Greater 30-day Mortality Research Articles

Treatment and outcomes of acute coronary syndromes in India (CREATE): a prospective analysis of registry data

India has the highest burden of acute coronary syndromes in the world, yet little is known about the treatments and outcomes of these diseases. We aimed to document the characteristics, treatments, and outcomes of patients with acute coronary syndromes who were admitted to hospitals in India. We did a prospective registry study in 89 centres from 10 regions and 50 cities in India. Eligible patients had suspected acute myocardial infarction with definite electrocardiograph changes (whether elevated ST [STEMI] or non-STEMI or unstable angina), or had suspected myocardial infarction without ECG changes but with prior evidence of ischaemic heart disease. We recorded a range of clinical outcomes, and all-cause mortality at 30 days. We enrolled 20,937 patients. Of the 20,468 patients who were given a definite diagnosis, 12,405 (60.6%) had STEMI. The mean age of these patients was 57.5 (SD 12.1) years; patients with STEMI were younger (56.3 [12.1] years) than were those with non-STEMI or unstable angina (59.3 [11.8] years). Most patients were from lower middle 10,737 (52.5%) and poor 3999 (19.6%) social classes. The median time from symptoms to hospital was 360 (IQR 123-1317) min, with 50 (25-68) min from hospital to thrombolysis. 6226 (30.4%) patients had diabetes; 7720 (37.7%) had hypertension; and 8242 (40.2%) were smokers. Treatments for STEMI differed from those for non-STEMI or unstable angina. More patients with STEMI than with non-STEMI were given anti-platelet drugs (98.2%vs 97.4%); angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB) (60.5%vs 51.2%); and percutaneous coronary interventions (8.0%vs 6.7%, p<0.0001 for all comparisons). Thrombolytics (96.3% streptokinase) were used for 58.5% of patients with STEMI. Conversely, fewer patients with STEMI than those with non-STEMI or unstable angina were given beta blockers (57.5%vs 61.9%); lipid-lowering drugs (50.8%vs 53.9%); and coronary bypass graft surgery (1.9%vs 4.4%, p<0.0001 for all comparisons). The 30-day outcomes for patients with STEMI were death (8.6%), reinfarction (2.3%), and stroke (0.7%). Outcomes for those with non-STEMI or unstable angina were better: death (3.7%), reinfarction (1.2%), and stroke (0.3%, p<0.0001 for all comparisons). Use of key treatments also differed by socioeconomic status: more rich patients than poor patients were given thrombolytics (60.6%vs 52.3%), beta blockers (58.8%vs 49.6%), lipid-lowering drugs (61.2%vs 36.0%), ACE inhibitors or ARB (63.2%vs 54.1%), percutaneous coronary intervention (15.3%vs 2.0%), and coronary artery bypass graft surgery (7.5%vs 0.7%, p<0.0001 for all comparisons). Mortality was higher for poor patients than for rich patients (8.2%vs 5.5%, p<0.0001). Adjustment for treatments (but not risk factors and baseline characteristics) eliminated this difference in mortality. Patients in India who have acute coronary syndromes have a higher rate of STEMI than do patients in developed countries. Since most of these patients were poor, less likely to get evidence-based treatments, and had greater 30-day mortality, reduction of delays in access to hospital and provision of affordable treatments could reduce morbidity and mortality.

Trends in Outcomes and Quality of Care in Acute Myeloid Leukemia over Four Decades in Ontario, Canada.

Acute myeloid leukemia (AML) is associated with a poor prognosis, particularly in patients age 60 or older, who comprise the largest group of patients with AML. However, most published data on AML outcomes are institution-based rather than population-based, and are associated with significant selection and referral biases. There is a paucity of data on quality of care in this population. Recent data from specialized centres have shown that with careful patient selection and aggressive chemotherapy, a significant number of older AML patients can achieve improved outcomes. This suggests that variations in outcomes may exist and may be due to differential rates of treatment, referral to specialized centres, or other aspects of quality of care. However, this issue has not been formally examined.We used the Ontario Cancer Registry, a comprehensive provincial cancer registry, to identify all patients diagnosed with AML in the province of Ontario between 1965 and 2003. Comorbidity was captured with the Charlson-Deyo Index. 30-day and one-year survival were examined across geographic region (8 regions), age group, and time using multivariable logistic regression. Referral to regional cancer centres (RCC) and receipt of chemotherapy were examined as quality of care indicators.A total of 9,365 patients (mean age, 58.1 y, range 0–103 y) were diagnosed with AML between 1965 and 2003. Mean age at diagnosis increased from 49.1 y in 1965 to 62.4 y in 2003. 53.3% of patients were male. There was a steady increase in the number of new cases per year that was greater than the population growth rate. Overall, 75.5% and 33.3% of patients survived to 30 days and one year. 30-day survival was 67.4% among patients age 60+ vs. 85.6% among age 19–59. One-year survival was also considerably lower at 20.3% vs. 49.2%. Both 30-day and one-year survival decreased per decade of age from age 19 onwards. Although 30-day and one-year survival improved over time among patients age 19–59, similar improvements were not seen in patients age 60+. Among patients age 60+, 30-day survival varied from 62.0% to 72.3% across regions, whereas one-year survival varied from 16.8% to 25.4%. The proportion of patients receiving chemotherapy declined with age (56.4% vs.28.0% among 19–59 vs. 60+ year olds). Similarly, significantly fewer patients age 60 or older were referred to a RCC (20.8% vs. 29.9%). Increasing age, increasing comorbidity, geographic region, lack of receipt of chemotherapy, and not being referred to a RCC were associated with greater 30-day mortality in multivariable models. Findings were similar for one-year survival although region was no longer a statistically significant predictor.The incidence of AML has been increasing over the last four decades, with a slight preponderance among males. The mean age at diagnosis has also slowly increased. Although the prognosis has improved over time among children and adults up to age 59, it remains poor among those age 60 or older. Clinically important differences in survival were seen across geographic regions. These differences were only partially explained by receipt of chemotherapy and referral to specialized cancer centres. More detailed clinical information is required to determine if opportunities exist to enhance the quality of care and thereby improve outcomes among older adults with AML.

