Determinants Of Long-term Mortality Research Articles

Determinants of long-term survival in late HIV presenters: The prospective PISCIS cohort study.

SummaryBackgroundLate HIV diagnosis (i.e CD4≤350 cells/µL) is associated with poorer outcomes. However, determinants of long-term mortality and factors influencing immune recovery within the first years after antiretroviral treatment (ART) initiation are poorly defined.MethodsFrom PISCIS cohort, we included all HIV-positive adults, two-year survivors after initiating ART between 2005–2019. The primary outcome was all-cause mortality according to the two-year CD4 count. We used Poisson regression. The secondary outcome was incomplete immune recovery (i.e., two-year CD4<500 cells/µL). We used logistic regression and propensity score matching.FindingsWe included 2,719 participants (16593·1 person-years): 1441 (53%) late presenters (LP) and 1278 non-LP (1145 non-LP with two-year CD4 count >500 cells/µL, reference population). Overall, 113 patients (4·2%) died. Mortality was higher among LP with two-year CD4 count 200–500 cells/µL (aMRR 1·95[95%CI:1·06-3·61]) or <200 cells/µL (aMRR 4·59[2·25-9·37]).Conversely, no differences were observed in participants with two-year CD4 counts >500 cells/µL, regardless of being initially LP or non-LP (aMRR 1·05[0·50-2·21]). Mortality rates within each two-year CD4 strata were not affected by the initial CD4 count at ART initiation (test-interaction, p = 0·48). The stronger factor influencing immune recovery was the CD4 count at ART initiation. First-line integrase-inhibitor-(INSTI)-based regimens were associated with reduced mortality compared to other regimens (aMRR 0·54[0·31-0·93]) and reduced risk of incomplete immune recovery in LP (aOR 0·70[0·52-0·95]).InterpretationTwo-year immune recovery is a good early predictor of long-term mortality in LP after surviving the first high-risk 2 years. Nearly half experienced a favorable immune recovery with a life expectancy similar to non-LP. INSTI-based regimens were associated with higher rates of successful immune recovery and better survival compared to non-INSTI regimens.FundingSouthern-Denmark University, Danish AIDS-foundation, and Region of Southern Denmark.

Abstract WP202: Comorbidities, But Not Mechanism, Are Associated With Long-term Mortality After Stroke

Introduction: Stroke is one of the leading causes of death worldwide. Our study aimed to investigate clinical variables that influence long-term mortality. Methods: A retrospective study was done in patients admitted with stroke to Columbia University Irving Medical Center - New York Presbyterian Hospital between 1990 and 2020 from whom data adjudication and long-term outcome were available at the time of analyses. Stroke was classified as cardioembolic, large vessel, small vessel and cryptogenic. We established 5 models which were progressively adjusted for cardiovascular risk factors and treatment modalities. Data was analyzed using cox proportional regression analysis to obtain hazard ratios (HR) with 95% confidence intervals (CI). Results: The study included 775 patients with a mean age of 67±16 years; 47% were men, 32% had diabetes, 39% had dyslipidemia and 22% had a history of atrial fibrillation (AF). On discharge, 84% received statin therapy. After 8.9±5.9 years (0-17 years) of follow-up, 257 (33.2%) of the initial cohort died. In univariate analysis, stroke due to AF was the only predictor of long-term mortality compared to other mechanisms (HR 1.9, 95% CI 1.5-2.3), but the effect size and statistical significance were progressively attenuated after adjusting for confounders (HR 1.2, 95% CI 0.9-1.6). In the fully adjusted model, statin therapy on discharge (HR 0.6, 95% CI 0.5-0.9) was associated with decreased long-term mortality whereas higher NIHSS score on admission, older age and a history of diabetes were associated with higher long-term mortality (Table 1). Conclusion: Comorbidities, and not stroke mechanism per se, are determinants of long-term mortality after stroke. Advanced age, diabetes mellitus, high NIHSS score are associated with higher long-term mortality whereas statin prescription upon discharge is associated with lower mortality. Post-stroke care strategies need to be targeted to reduce the risk of mortality in high-risk patients.

