ontario Registered Persons Database (RPDB) to calculate post-procedural outcomes. The primary outcomes measured were crude unadjusted all-cause mortality and readmission rates and were calculated at varying time points, out to 3-years post-procedure. A secondary analysis was performed focusing on outcomes for more recent TAVI procedures (January 2010 to November 2013). This study was developed by CCN, with data analysis completed by the Institute for Clinical Evaluative Sciences. A total of 1,105 unique TAVI procedures were identified and linked to the CIHI-DAD and RPDB. Analysis of TAVI procedures in Ontario revealed that the majority of procedures performed were done via femoral access (73.7%). In-hospital mortality was found to be 6.2% overall with rates being lower for transfemoral procedures (4.2%) versus non-transfemoral (11.7%). At 1-year post-procedure the overall all-cause mortality rate was 19.4% with an all-cause readmission rate of 49.3%. At 3-years post-procedure, the overall all-cause mortality rate was 43.9% with an all-cause readmission rate of 74.7%. Overall, mortality rates in Ontario following TAVI procedures are comparable to rates reported by other jurisdictions. Although all-cause mortality and readmission rates at 3-years are high, this may be explained by comorbidities and frailty in the TAVI patient population, as well as the fact this registry covers the early experience for most centres. In general we believe based on these outcomes that TAVI is a relatively safe and effective procedure to treat aortic stenosis in patients who are at extreme or high risk for conventional cardiac surgery in Ontario. CCN will continue to report on outcomes following TAVI procedures in Ontario to ensure that all Ontarians have access to the highest possible quality of cardiac care.

Risk of mortality on and off methadone substitution treatment in primary care: a national cohort study.

To assess whether risk of death increases during periods of treatment transition, and investigate the impact of supervised methadone consumption on drug-related and all-cause mortality. National Irish cohort study. Primary care. A total of 6983 patients on a national methadone treatment register aged 16-65 years between 2004 and 2010. Drug-related (primary outcome) and all-cause (secondary outcome) mortality rates and rate ratios for periods on and off treatment; and the impact of regular supervised methadone consumption. Crude drug-related mortality rates were 0.24 per 100 person-years on treatment and 0.39 off treatment, adjusted mortality rate ratio 1.63 [95% confidence interval (CI) = 0.66-4.00]. Crude all-cause mortality rate per 100 person-years was 0.51 on treatment versus 1.57 off treatment, adjusted mortality rate ratio 3.64 (95% CI = 2.11-6.30). All-cause mortality off treatment was 6.36 (95% CI = 2.84-14.22) times higher in the first 2 weeks, 9.12 (95% CI = 3.17-26.28) times higher in weeks 3-4, compared with being 5 weeks or more in treatment. All-cause mortality was lower in those with regular supervision (crude mortality rate 0.60 versus 0.81 per 100 person-years) although, after adjustment, insufficient evidence exists to suggest that regular supervision is protective (mortality rate ratio = 1.23, 95% CI = 0.67-2.27). Among primary care patients undergoing methadone treatment, continuing in methadone treatment is associated with a reduced risk of death. Patients' risk of all-cause mortality increases following treatment cessation, and is highest in the initial 4-week period.

