Higher Incidence Of All-cause Death Research Articles

Impact of atrial fibrillation on long-term clinical outcomes in heart failure outpatients

Purpose: Atrial fibrillation (AF) is a common arrhythmia in patients with heart failure (HF). Recently, several reports revealed that AF was not associated with adverse long-term clinical outcomes of hospitalized HF patients. However, the impact of AF in unselected HF outpatients on long-term clinical outcomes remained unclear. In the present study, we aimed to clarify the impact of AF on clinical outcomes among Japanese HF outpatients in real-world clinical practice. Methods: With a single hospital-based cohort in the Shinken Database 2004-2011, comprising all the new patients (n=17517) visiting the Cardiovascular Institute Hospital, we followed 2024 outpatients who were diagnosed as having symptomatic HF at the initial visit. Results: AF was observed in 310 patients (15%). Patients with AF were older, and more likely to be female, more likely to have a lower rate of obesity, hypertension, dyslipidemia, diabetes mellitus, ischemic heart disease, whereas, had a higher rate of anemia, chronic kidney disease, valvular heart disease, dilated cardiomyopathy and prior history of stroke. Averaged BNP in patients with AF was significantly higher than that in patients without AF. AF group had a lower prevalence of NYHA II, whereas a higher prevalence of NYHA III and IV heart failure than Non-AF group. Patients using beta-blockers, renin-angiotensin-system inhibitors, diuretics, digitalis, anti-arrhythmic drugs, and warfarin were more common in patients with AF. Left ventricular ejection fraction was lower in patients with AF than those without. Cox regression analysis showed that AF was associated with higher incidence of all-cause death (p=0.015, hazard ratio (HR) 1.631, 95% confidence interval (CI) 1.099-2.420), cardiovascular death (p=0.009, HR 2.022, 95% CI 1.196-3.420), and HF admission (p<0.001, HR 3.107, 95% CI 2.286-4.224). The Cox regression model used in the analysis adjusted for the covariates showed that patients with AF had a comparable risk for all-cause death (p=0.115, HR 0.573, 95% CI 0.286-1.146), HF death (p=0.608, HR 0.690, 95% CI 0.167-2.844), and cardiovascular death (p=0.564, HR 0.772, 95% CI 0.320-1.861), whereas had significantly higher risk for HF admission (p=0.007, HR 1.781, 95% CI 1.172-2.704). Sub analysis showed that the clinical impact of AF on HF outpatients might be stronger in patients with female, younger age, ischemic etiology, preserved EF, and mild HF symptom. Conclusions; Among unselected HF outpatients, AF was commonly observed. AF was not associated with long-term mortality, but independently associated with HF admission in HF outpatients.

Venous Thromboembolism Prophylaxis for Medical Service—Mostly Cancer—Patients at Hospital Discharge

Objective Many hospitalized Medical Service patients remain at high risk for venous thromboembolism (VTE) after hospital discharge. Our aim was to compare the effect of the use or omission of extended pharmacologic VTE prophylaxis after hospital discharge among Medical Service patients on the incidence of symptomatic deep vein thrombosis (DVT) or pulmonary embolism (PE) over the ensuing 3 months. Methods In this case-control study, we identified a case population of 461 patients for whom parenteral pharmacological VTE prophylaxis was prescribed to continue after discharge and matched them according to age, sex, and VTE risk score to a control group of 922 patients for whom VTE prophylaxis was not continued after discharge. Results The primary endpoint of symptomatic DVT or PE at 90 days occurred in 5.0% of patients receiving extended prophylaxis compared with 4.3% of patients who received no prophylaxis after discharge ( P = .58). Fewer patients were alive at 90 days in patients receiving extended pharmacologic VTE prophylaxis, compared with those who received no prophylaxis after discharge (56.8% vs 68.4%, P <.001). Major bleeding, defined as those events requiring blood transfusion, medical, or surgical intervention, occurred more frequently in patients receiving extended VTE prophylaxis after discharge than in those patients who received no prophylaxis after discharge (3.9% vs 1.9%, P = .03). Conclusion Extended pharmacologic thromboprophylaxis in high-risk Medical Service patients did not reduce symptomatic DVT and PE in the ensuing 90 days after hospital discharge. There was a higher incidence of all-cause death and major bleeding episodes in patients receiving extended prophylaxis. Our observations do not support the routine use of extended VTE prophylaxis in Medical Service patients. Further research is needed to identify patients who may benefit from extended pharmacologic VTE prophylaxis and those who may have too great a bleeding risk.

Impact of Metabolic Syndrome on Clinical Outcomes After Drug-Eluting Stent Implantation in Patients With Coronary Artery Disease

Metabolic syndrome (MetS) is regarded as a risk factor for coronary artery disease (CAD). However, the influence of MetS on morbidity and mortality after drug-eluting stent (DES) implantation in Chinese patients with CAD remains unknown. We evaluated the impact of MetS on the clinical outcome of 1224 patients following DES implantation. After a mean follow-up of 35.4 months, patients with MetS had a significantly higher incidence of all-cause death and major adverse cardiovascular events (MACE) compared with patients without MetS (P < .001). Analyses of individual MetS components showed that dysglycemia at the time of DES implantation predicted increased all-cause mortality, while the presence of hypertension and dysglycemia predicted increased incidence of MACE.

