Incidence Of Major Cardiovascular Complications Research Articles

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Impact of cardio-renal syndrome on adverse outcomes in patients with Fabry disease in a long-term follow-up

AimsFabry disease (FD) is a rare X-linked lysosomal storage disease with a deficiency of α-galactosidase A leading to progressive sphingolipid accumulation in different organs, among them heart and kidney. We evaluated the impact of cardio-renal syndrome (CRS) on the incidence of major cardiovascular complications and death in a prospective FD cohort. Methods and resultsA total of 104 genetically proven FD patients were annually followed at the University Hospitals Zurich and Bern. The main outcome was a composite of incident renal replacement therapy (RRT), hospitalisation due to decompensated Heart Failure, new onset atrial fibrillation, pacemaker/ICD implantation, stroke/TIA and death. Estimated glomerular filtration rate (eGFR) and left ventricular myocardial mass index (LVMMI) where explored as the primary exposure variables. During the median follow-up of 103 [59–155] months, events occurred in 27 patients. In a Cox regression analysis, both higher LVMMI and lower eGFR were independently associated with a greater risk of developing adverse events after adjustment for multiple confounders (HR 1.67 [1.04–2.73] P=0.03 per SD increase in LVMMI, HR 0.45 [0.25–0.83], P=0.01 per SD decrease in eGFR). In patients with CRS, the risk to develop events was significantly increased if adjusted for demographics and RRT (HR 4.46 [1.07–18.62], P=0.04), approaching significance if additionally adjusted for hypertension (HR 4.05 [0.95–17.29], P=0.06). In Kaplan-Meier-Analysis, the poorest event-free survival was observed among patients with CRS. ConclusionsCRS was associated with a high risk to develop cardiovascular complications and death, emphasizing the importance of its prevention and early recognition. A focus on cardio-reno-protective therapies is crucial.

Mortality in isolated coronary artery bypass surgery in elderly patients. A retrospective analysis over 14 years

Abstract Introduction We aim to describe our experience in coronary artery bypass graft in elderly patients older than 80 years and assess the associated risk and predictors of mortality in this subgroup. Material and method From January 1999 to June 2013, 3097 patients underwent consecutive coronary artery bypass graft surgery. Patients aged over 80 years were identified. Multivariate survival analysis using Cox's regression model was performed. Results We identified 99 patients older than 80 years (80-group; mean age 82 ± 3.5 years) and 2957 younger than 80 years (control group) (mean age 64.2 ± 9.7 years). Additive EuroSCORE was 8.4 ± 4.8 and 4.6 ± 4.6 (p 0 .001) in the 80-group vs. control group, respectively. Off-pump coronary artery bypass graft was performed in 79.6 vs. 41.6% (p 0 .001) in the 80-group vs. the control group, respectively. There was significantly higher 30 day-mortality in the 80-group, 11.2 vs. 3.3%, respectively (p 0 .001). Patients in the 80-group underwent reintervention for bleeding more frequently (9.2 vs. 2.9%; p = 0 .001) and had a higher incidence of major cardiovascular complications than the control group (6.1 vs. 2.1%; p = 0 .001). Independent predictors of mortality for the 80-group were: reoperation for bleeding (HR 5.7; 95% CI 1.6–19.5) and cardiovascular complications (HR 3.7; 95% CI 1.1–12.2). The mean follow-up was 6.3 ± 4.2 years for the octogenarian group. The cumulative survival of these patients was 65.7% during the study period. Conclusion Coronary artery bypass graft is performed preferably in patients over 80 years old under the off-pump procedure. Mortality is higher in this group of patients probably related to a higher incidence of cardiovascular complications and reintervention for bleeding in the immediate postoperative period.

Mortalidad de la cirugía coronaria aislada en octogenarios. Análisis restrospectivo de 14 años

IntroductionWe aim to describe our experience in coronary artery bypass graft in elderly patients older than 80 years and assess the associated risk and predictors of mortality in this subgroup. Material and methodFrom January 1999 to June 2013, 3097 patients underwent consecutive coronary artery bypass graft surgery. Patients aged over 80 years were identified. Multivariate survival analysis using Cox's regression model was performed. ResultsWe identified 99 patients older than 80 years (80-group; mean age 82±3.5 years) and 2957 younger than 80 years (control group) (mean age 64.2±9.7 years). Additive EuroSCORE was 8.4±4.8 and 4.6±4.6 (P<.001) in the 80-group vs. control group, respectively. Off-pump coronary artery bypass graft was performed in 79.6 vs. 41.6% (P<.001) in the 80-group vs. the control group. respectively. There was significantly higher 30 day-mortality in the 80-group, 11.2 vs. 3.3%, respectively (P<.001). Patients in the 80-group underwent reintervention for bleeding more frequently (9.2 vs. 2.9%; P=.001) and had a higher incidence of major cardiovascular complications than the control group (6.1 vs. 2.1%; P=.001). Independent predictors of mortality for the 80-group were: reoperation for bleeding (HR 5.7; 95% CI 1.6-19.5) and cardiovascular complications (HR 3.7; 95% CI 1.1-12.2). The mean follow-up was 6.3±4.2 years for the octogenarian group. The cumulative survival of these patients was 65.7% during the study period. ConclusionCoronary artery bypass graft is performed preferably in patients over 80 years old under the off-pump procedure. Mortality is higher in this group of patients probably related to a higher incidence of cardiovascular complications and reintervention for bleeding in the immediate postoperative period.