Rethinking 30-day mortality risk after radical prostatectomy

Objectives Although radical prostatectomy (RP) is associated with greater 30-day mortality in older men, the magnitude of the excess risk in older age groups compared with younger ones has not been well characterized. Methods Using data from the Ontario Cancer Registry, we identified 11,010 men who underwent RP from 1990 to 1999 in Ontario, Canada and compared the 30-day mortality risk immediately after RP with the 1-month mortality risk in the same population of men 7 to 12 months after RP and that of an age-matched general population of men. Results Overall, 53 men (0.48%) died within 30 days of surgery. The absolute excess 30-day mortality risk associated with RP was 0.18%, 0.51%, and 0.59% for men aged 50 to 59, 60 to 69, and 70 to 79 years, respectively, and was similar for men aged 60 to 69 and 70 to 79 years ( P >0.05). The relative mortality risk within 30 days of RP was approximately nine times the baseline risk (95% confidence interval 3 to 38) and was similar for men in all three age groups ( P >0.05). Conclusions The results of our study indicate that men aged 70 to 79 years do not have a greater absolute excess or relative risk of 30-day mortality after RP compared with men aged 60 to 69 years.

Troponin t levels and risk of 30-day outcomes in patients with the acute coronary syndrome: prospective verification in the gusto-iv trial

Background A third-generation troponin T assay with improved precision and a lower detection limit has been developed. However, the appropriate cutoff for identifying patients with the acute coronary syndrome who are at low risk of subsequent mortality has not been established. Methods A retrospective evaluation of data from the Fragmin and fast Revascularization during InStability in Coronary artery disease II (FRISC-II) trial suggested that a cutoff below 0.1 μg/L for troponin T levels might be more useful in risk stratification. A prospective validation of two cutoff levels (0.03 μg/L and 0.01 μg/L) was performed in 7115 patients with non–ST-elevation acute coronary syndrome from the Global Utilization of Strategies To open Occluded arteries IV (GUSTO-IV) trial. Results Patients with troponin T levels >0.1 μg/L had greater 30-day mortality (5.5% [201/3679]) than did those with levels ≤0.1 μg/L (2.2% [75/3436], P <0.001). A cutoff value of 0.03 μg/L provided better discrimination between high and low risk: 5.1% (234/4552) versus 1.6% (42/2563). However, a cutoff value at the lower limit of detection, 0.01 μg/L, provided the best discrimination: 5.0% (254/5123) versus 1.1% (22/1992) ( P<0.001). This cutoff level had the highest negative predictive value; it also discriminated best for the combined endpoint of death and myocardial infarction. Conclusion Using a cutoff of ≤0.01 μg/L for the third-generation troponin T assay, the detection level of the assay, is useful for identifying patients with the acute coronary syndrome who are at low risk of subsequent mortality.

Surgery of popliteal artery aneurysms: a 12-year experience.