155 Evaluation of the Rapid Access Chest Pain Clinic Service

<h3>Introduction</h3> Rapid access chest pain clinics (RACPC) evolved to urgently assess and manage patients with recent onset chest pain of cardiac origin. In 2010, NICE guidance transformed our assessment of recent onset chest pain with subsequent increase use of resource. We therefore sought to evaluate our contemporary RACPC service as part of plans to develop and improve our service. <h3>Methods</h3> A retrospective cohort analysis of patients attending RACPC was performed over a 6-month period (01/10/2013 to 31/03/2014). Data pertaining to the patient episode including baseline demographics, referral source, waiting time, chest pain description, cardiovascular risk factors, subsequent investigations and patient disposal were collated from patient medical records. Patients with pre-existing ischaemic heart disease (IHD) were excluded from further analysis. Primary endpoints include final diagnosis of coronary artery disease (CAD), all-cause mortality and subsequent hospitalisation with chest pain. Statistical analyses were performed using StatView for Windows Version 5.0 and 95% confidence intervals were taken as statistically significant in all analyses. <h3>Results</h3> In the 6-month period, 625 patients attended RACPC with 57 (9.1%) excluded as they had a pre-existing diagnosis of IHD. Most patients were referred from primary care (PC) (82.9%). The mean time to referral was 12.5 days (s.d = 8.0) with 91% seen within 14 days. Mean age was 58.0 years (s.d. = 12.6) and 51.1% were male. No significant difference in age (years) (58.2 ± 12.6 vs 56.7 ± 12.5, <i>p = 0</i>.2802), gender (male) (51.2% vs 50.5%, <i>p = 0</i>.9068) or risk factors (smoking (19.8% vs 25.9%,<i>p = 0</i>.3944), diabetes (14.6% vs 19.3%, <i>p = 0</i>.2682), hypertension (34.6% vs 28.7%, <i>p = 0</i>.2827), hyperlipidaemia (20.0% vs 24.7%, <i>p = 0</i>.3222) and family history (39.2% vs 31.1%, <i>p = 0</i>.1454)) were observed between PC or Accident and Emergency (A&amp;E) referrals. Referrals from A&amp;E compared to PC were more likely declared non-cardiac chest pain (40.2% vs 24.4%, <i>p = 0</i>.0006), discharged after first review (40.2% vs 24.0%, <i>p = 0</i>.0010) and had fewer investigations ordered (67.0% vs 83.9%, <i>p</i> = &lt;0.0001). Diagnosis of CAD was established in only 10.7% of all referrals with similar rates observed from A&amp;E and PC (7.2% vs 11.5%, <i>p = 0</i>.1865). Crude all-cause mortality was 0.9% and hospitalisation with chest pain was 4.4%. No adverse outcome was observed in patients referred from A&amp;E. <h3>Conclusion</h3> Our current RACPC service provides low diagnostic yield of CAD (10.7%) and adverse outcomes are otherwise small. This is particularly apparent in patients referred from A&amp;E, possibly explained by differences in chest pain presentation. This data has implications for our future RACPC service suggesting improved triage of patients’ may improve the efficiency and cost-effectiveness of the service.

Achieving a 25% reduction in premature non-communicable disease mortality: the Swedish population as a cohort study.

BackgroundThe 2012 World Health Assembly set a target for Member States to reduce premature non-communicable disease (NCD) mortality by 25% over the period 2010 to 2025. This reflected concerns about increasing NCD mortality burdens among productive adults globally. This article first considers whether the WHO target of a 25% reduction in the unconditional probability of dying between ages of 30 and 70 from NCDs (cardiovascular diseases, cancer, diabetes, or chronic respiratory diseases) has already taken place in Sweden during an equivalent 15-year period. Secondly, it assesses which population sub-groups have been more or less successful in contributing to overall changes in premature NCD mortality in Sweden.MethodsA retrospective dynamic cohort database was constructed from Swedish population registers in the Linnaeus database, covering the entire population in the age range 30 to 69 years for the period 1991 to 2006, which was used directly to measure reductions in premature NCD mortality using a life table method as specified by the WHO. Multivariate Poisson regression models were used to assess the contributions of individual background factors to decreases in premature NCD mortality.ResultsA total of 292,320 deaths occurred in the 30 to 69 year age group during the period 1991 to 2006, against 70,768,848 person-years registered. The crude all-cause mortality rate declined from 5.03 to 3.72 per 1,000 person-years, a 26% reduction. Within this, the unconditional probability of dying between the ages of 30 and 70 from NCD causes as defined by the WHO fell by 30.0%. Age was consistently the strongest determinant of NCD mortality. Background determinants of NCD mortality changed significantly over the four time periods 1991–1994, 1995–1998, 1999–2002, and 2003–2006.ConclusionsSweden, now at a late stage of epidemiological transition, has already exceeded the 25% premature NCD mortality reduction target during an earlier 15-year period. This should be encouraging news for countries currently implementing premature NCD mortality reduction programmes. Our findings suggest, however, that it may be difficult for Sweden and other late-transition countries to reach the current 25 × 25 target, particularly where substantial premature mortality reductions have already been achieved.