STEMI around-the-clock: how off-hours admissions impact door-to-balloon time and the long-term prognosis of ST-segment Elevation Myocardial Infarction

Abstract Introduction The outcomes of reperfusion in ST-segment Elevation Myocardial Infarction (STEMI) are time-dependent, and percutaneous coronary intervention (PCI) should be performed within 60 minutes from hospital admission in PCI centers – door-to-balloon time (D2B). The association between Off-Hours Admission (OHA) and long-term outcomes is controversial when considering contemporary organized STEMI networks. Purpose This study aims to analyze how OHA influences D2B and long-term mortality. Methods Retrospective study of consecutive STEMI patients (pts), admitted in a PCI-centre with a local Emergency Department, between 2010 and 2015. Pts submitted to rescue-PCI were excluded. OHA was defined as admission at night (8p.m. to 8a.m), weekends and nonworking holidays. Predictors of OHA and D2B were studied by logistic regression analysis. Demographic, clinical, angiographic and procedural variables were evaluated using stepwise Cox regression analysis to determine independent predictors of 5-year all-cause mortality (5yM). The cumulative incidence of 5yM stratified by hours of admission was calculated according to the Kaplan-Meier method. Results Of 901 pts, 472pts (52.4%) were admitted during off-hours. These pts were younger (61±13 vs 64±12, p=0.002) and had a lower median patient-delay time (128min vs 157min, p=0.014). Clinical severity at presentation, defined by systolic arterial pressure and Killip-Kimball (KK) class, did not differ between groups. OHA did not impact D2B (89 min vs 88 min, p=0.550), which was in turn influenced by age ≥75y (OR 1.85, 95% CI 1.31–2.61, p&amp;lt;0.001). Mean clinical follow-up (FUP) was 68±37 months, with 75.1% of pts achieving a FUP &amp;gt;5 years. 5yM rate was 9.7%. After multivariate cox regression analysis, independent determinants of long-term mortality were age (HR 1.05, 95% CI 1.02–1.08, p&amp;lt;0.001), previous history of heart failure (HR 6.76, 95% CI 1.32–34.72, p=0.022) and pulmonary disease (HR 3.79, 95% CI 1.16–12.33, p=0.027), presentation with KK ≥2 (HR 2.82, 95% CI 1.32–6.01, p=0.007) and radial artery access in catheterization (HR 0.39, 95% CI 0.18–0.83, p=0.014) – figure 1. Although there was an association between a higher D2B time and 5yM (87min vs 101min, p=0.024), neither OHA nor D2B were independent predictors of long-term mortality – figure 2. Conclusion OHA did not seem to influence D2B and long-term STEMI outcomes in our PCI-centre. 5yM was mostly influenced by patient characteristics and clinical severity at presentation. Funding Acknowledgement Type of funding sources: None. Figure 1. Predictors of long-term mortalityFigure 2. 5-year survival stratified by OHA

Prognosis of persistent mitral regurgitation in patients undergoing transcatheter aortic valve replacement

ObjectiveThe objective of this study was to assess imaging predictors of mitral regurgitation (MR) improvement and to evaluate the impact of MR regression on long-term outcome in patients undergoing transcatheter aortic valve replacement (TAVR).BackgroundConcomitant MR is a frequent finding in patients with severe aortic stenosis but usually left untreated at the time of TAVR.MethodsMitral regurgitation was graded by transthoracic echocardiography before and after TAVR in 677 consecutive patients with severe aortic stenosis. 2-year mortality was related to the degree of baseline and discharge MR. Morphological echo analysis was performed to determine predictors of MR improvement.Results15.2% of patients presented with baseline MR ≥ 3 +, which was associated with a significantly decreased 2-year survival (57.7% vs. 74.4%, P < 0.001). MR improved in 50% of patients following TAVR, with 44% regressing to MR ≤ 2 +. MR improvement to ≤ 2 + was associated with significantly better survival compared to patients with persistent MR ≥ 3 +. Baseline parameters including non-severe baseline MR, the extent of mitral annular calcification and large annular dimension (≥ 32 mm) predicted the likelihood of an improvement to MR ≤ 2 +. A score based on these parameters selected groups with differing probability of MR ≤ 2 + post TAVR ranging from 10.5 to 94.4% (AUC 0.816; P < 0.001), and was predictive for 2-year mortality.ConclusionUnresolved severe MR is a critical determinant of long term mortality following TAVR. Persistence of severe MR following TAVR can be predicted using selected parameters derived from TTE-imaging. These data call for close follow up and additional mitral valve treatment in this subgroup.Graphic abstractFactors associated with MR persistence or regression after TAVR