Cardiovascular complications and drug prescriptions in subjects with and without diabetes in a Northern region of Italy, in 2002 and 2012

Background and aimsIn contrast to the well-documented global prevalence of diabetes, much less is known about the epidemiology of cardiovascular (CV) complications in recent years. We describe the incidence of major CV events, deaths and drug prescribing patterns from 2002 to 2012 in subjects with (DM) or without diabetes mellitus (No DM). Methods and resultsSubjects and outcomes were identified using linkable health administrative databases of Lombardy, a region in Northern Italy. A logistic regression model was used to compare myocardial infarction (MI), stroke, major amputation and death between DM and No DM in 2002 and 2012 and between the two index years in each population. The interaction between years and diabetes was introduced in the model.From 2002 to 2012 the incidence of major CV complications and death fell in both groups with a larger reduction among DM only for CV events: OR (95% CI) for the interaction 0.86 (0.79–0.93) for MI, 0.89 (0.82–0.96) for stroke, 0.78 (0.57–1.06) for major amputations. CV prevention drugs rose considerably from 2002 to 2012 particularly in DM and a switch towards safer antihyperglycemic drugs was also observed. ConclusionsMajor CV complications and death declined from 2002 to 2012 in both DM and No DM. This might be due to a larger increase in prescriptions of CV drugs in DM and a relevant change toward recommended antihyperglycemic drugs.

Elevated risk of death and major cardiovascular events in subjects with newly diagnosed diabetes: Findings from an administrative database

AimsTo investigate the incidence of major cardiovascular complications and mortality in the first years of follow-up in patients with newly diagnosed diabetes. Methods and resultsWe examined incidence rates of hospitalization for cardiovascular reasons and death among new patients with diabetes using the administrative health database of the nine million inhabitants of Lombardy followed from 2002 to 2007. Age and sex-adjusted rates were calculated and hazard ratios (HR) were estimated with a matched population without diabetes of the same sex, age (±1 year) and general practitioner.There were 158,426 patients with newly diagnosed diabetes and 314,115 subjects without diabetes. Mean follow-up was 33.0 months (SD ± 17.5). 9.7% of patients with diabetes were hospitalized for cardiovascular events vs. 5.4% of subjects without diabetes; mortality rate was higher in patients with diabetes (7.7% vs. 4.4%). The estimated probability of hospitalization during the follow up was higher in patients with diabetes than in subjects without for coronary heart disease (HR 1.4, 95% CI 1.3–1.4), cerebrovascular disease (HR 1.3.95% CI 1.2–1.3), heart failure (HR 1.4, 95% CI 1.3–1.4) as was mortality (HR 1.4, 95% CI 1.4–1.4).Younger patients with diabetes had a risk of death or hospital admission for cardio-cerebrovascular events similar to subjects without diabetes ten years older. ConclusionsThe elevated morbidity and mortality risks were clear since the onset of diabetes and rose over time. These data highlight the importance of prompt and comprehensive patients care in addition to anti-diabetic therapy in patients with newly diagnosed diabetes.

Predictive factors of complications after coronary stent implantation.

To analyze the predictive factors of complications after implantation of coronary stents in a consecutive cohort study. Clinical and angiographic characteristics related to the procedure were analyzed, and the incidence of major cardiovascular complications (myocardial infarction, urgent surgery, new angioplasty, death) in the in-hospital phase were recorded. Data were stored in an Access database and analyzed by using the SPSS 6.0 statistical program and a stepwise backwards multiple logistic regression model. One thousand eighteen (mean age of 61 +/-11 years, 29% females) patients underwent 1070 stent implantations. The rate of angiographic success was 96.8%, the rate of clinical success was 91%, and the incidence of major cardiovascular complications was 7.9%. The variables independently associated with major cardiovascular complications, with their respective odds ratio (OR) were: rescue stent, OR = 5.1 (2.7-9.6); filamentary stent, OR = 4.5 (2.2-9.1); first-generation tubular stent, OR = 2.4 (1.2-4.6); multiple stents, OR = 3 (1.6-5.6); complexity of the lesion, OR = 2.4 (1.1-5.1); thrombus, OR = 2 (1.1-3.5). The results stress the importance of angiographic variables and techniques in the risk of complications and draw attention to the influence of the stent's design on the result of the procedure.