Opioid substitution therapy as a strategy to reduce deaths in prison: Retrospective cohort study

Objectives To describe deaths in prison among opioid-dependent people, and examine associations between receipt of opioid substitution therapy (OST) and risk of death in prison. Design Retrospective cohort study. Setting Adult prisons in New South Wales (NSW), Australia. Participants 16 715 opioid-dependent people who were received to prison between 2000 and 2012. Interventions Opioid substitution therapy. Primary outcome measures Natural and unnatural (suicide, drug-induced, violent and other injury) deaths in prison. Results Cohort members were in prison for 30 998 person-years (PY), during which time there were 51 deaths. The all-cause crude mortality rate (CMR) in prison was 1.6/1000 PY (95% CI 1.2 to 2.2/1000 PY), and the unnatural death CMR was 1.1/1000 PY (95% CI 0.8 to 1.6/1000 PY). Compared to time out of OST, the hazard of all-cause death was 74% lower while in OST (adjusted HR (AHR): 0.26; 95% CI 0.13 to 0.50), and the hazard of unnatural death was 87% lower while in OST (AHR: 0.13; 95% CI 0.05 to 0.35). The all-cause and unnatural death CMRs during the first 4 weeks of incarceration were 6.6/1000 PY (95% CI 3.8 to 10.6/1000 PY) and 5.5/1000 PY (95% CI 2.9 to 9.4/1000 PY), respectively. Compared to periods not in OST, the hazard of all-cause death during the first 4 weeks of incarceration was 94% lower while in OST (AHR: 0.06; 95% CI 0.01 to 0.48), and the hazard of unnatural death was 93% lower while in OST (AHR: 0.07; 95% CI 0.01 to 0.53). Conclusions Mortality of opioid-dependent prisoners was significantly lower while in receipt of OST.

Stenotrophomonas maltophilia infection among young children in a cardiac intensive care unit: a single institution experience.

Stenotrophomonas maltophilia can present as bacteremia, respiratory tract infection, urinary tract infection, soft tissue and wound infections, bone and joint infections, meningitis, and endocarditis especially in immunosuppressed patients and those with underlying medical conditions. The incidence and impact of S. maltophilia in young children with heart disease are poorly defined. A single center retrospective observational study was conducted in infants <180days of age with positive S. maltophilia cultures over a period of 5years. The overall incidence for S. maltophilia infection was 0.8% (n=32/3656). Among 32 identified infants, there were 47 episodes of S. maltophilia infection 66% of infants had prior exposure to broad spectrum antibiotics. 97% of positive isolates were susceptible to trimethoprim/sulfamethoxazole and 91% to levofloxacin as well as ticarcillin/clavulanate. Ventilator-free days and absolute lymphocyte count prior to acquiring infection were significantly lower in non-survivors than in survivors. 100% of survivors had clearance of positive cultures compared to 50% in non-survivors (p<0.05). The crude all-cause mortality rate was 37.5%. All non-survivors had increased length of ICU stay and duration of mechanical ventilation and had delayed clearance of infection and required longer duration of treatment.

Substance use and risk of death in young offenders: a prospective data linkage study.

Young offenders are at increased risk of preventable death after release from custody, but risk factors for death in this population are poorly understood. Despite their poor health profiles, no studies have examined mortality outcomes in young people who have served community-based orders. The aims of this study were to describe the causes and identify risk factors for death in a cohort of young offenders in Victoria, Australia. We interviewed young people serving a custodial (n = 273) or community-based order (n = 242) in Victoria, Australia in 2002-2003. Measures included demographics and family history, offence history, experience of victimisation, mental illness, self-harm and substance use. Deaths up to 31 December 2011 were identified through a probabilistic linkage with the National Death Index. The all-cause crude mortality rate was 4.2 (95% confidence interval 2.7-6.8) per 1000 person years and was not significantly different for those who had served custodial and community-based orders. Most deaths were due to drug overdose, traffic accidents or suicide. Adjusting for age, sex and order type, risk factors for death from the baseline interview included weekly use of opioids, sleeping pills or painkillers, polydrug use and injecting drug use. Young people who have served community-based and custodial orders are at an increased risk of preventable death. Those engaging in risky substance use, particularly injecting drug use and use of multiple central nervous system depressants, are at greatest risk. There is an urgent need to develop and rigorously evaluate preventive interventions.