Does Metabolic Syndrome Influence Outcome Following Percutaneous Coronary Intervention?

In this issue of Angiology, Hu et al report the relationship between metabolic syndrome (MetS) and the outcome following drug-eluting stent (DES) implantation in Chinese patients (n 1⁄4 1224) with coronary heart disease (CHD). After a mean follow-up of 35.4 months, patients with MetS had a significantly higher incidence of all-cause death and major adverse cardiovascular events (MACE) compared with patients without MetS (P < .001). Dysglycemia at the time of stenting predicted increased all-cause mortality, while hypertension and dysglycemia predicted increased incidence of MACE. Furthermore, the combination of type 2 diabetes mellitus (T2DM) with MetS was associated with a worse prognosis than MetS alone. Patients with T2DM have a greater risk of vascular events and poor outcome following coronary revascularization with stenting using bare metal stents (BMS) compared with patients who do not have T2DM. However, this interpretation has been challenged by the use of DES instead of BMS. Similarly, an increased vascular risk has been linked with MetS, but the outcome after coronary stenting for CHD is not well documented. Therefore, Hu et al provide useful information regarding both the role of MetS and glycemia following coronary stenting using DES. There are several topics of interest in this field that we will address in this editorial. The results of any study involving MetS will undoubtedly depend on which definition of this syndrome is used. We reported significant differences in the prevalence of MetS and associated vascular disease as well as in the calculated vascular risk depending on the definition used. We also showed, in agreement with Hu et al, that MetS þ T2DM was associated with more vascular disease than MetS alone. Agreement between studies may improve if the 2009 consensus definition of MetS becomes widely accepted. There is emerging evidence supporting the use of ‘‘statin loading’’ pre-percutaneous coronary intervention (PCI). This does not seem to have been carried out by Hu et al probably because it is not currently a universally implemented procedure. There is also evidence that ‘‘getting to low-density lipoprotein cholesterol (LDL-C) target’’ is important for statin treatment. The mean LDL-C levels of 112 mg/dL (2.9 mmol/L) reported in the study by Hu et al is above target for high-risk patients (ie, 70-100 mg/dL; 1.8-2.6 mmol/L). However, this may be because the diagnosis of CHD was only confirmed after angiography. Whether similar adverse effects of MetS and/or T2DM are valid for interventions involving other arteries (eg, carotid and renal artery stenting or radial catheterization) remains to be established. In this context, there is evidence that patients with MetS undergoing carotid or renal artery stenting have a worse outcome than those without Mets. Furthermore, ‘‘statin loading’’ has been proposed to counter the inflammatory response after radial catheterization for coronary angiography. Clearly, there is a need to assess whether PCI is inferior to coronary artery bypass grafting (CABG) not only in patients with T2DM but also those with MetS without T2DM. DES use as well as other measures (eg, statin loading,, achieving LDL-C targets, aggressive antiplatelet therapy, control of hypertension, and smoking cessation) may further improve outcomes after stenting in these patients.

Effect on Outcome of an Increase of Serum Cardiac Troponin T in Patients With Healing or Healed ST-Elevation Myocardial Infarction

Recently, an association between minimally elevated cardiac troponin levels and cardiovascular risk in the general population has been reported. However, the prevalence and clinical importance of elevated cardiac troponin T (cTnT) levels remain unclear in patients with histories of myocardial infarction (MI). In this study, 1,807 consecutive patients with ST-segment elevation MIs were prospectively studied (77.1% men; mean age 64.4 years). Venous blood samples were obtained in the chronic stage of MI (28 +/- 7 days after onset), and serum cTnT levels were determined. During the average follow-up of 1,042 days, 84 patients died and 83 had nonfatal reinfarctions. Patients with cTnT levels in the highest quartile (> or = 0.040 ng/ml [n = 353]) had a higher incidence of all-cause death (8.2% vs 5.2%, p = 0.049) and nonfatal reinfarction (8.3% vs 5.1%, p = 0.048) than patients with cTnT levels from the lower 3 quartiles (<0.040 ng/ml [n = 1,064]). Multivariate Cox regression analysis revealed that a minimally elevated cTnT level (> or =0.040 ng/ml) was a significant predictor of all-cause mortality (hazard ratio 1.79, 95% confidence interval 1.10 to 2.90, p <0.02) and nonfatal reinfarction (hazard ratio 1.50, 95% confidence interval 1.13 to 2.20, p <0.03). Subgroup analysis showed that an elevated cTnT level was also a predictor of all-cause mortality and nonfatal reinfarction in patients without heart failure. In conclusion, minimally elevated cTnT levels in the chronic stage of MI predicted long-term adverse clinical outcomes.