Preoperative Sarcopenia Portends Worse Outcomes After Descending Thoracic Aortic Aneurysm Repair

Sarcopenia may be an indicator of frailty. We used the total psoas area index (TPAI) to identify sarcopenia and evaluated the effect of preoperative TPAI on outcomes after descending thoracic aortic aneurysm (DTAA) repair. Patients with DTAA between 2007 and 2015 who were undergoing thoracic endovascular aortic repair (TEVAR) and open surgical repair (OSR) with available preoperative imaging were analyzed. Sarcopenia was defined as TPAI <6.5cm2/m2. An adverse event was defined as the composite endpoint of three or more multisystem complications, discharge to other than home, or death within 30 days. A total of 282 of 386 DTAA repairs had imaging available for TPAI measurements; 71 of 282 (25%) patients underwent TEVAR, and 211 of 282 (75%) underwent OSR. Preoperative sarcopenia was similar in the two groups (OSR, 57% vs TEVAR, 48%, p= 0.188). Risk factors for sarcopenia were age >70 years, female sex, and large body surface area, whereas heritable thoracic aortic disease was a protective factor. OSR-treated patients with sarcopenia were older compared with patients without sarcopenia (p < 0.001), whereas TEVAR-treated patients had a similar age category distribution (p= 0.187). Patients with sarcopenia had significantly increased adverse events compared with patients who did not have sarcopenia in both groups (sarcopenia-TEVAR, 41% vs nonsarcopenia-TEVAR, 16%, p= 0.020; sarcopenia-OSR, 49% vs nonsarcopenia-OSR, 32%, p= 0.012). Determinants of long-term mortality were increasing age (parameter estimate [PE], 0.06, p<0.001), TPAI as a decreasing linear function (PE, 0.36, p= 0.003), OSR (PE, 2.92, p= 0.003), and interaction between OSR and TPAI (PE,-0.34, p= 0.010). The interaction term showed that OSR increases long-term mortality risk in more sarcopenic patients. Preoperative sarcopenia significantly correlated with postoperative adverse events and long-term mortality after DTAA repair. If anatomically feasible, TEVAR should be considered in sarcopenic patients.

Long-Term Mortality Trends After Total Hip and Knee Arthroplasties: A Population-Based Study

BackgroundMortality after total hip and knee arthroplasty is lower than that in the general population, but it is unknown whether there are differences by surgery type, demographics, and calendar year. Our objective was to evaluate trends and determinants of long-term mortality among patients with total hip and knee arthroplasties. MethodsUsing a historical cohort study design, we passively followed up population-based cohorts of total hip and total knee arthroplasty patients with degenerative arthritis who underwent surgery between January 1, 1969 and December 31, 2008. Patients were followed up until death or August 31, 2014. Observed and expected survival was compared using standardized mortality ratios (SMRs). Poisson regression models were used to examine relative mortality patterns by surgery type, age, sex, calendar year, and time since surgery. ResultsThe overall age- and sex-adjusted mortality was significantly lower than that in the general population after both total hip (SMR: 0.82, 95% CI: 0.76-0.88) and total knee (SMR = 0.80, 95% CI: 0.75-0.86) arthroplasties. Despite the low relative mortality within the first 8 years of surgery, we observed a worsening of relative mortality beyond 15 years after total knee arthroplasty surgery. Both short- and long-term mortality improved over calendar time, and the improvement occurred about a decade earlier in total knee arthroplasty than in total hip arthroplasty. ConclusionSurvival after total hip and total knee arthroplasties is better than that in the general population for about 8 years after surgery. Secular trends are encouraging and suggest that survival after both procedures has been improving even further in recent years.