Opioid substitution therapy as a strategy to reduce deaths in prison: retrospective cohort study

ObjectivesTo describe deaths in prison among opioid-dependent people, and examine associations between receipt of opioid substitution therapy (OST) and risk of death in prison.DesignRetrospective cohort study.SettingAdult prisons in New South...

Impact of diabetes mellitus and renal insufficiency on 5-year mortality following coronary artery bypass graft surgery: a cohort study of 4869 UK patients

Diabetes mellitus (DM) and renal impairment (RI) are both independent predictors of mortality after coronary artery bypass graft surgery (CABG). The two conditions often coexist, yet the impact on long-term prognosis after CABG of each factor relative to the other and the two in combination is uncertain. We undertook a prospective cohort study of 4869 patients who underwent CABG between 2003 and 2007. The cohort was divided into four groups according to preoperative diabetic status and renal function: patients without either DM or RI (reference group), patients with DM alone, patients with RI alone and patients with both DM and RI. Clinical outcomes were compared between groups. Patients receiving renal replacement therapy were excluded. The primary outcome was 5-year all-cause mortality. The crude 5-year all-cause mortality rate was 9.0% for patients in the reference group, 11.1% for patients with DM alone, 20.3% for patients with RI alone and 28.5% for patients with both DM and RI (P < 0.0001). Five-year survival adjusted for potential confounding factors was significantly worse for patients with DM (hazard ratio (HR) 1.30; 95% confidence interval (CI) 1.06-1.59), patients with RI (HR 1.32; 95% CI 1.08-1.61) and patients with both DM and RI (HR 2.04; 95% CI 1.65-2.53) when compared with patients with neither condition. Preoperative DM and RI were important predictors of 5-year mortality after CABG. Patients with RI alone had a higher mortality rate than patients with DM alone, but this difference was largely accounted for by age and other comorbidities. The combination of DM and RI doubled the 5-year mortality rate after CABG independently of potential confounding factors.

Predictors of mortality in atypical antipsychotic-treated community-dwelling elderly patients with behavioural and psychological symptoms of dementia: a prospective population-based cohort study from Italy

To evaluate the effect of a broad range of covariates on the survival of a real-life long-term follow-up cohort of community-dwelling patients with behavioural and psychological symptoms of dementia who were new users of atypical antipsychotic medications (APMs). This was a prospective cohort study of 1,618 subjects aged ≥65 years with dementia and BPSD ("behavioural and psychological symptoms of dementia") who were new users of atypical APMs and registered in a Dementia Evaluation Unit of Campania Region (Italy) from September 2006 to March 2010. The potential of baseline features to predict mortality was assessed with the Cox proportional hazards model. The average follow-up was 309 days. Of the 1,618 new users of atypical antipsychotics, 9.3 % experienced at least one adverse event, including death (5.1 %), drug therapeutic failure (3.0 %), extrapyramidal symptoms (0.5 %) and stroke (0.2 %). The crude all-cause mortality rate was 6.0 per 100 person-years [95 % confidence interval (CI) 4.8-7.4]; the rate was higher in patients aged >85 years (9.0 per 100 person-years, 95 % CI 6.4-12.7) and among male patients (7.5 per 100 person-years, 95% CI 5.3-10.6). In the multivariate analysis, only age was associated to all-cause mortality [hazard ratio (HR) 1.1; 95 % CI 1.0-1.1 and HR 1.4; 95 % CI: 0.9-2.2, respectively). In contrast, hallucination (HR 0.4; 95 % CI 0.2-0.6) and dosage change (HR 0.4; 95 % CI 0.2-0.78) were significantly associated with a lower risk of all-cause mortality. Among our patient cohort, the mortality rate of patients with BPSD receiving long-term treatment with atypical APMs was lower than that reported in other studies, and only age was found to be significant predictor factor of mortality.