Management of asymptomatic popliteal aneurysm is controversial, and the prognosis for acutely thrombosed aneurysm is notoriously poor. We evaluated the management and outcome for popliteal aneurysm. A retrospective review of all patients with popliteal aneurysm between 1988 and 2000 was carried out. Fifty-two limbs were operated on in 41 patients. Data collected included findings at presentation, operative details, graft patency, limb salvage, complications, and 30-day mortality. Initial findings included acute ischemia (n = 14), no symptoms (n = 29), acute rupture (n = 2), chronic ischemia (n = 5), and symptoms of nerve or vein compressive (n = 2). All patients with symptomatic aneurysms and 22 patients with asymptomatic aneurysms (21 larger than 2 cm in diameter, 1 with thrombus at duplex ultrasound scanning) underwent surgery as first-line treatment. Of the 7 patients with asymptomatic aneurysm managed with surveillance with duplex ultrasound scanning, acute ischemia developed in three, 1 aneurysm ruptured, compressive symptoms developed in 1, and 2 remained asymptomatic but required surgery because of aneurysm enlargement (>2 cm). Of the 17 patients with acute ischemia, 13 had neurologic signs and underwent immediate thromboembolectomy (trifurcation alone in 8, ankle-level arteriotomy in 4) and bypass grafting (n = 12) or inlay grafting (n = 1), and the other 4 underwent intra-arterial thrombolysis initially. Of these 4 procedures, 2 were successful and had elective surgery; the other 2 required urgent surgery because of secondary distal embolism and failure of recanalization. Thirteen of the 17 grafts were to the crural vessels. Bypass grafting (medial approach) was used in 16 of the 17 patients with acute ischemia, all 5 patients with chronic ischemia, and the 8 patients with no symptoms. An inlay technique (posterior approach) was used in 16 patients with no symptoms, the 3 patients with symptoms of nerve or vein compression, and 1 patient with acute ischemia. The distal anastomoses were to the below-knee popliteal artery in 35 patients and the crural arteries in 15 patients, using autologous vein. Two of the patients with rupture underwent ligation alone, the other undergoing bypass grafting in addition. The overall 5-year primary patency rate was 69%, secondary patency rate was 87%, and limb salvage rate was 87%. Limb salvage was achieved in 14 of the 17 patients with acute ischemia. Patients with asymptomatic aneurysms had better secondary graft patency (100%) compared with symptomatic aneurysms (74%; P <.01). Acute ischemia, technique used, and crural artery grafts were not predictors of graft failure with either univariate or multivariate analysis. Symptomatic aneurysms were associated with more postoperative complications and greater 30-day mortality (4 of 28 vs 0 of 24). Thromboembolectomy followed by crural bypass grafting is an effective treatment for popliteal aneurysm with severe acute limb ischemia. Outcome is better with surgical management of asymptomatic popliteal aneurysm compared with symptomatic aneurysm.

Impact of sex and its interaction with age on the management of and outcome for patients with acute myocardial infarction in 4 Japanese hospitals

Background Several studies from the United States and from European countries have detected sex and age differences in clinical characteristics, management, and outcomes of acute myocardial infarction. The aim of this study was to determine how sex and age influence the management of and outcome for patients with acute myocardial infarction in Japan. Methods A retrospective cohort study was performed by means of patient chart review at 4 teaching hospitals in Japan. There was a total of 482 patients (136 females [28%], 346 males [72%]) admitted consecutively with a diagnosis of acute myocardial infarction between July, 1995 and June, 1996. Results Female patients were older and had more comorbid diseases than male patients. Female patients also tended to have more cardiac complications during hospitalization and a greater 30-day mortality (10% vs 4%, P <.05). After adjustment for baseline characteristics and age/sex interaction, it was found that female patients were less likely to undergo thrombolytic therapy, cardiac catheterization, or revascularization, and they had a greater 30-day mortality. These sex differences in cardiac catheterization and revascularization were more pronounced for older patients. On the other hand, the sex differences in 30-day mortality were greater for younger patients. Conclusions Our data suggest that cardiac catheterization, revascularization and 30-day mortality may have been related to patient sex and age, but further study is needed. (Am Heart J 2002;144:101-7.)

Management of intracerebral hemorrhage in a large metropolitan population.

The management of all patients with spontaneous, nonaneurysmal intracerebral hemorrhages that occurred in the 1.26 million population of Greater Cincinnati during 1988 was reviewed. Of the 188 patients with intracerebral hemorrhage, 26 had operative removal of their intracerebral hemorrhage, and 8 had removal of their intracerebral hemorrhage and an arteriovenous malformation. In 15 of the 34 patients, the operation was performed within 12 hours of onset. The operative removal of parenchymal hemorrhages was performed in 29% of cerebellar, 24% of lobar, 13% of deep, and 10% of pontine hemorrhages. Admission Glasgow Coma Scale scores were similar for operated and nonoperated patients (11 +/- 3 versus 11 +/- 3), but operated patients were significantly younger (58 +/- 17 versus 72 +/- 15 yr), were more likely to have a lobar hemorrhage (64 versus 43%) or a cerebellar hemorrhage (29 versus 7%), and had larger parenchymal hemorrhages (50 +/- 31 versus 37 +/- 38 ml). Operated patients had a borderline lower 30-day mortality (25%) than nonoperated patients (46%), but the overall morbidity and mortality for the two groups did not differ significantly. Patients undergoing an early operation were more critically ill preoperatively and had a greater 30-day mortality (45%) than did those patients undergoing a late operation (12%). Half of the 43% mortality for all hospitalized cases occurred during the first 2 days after onset, and two-thirds occurred during the first 4 days. Only 12% of all patients had a minor handicap or better at 30 days. Neurosurgeons in our community performed operative removal of parenchymal hemorrhage in nearly one fifth of all patients with intracerebral hemorrhage.(ABSTRACT TRUNCATED AT 250 WORDS)