The American Society of Anesthesiologists (ASA) Physical Status Classification System Is an Independent Determinant of Long-Term Mortality in Older Patients With Hip Fracture: Systematic Review and Meta-Analysis of Longitudinal Studies

The American Society of Anesthesiologists (ASA) Physical Status Classification System Is an Independent Determinant of Long-Term Mortality in Older Patients With Hip Fracture: Systematic Review and Meta-Analysis of Longitudinal Studies

Type of Fracture Is an Independent Determinant of Long-Term Mortality in Older Patients With Hip Fracture: Systematic Review and Meta-Analysis of Longitudinal Studies

s 423 Results: In our study group, mean age was 61.1 11.7 years and mean BMI was 27.9 5.3 kg/m. At the time of baseline DXA scan, women with incident fracture (n5164) were shorter (1.527 0.065 m vs. 1.560 0.078 m; P!0.001), were older (65.0 11.5 years vs. 60.4 11.6 years; P!0.001), had a higher BMI (29.4 5.3 kg/m vs. 27.6 5.3 kg/m; P!0,001), had a lower femoral neck BMD (0.736 0.120 g/cm vs. 0.796 0.158 g/cm; P!0.001) and had a lower FN CSI (3.55 0.74 g/kg m vs. 3.88 0.81 g/kg m; P!0.001) than women without fracture (n5836). Body weight was not significantly different between women with incident fracture and women without simple logistic regression (odds ratio [95%CI]50.51 [0.385-0.653]). Femoral neck BMD was significantly (P!0.001) associated with the presence of fracture using a simple logistic regression (odds ratio [95%CI]50.041 [0.011-0.152]). Age, height and BMI were also significantly associated with the presence of fracture using simple logistic regressions (P! 0.001). When a multivariate logistic regression analysis was performed with the presence of fracture as a dependent variable and each age, FN BMD and FN CSI as independent variables, only FN BMD (P50.005) and FN CSI (P50.004) were found to be associated with the presence of fracture. Conclusion: This study suggests that FN CSI is an independent predictor of osteoporotic fractures in postmenopausal women. Further research is needed to determine the relative importance of FN CSI on fracture risk prediction in postmenopausal women.

Immune dysfunction prior to Staphylococcus aureus bacteremia is a determinant of long-term mortality.

PurposeThe clinical implications for patients who survive serious infections are not well understood. It has been hypothesized that the excess mortality for survivors of sepsis observed in epidemiological studies is due to increased vulnerability to subsequent infections. We undertook this study to identify characteristics of patients who are at high risk for death after surviving a common type of blood-stream infection.Materials and MethodsAt a single academic medical center, 237 patients with Staphylococcus aureus bacteremia admitted during a three-year period were retrospectively identified. The primary outcomes were 30-day and 31 to 90-day mortality after the first positive blood culture. The primary predictor variable of interest was clinical immune dysfunction prior to bacteremia.ResultsThe 30-day mortality was not significantly different for patients with and without prior immune dysfunction. However, during days 31 to 90, 11 patients (20%) with prior immune dysfunction compared to 10 patients (8.6%) without prior immune dysfunction died (OR 2.59, 95% CI 1.03–6.53, p = 0.04). In a Cox-proportional hazard model controlling for age, there was a significant association between prior immune dysfunction and greater 31 to 90 day mortality (HR 2.44, 95% CI 1.01–5.90, p = 0.05) and a non-significant trend towards occurrence of subsequent infections and greater 31 to 90 day mortality (HR 2.12, 95% CI 0.89–5.07, p = 0.09).ConclusionsPatients with prior immune dysfunction are at high risk for death 31 to 90 days, but not <30 days, after S. aureus bacteremia. Further investigation is needed to determine if this finding is due to poor prognosis of chronic disease or increased vulnerability to subsequent infections.

Determinants of Long-Term Mortality After Critical Illness

Department of MedicineEmory UniversityAtlanta, GA *See also p. 1237. Dr. Martin has consulted for Agennix, AstraZeneca, Cumberland Pharmaceuticals, and Pulsion Medical Systems; and has received grant support from the National Institutes of Health, Food and Drug Administration, Baxter Healthcare, and Abbott Laboratories.