Spatial clustering of all-cause and HIV-related mortality in a rural South African population (2000-2006).

BackgroundSub-Saharan Africa bears a disproportionate burden of HIV infection. Knowledge of the spatial distribution of HIV outcomes is vital so that appropriate public health interventions can be directed at locations most in need. In this regard, spatial clustering analysis of HIV-related mortality events has not been performed in a rural sub-Saharan African setting.Methodology and ResultsKulldorff’s spatial scan statistic was used to identify HIV-related and all-cause mortality clusters (p<0.05) in a population-based demographic surveillance survey in rural KwaZulu Natal, South Africa (2000–2006). The analysis was split pre (2000–2003) and post (2004–2006) rollout of antiretroviral therapy, respectively. Between 2000–2006 a total of 86,175 resident individuals ≥15 years of age were under surveillance and 5,875 deaths were recorded (of which 2,938 were HIV-related) over 343,060 person-years of observation (crude all-cause mortality rate 17.1/1000). During both time periods a cluster of high HIV-related (RR = 1.46/1.51, p = 0.001) and high all-cause mortality (RR = 1.35/1.38, p = 0.001) was identified in peri-urban communities near the National Road. A consistent low-risk cluster was detected in the urban township in both time periods (RR = 0.60/0.39, p = 0.003/0.005) and in the first time period (2000–2003) a large cluster of low HIV-related and all-cause mortality in a remote rural area was identified.ConclusionsHIV-related and all-cause mortality exhibit strong spatial clustering tendencies in this population. Highest HIV-related mortality and all-cause mortality occurred in the peri-urban communities along the National Road and was lowest in the urban township and remote rural communities. The geography of HIV-related mortality corresponded closely to the geography of HIV prevalence, with the notable exception of the urban township where high HIV-related mortality would have been expected on the basis of the high HIV prevalence. Our results suggest that HIV treatment and care programmes should be strengthened in easy-to-reach high density, peri-urban populations near National Roads where both HIV-related and all-cause mortality are highest.

High Morbidity and Mortality in Adults Hospitalized for Respiratory Syncytial Virus Infections

Better understanding of complications and outcomes of adults hospitalized with respiratory syncytial virus (RSV) infection is necessary. A retrospective cohort study was conducted on all adults (≥ 18 years) admitted to 3 acute care general hospitals in Hong Kong with virologically confirmed RSV infection during 2009-2011 (N = 607). Adults hospitalized for seasonal influenza during the period were used for comparison (n = 547). Both infections were prospectively diagnosed following a standard protocol. Independent reviews of chest radiographs were performed by radiologists. Main outcome measures were all-cause death, respiratory failure requiring ventilatory support, and hospitalization duration. Cox proportional hazards models were used for analyses. The mean age of RSV patients was 75 (SD, 16) years; 87% had underlying conditions. Lower respiratory and cardiovascular complications were diagnosed in 71.9% (pneumonia, 42.3%; acute bronchitis, 21.9%; chronic obstructive pulmonary disease/asthma exacerbation, 27.3%) and 14.3% of patients, respectively; 12.5% had bacterial superinfections. Supplemental oxygen and ventilatory support were required in 67.9% and 11.1%, respectively. Crude all-cause mortality was 9.1% and 11.9% within 30 days and 60 days, respectively; mean length of stay of survivors was 12 (SD, 13) days. Advanced age, radiographic pneumonia, requirement for ventilation, bacterial superinfection, and elevated urea level and white blood cell count were independently associated with poorer survival. Systemic corticosteroid use was associated with longer hospitalization and secondary infections. The overall outcomes of survival and length of stay were not significantly different from those in influenza. RSV can cause severe lower respiratory complications in older adults, resulting in respiratory failure, prolonged hospitalization, and high mortality similar to seasonal influenza. Corticosteroids did not seem to improve outcomes. The unmet need for antiviral therapy and vaccination against RSV in adults should be promptly addressed.

A Nationwide Cohort Study of Mortality Risk and Long-Term Prognosis in Infective Endocarditis in Sweden

Objectives: Infective endocarditis (IE) remains a serious disease with substantial mortality. In this study we investigated the incidence of IE, as well as its associated short and long term mortality rates.MethodsThe IE cases were identified in the Swedish national inpatient register using ICD-10 codes, and then linked to the population register in order to identify deaths in the cohort. Crude mortality rates among IE patients were obtained for different time intervals. These rates were directly standardized using sex- and age-matched mortality in the general population.ResultsThe cohort consisted of 7603 individuals and 7817 episodes of IE during 1997–2007. The 30 days all-cause crude mortality rate was 10.4% and the standardized mortality ratio (SMR) was 33.7 (95% confidence interval [CI]: 31.0–36.6). Excluding the first year of follow-up, the long term mortality (1–5 years) showed an increased SMR of 2.2 (95% CI: 2.0–2.3) compared to the general population. Significantly higher SMR was found for cases of IE younger than 65 years of age with a 1–5 year SMR of 6.3, and intravenous drug-users with a SMR of 19.1. Native valve IE cases, in which surgery was performed had lower crude mortality rates and Mantel-Haenzel odds ratios of less than one compared to those with medical therapy alone during 30-day and 5-years follow-up.ConclusionsThe 30-days crude mortality rate for IE was 10.4% and long-term relative mortality risk remains increased even up to 5 years of follow-up, therefore a close monitoring of these patients would be of value.

Abstract 156: Body Mass Index and Outcomes among Patients with Atrial Fibrillation from the ATRIA2-CVRN Study

Atrial fibrillation (AF) is a strong, independent risk factor for stroke, CVD-related mortality, and other cardiovascular complications. While studies have reported associations between higher BMI and AF incidence, few have examined the risk of thromboembolic and bleeding outcomes attributable to overweight or obesity in AF patients. We examined the longitudinal effect of BMI on all-cause mortality, as well as thromboembolic and major bleeding events, in a large cohort of incident AF patients from Kaiser Permanente Northern and Southern California. Outcomes include stroke (STR), STR and/or any other thromboembolic event (OTE), STR and/or intracranial hemorrhage (ICH), ICH and/or any other bleed (OBL). BMI (kg/m 2 ) measured nearest AF diagnosis, and demographic and clinical covariates were extracted from electronic health records and administrative databases. BMI was categorized as underweight (BMI &lt; 18.5), normal weight (18.5 &lt; BMI &lt; 25), overweight (25 &lt; BMI &lt; 30), moderately obese (30 &lt; BMI &lt; 40) or extremely obese (BMI &gt; 40). Multivariable Cox proportional hazard models were used to estimate the effect of BMI on time to event, during off-warfarin periods, adjusted for age, sex, race/ethnicity, and history of hypertension, diabetes and coronary artery disease. Among 22,487 AF patients (46% female; 6% Black, 12% Hispanic, 7% API) with off-warfarin time during follow-up, 34% were overweight, 29% obese and 6% extremely obese. Mean age ± SD was 72 ± 13 years. Median (IQR) length of off-warfarin follow-up was 1.38 (1.57) years. Crude all-cause mortality and incident thromboembolic and bleeding rates were highest among underweight or normal weight patients and gradually declined with increasing BMI (Table; all P-trend &lt; 0.002). The unadjusted relative risks for all outcomes were substantially and significantly lower with increasing BMI (Table). However, after adjustment for demographic and clinical confounders, only risk of all-cause mortality was significantly lower for overweight and moderately obese compared to normal weight patients (Table). In conclusion, overweight and moderate obesity appear protective for all-cause mortality in at-risk AF patients during off-warfarin periods, but these effects do not appear to be mediated by reduced risk of thromboembolism or major bleeding.