Prognostic heterogeneity among patients with chronic stable coronary disease: determinants of long-term mortality after treatment with percutaneous intervention

To evaluate the risk and predictors of death in a large population of patients with stable coronary disease treated with percutaneous intervention. The study population comprised 1,276 patients with chronic angina or silent ischaemia who underwent elective coronary angioplasty. Baseline and in-hospital mortality data were prospectively collected for all patients during the index hospitalisation. Post-discharge outcome was assessed at out-patient clinic, by review of the patients' records, or direct phone contact. Deaths were classified as cardiac and non-cardiac. Age, peripheral arterial disease, congestive heart failure with NYHA class >or= III, triple-vessel disease, and procedural success (i.e. angiographic success for all lesions in the absence of peri-procedural infarction) remained as multivariate independent predictors of death. For the entire population 4-year cumulative all-cause and cardiac mortality were respectively 5.4% and 4.1%. Four-year mortality for patients without any multivariate predictor was 2.4%, while for patients with two or more predictors the death rate was 16.3% after four years. Patients with stable coronary disease undergoing percutaneous treatment have an overall low mortality rate after four years. Nevertheless, stable patients comprise a heterogeneous population in terms of risk profile, ranging from patients at very low risk of late death to individuals with a poor long-term prognosis.

P-197 Determinants of Long-Term Mortality in Patients with Type B Acute Aortic Dissection

P-197 Determinants of Long-Term Mortality in Patients with Type B Acute Aortic Dissection

Determinants of Long-Term Mortality in Patients With Type B Acute Aortic Dissection

Type B acute aortic dissection (AAD) carries a high short- and midterm mortality rate; however, knowledge related to long-term outcome is largely incomplete. The objective of this study was to identify long-term predictors including antihypertensive medications in type B AAD. We conducted a clinical follow-up study on 202 type B AAD patients. Univariate and multivariate Cox regression analyses were performed to identify predictors of mortality. There were 44 postdischarge deaths in 202 consecutive type B AAD patients with a median follow-up of 55 months. In univariate Cox regression analysis, age (10 year incremental: hazard ratio (HR) 1.82, 95% confidence interval (CI) 1.35-2.46, P < 0.0001), previous myocardial infarction or angina pectoris (HR 3.93, 95% CI 1.72-8.99, P = 0.001), and impaired renal function (HR 4.90, 95% CI 2.48-9.65, P < 0.0001) were predictors of death. Calcium channel blockers (CCBs), beta-blockers, and angiotensin-converting enzyme (ACE) inhibitors as antihypertensive medications at discharge were predictors of increased survival. In multivariate Cox regression analysis, CCBs were a significant predictor of increased survival (vs. no antihypertensive medication at discharge: HR 0.38, 95% CI 0.15-0.97, P = 0.04). Impaired renal function was a significant predictor of death (HR 3.41, 95% CI 1.58-7.33, P = 0.002). No antihypertensive medication at discharge group was significantly associated with increased mortality (vs. 1 class of antihypertensive medication: HR 9.51, 95% CI 1.85-48.79, P = 0.007). Impaired renal function was a predictor for adverse outcome in patients with type B AAD. The use of CCBs as antihypertensive medication at discharge was associated with increased survival.

Determinants of Long-Term Mortality after Prolonged Mechanical Ventilation

The poor long-term survival of patients requiring prolonged mechanical ventilation may be due to potentially modifiable factors. We therefore sought to assess the early determinants of long-term survival after discharge from a specialized respiratory unit. Eighty of 113 patients (71%) admitted to a respiratory care unit from June 2001 to August 2003 survived to discharge. Mortality outcomes and dates of death were determined by review of the records and survey in April 2005 of a national Death Master File. Potential determinants of survival after discharge were collected during the admission to the unit. Fifty-five percent of patients died within the first year after discharge. Age of 65 years or older, sacral ulcers, a serum creatinine >124 micromol/L, and failure to wean were each individually associated with shorter survival. Age, skin integrity, and wean status on discharge remained independent determinants of survival in a multivariable analysis. In a post-hoc analysis, chronic irreversible neurologic diseases were also independently associated with poor long-term survival. Mortality after discharge from a respiratory care unit is high. Interventions that may favorably impact long-term survival in these patients could target the modifiable factors identified, including measures that facilitate weaning and prevent or treat renal dysfunction and skin breakdown.