Impact of Baseline Heart Failure Burden on Post-Implantable Cardioverter-Defibrillator Mortality Among Medicare Beneficiaries

This study sought to assess the impact of baseline heart failure (HF) burden on survival with primary implantable cardioverter-defibrillator (ICD) among Medicare recipients. Survival after primary ICD implantation may differ between trial and Medicare populations. Linking data from the CMS (Centers for Medicare and Medicaid Services) ICD registry and the Medicare files (2005 to 2009), we identified primary ICD recipients age ≥66 years with ejection fraction ≤35%. Number of previous HF hospitalizations (prev-HF-hosp) and length of hospitalization prior to implantation were used to define HF burden. Crude all-cause mortality was estimated. Adjusted hazard ratios (HR) were derived from Cox models. Of 66,974 ICD recipients (73% men, 88% white, mean age 75 years), 11,876 died (average follow-up = 1.4 years), with 3-year mortality of 31%. Among patients with no prev-HF-hosp, 3-year mortality was 27% compared with 63% in those with ≥3 prev-HF-hosp (adjusted HR: 1.8). Among patients with same-day implantation, 3-year mortality was 25% compared with 53% in those with >1-week hospitalization days prior to implantation (adjusted HR: 1.9). Mortality at 3-year follow-up among the 31,685 ICD recipients with no prev-HF-hosp and same-day implantation (low HF burden) was similar to that in trials (22%). Nearly one-third of Medicare ICD recipients died within 3 years, reflecting a population with more advanced age and disease than seen in trial populations for primary prevention ICD. Nearly one-half of Medicare recipients had a low HF burden and had a survival similar to trial ICD recipients. Future research is warranted to understand the effectiveness of primary ICD implantation among Medicare beneficiaries with heavy HF burdens.

Outcomes Among 3.5 Million Newly Diagnosed Hypertensive Canadians

BackgroundThis population-based study assessed rates of all-cause mortality, myocardial infarction, heart failure, and stroke for up to 12 years of follow-up in 3.5 million Canadian adults newly diagnosed with hypertension. MethodsHypertension cohort, outcomes, and covariates were defined using validated case definitions applied to inpatient and outpatient administrative health databases. Factors associated with each outcome were identified using Cox proportional hazards models. ResultsOf 3,531,089 adults newly diagnosed with hypertension and without a previous history of cardiovascular disease, 29.4% were younger than 50 years of age; 48.2% were male, and 17.2% resided in a rural area. Over a median follow-up length of 6.1 years, the crude all-cause mortality rate was 22.4 per 1000 person-years. The incidence of hospitalized myocardial infarction (8.4 per 1000 person-years) and hospitalized heart failure (8.5 per 1000 person-years) was higher than stroke (6.9 per 1000 person-years). The incidence rate for any cardiovascular hospitalization was 19.3 per 1000 person-years. Older age, male sex, lower income, rural residence, and a higher number of Charlson comorbidities were each independently associated with a higher risk of mortality and incident cardiovascular disease hospitalizations. ConclusionsIn a nationally-representative incident cohort of hypertensive adults we have demonstrated higher mortality rates and poorer outcomes for the elderly, males, and those living in rural or low income locations. Innovative approaches to the provision of care for these high-risk individuals will lead to improved patient outcomes.

Low Serum Concentration of Obestatin as a Predictor of Mortality in Maintenance Hemodialysis Patients

Obestatin, a proposed anorexigenic gut hormone, has been shown to have a number of beneficial cardiotropic effects in experimental studies. We hypothesized that obestatin alteration in hemodialysis patients may link to clinical outcomes. This cross-sectional study with prospective followup for almost 4 years was performed on 94 prevalent hemodialysis patients. Obestatin, leptin, proinflammatory cytokines (tumor necrosis factor-α [TNF-α], interleukin-6, and various nutritional markers were measured. Patients with low obestatin levels, defined as a level less than median, had a worse all-cause mortality and cardiovascular mortality. The crude all-cause (HR 2.23, 95% CI 1.17 to 4.24) and cardiovascular mortality hazard ratios (HR 4.03, 95% CI 1.27 to 12.76) in these patients continued to be significant after adjustment for various confounders for all-cause mortality. Across the four obestatin-TNF-α categories, the group with low obestatin and high TNF-α (above median level) exhibited a worse outcome in both all-cause mortality and cardiovascular mortality. Clinical characteristics of patients in low obestatin high TNF-α group did not differ from other obestatin-TNF-α categorized groups. In summary, low serum obestatin concentration is an independent predictor of mortality in prevalent hemodialysis patients. Novel interactions were observed between obestatin and TNF-α, which were associated with mortality risk, especially those due to cardiovascular causes.