Double-blind comparison between zofenopril and lisinopril in patients with acute myocardial infarction: Results of the Survival of Myocardial Infarction Long-term Evaluation-2 (SMILE-2) study

Background Angiotensin-converting enzyme (ACE) inhibitors have been reported to be effective in placebo-controlled trials in various subsets of patients with acute myocardial infarction (MI). However, no direct comparisons have been performed between different ACE inhibitors in the same patient population. Methods This phase III, double-blind, parallel-group, multicenter study compared the safety and efficacy of zofenopril and lisinopril in 1024 thrombolyzed patients with acute MI. Patients, aged 18 to 75 years, were randomized to receive oral zofenopril (30-60 mg/day) or lisinopril (5-10 mg/day), starting within 12 hours of completion of thrombolytic therapy and continuing for 42 days. The primary study end point was the incidence of severe hypotension (systolic blood pressure <90 mm Hg), either cumulative or drug-related. Secondary end points included additional safety and efficacy parameters. Results The overall incidence of severe hypotension was slightly 5more reduced with zofenopril (10.9%) than with lisinopril (11.7%, P = .38). The incidence of drug-related severe hypotension was slightly but significantly lower with zofenopril than with lisinopril (6.7 vs 9.8%, 2-tailed P = .048). The 6-week mortality rate was 3.2% in the zofenopril group and 4.0% in the lisinopril group ( P = .38), and no significant differences were observed in the incidence of major cardiovascular complications or any safety variables between the 2 ACE inhibitors. Conclusions The SMILE-2 study demonstrates that both zofenopril and lisinopril are safe and associated with a rather low rate of severe hypotension when given in accordance with a dose-titrated scheme to thrombolyzed patients with acute MI. These findings could have a positive clinical impact and increase the proportion of patients with acute MI who can be safely treated with ACE inhibitors. (Am Heart J 2003;145:80-7.)

Cardiovascular risks of outpatient cardiac rehabilitation

Herz Kreislauf; Volume 28, 2, 1996 Title: Cardiovascular risks of outpatient cardiac rehabilitation by M. Unverdorben, C. Vallbracht, R. Gansser, H. Oster, P. Neuner, B. Kunkel Abstract: In 1995, ambulatory cardiac rehabilitation was initiated only for patients post myocardial infarction. Nowadays patients may join in coronary care groups unless they are symptomatic at rest or present with acute disease; thus, an incline in cardiovascular complications could be expected. To elucidate this issue, questionnaires on the type and incidence of cardiovascular complications answered by 903 outpatients and 144 physicians were evaluated. Casualties occurred in 1:750,000 patient exercise hours being comparable with fatality rates of healthy sports men. This rate remained unchanged despite a widened spectrum of disease and physical activities, the latter including anaerobic sports as well. Cardiovascular symptoms were reported by 38.4% mainly occurring during warm-up (17.9%) and endurance training (61.8%). Dyspnea (40.5%) and palpitations (28.9%) were the most frequent complaints. In conclusion, the incidence of major cardiovascular complications of cardiac patients in ambulatory sports is comparable with healthy sports men. Frequent complaints require adaptation of sports programs to the type and stage of disease.

Benefit and costs of anti-hypertensive treatment.

Hypertension is common throughout the world and represents the single greatest risk factor for increasing cardiovascular mortality, cardiovascular morbidity and overall mortality. Diseases associated with hypertension are not only, in general, of a chronic disabling nature, but, in most instances, require frequent hospitalization, with expensive drug treatment and management. Stroke, coronary heart disease, congestive heart failure and chronic renal insufficiency represent the most commonly encountered corollaries of inadequately treated hypertension. Anti-hypertensive treatment is accompanied by a reduction of hypertension-related cardiovascular risk and a clearcut benefit in terms of reduced incidence of major cardiovascular complications of hypertension and overall mortality. This benefit has frequently been underestimated in many clinical trials. Attempts to improve the cost-benefit ratio have included the use of treatment strategies based upon 24-h control of blood pressure, since it has been demonstrated that hypertension-related end-organ damage correlates more closely with 24-h average blood pressure and with 24-h blood pressure variability than with blood pressure measured in the clinic. It is hoped that new anti-hypertensive agents, which smoothly reduce 24-h blood pressure profile, will further reduce the incidence of hypertension-related end-organ damage.

Cognitive Effects After Epidural vs General Anesthesia in Older Adults

To compare the effect of epidural vs general anesthesia on the incidence of long-term cognitive dysfunction after total knee replacement surgery in older adults. Randomized controlled clinical trial. Orthopedic specialty academic hospital. A total of 262 patients undergoing elective primary total knee replacement with a median age of 69 years; 70% women. Random assignment to either epidural or general anesthesia. A thorough neuropsychological assessment was performed preoperatively and repeated at 1 week and 6 months postoperatively. Cognitive outcome was assessed by within-patient change on 10 tests of memory, psychomotor, and language skills. Prospective standardized surveillance for cardiovascular complications was performed to allow simultaneous assessment of anesthetic effects on cognitive and cardiovascular outcomes. The two groups were similar at baseline in terms of age, sex, comorbidity, and cognitive function. There were no significant differences between the epidural and general anesthesia groups in within-subject change from baseline on any of the 10 cognitive test results at either 1 week or 6 months. Overall, 5% of patients showed a long-term clinically significant deterioration in cognitive function. There was no difference between the anesthesia groups in the incidence of major cardiovascular complications (3% overall). The type of anesthesia, general or epidural, does not affect the magnitude or pattern of postoperative cognitive dysfunction or the incidence of major cardiovascular complications in older adults undergoing elective total knee replacement. This is the largest trial of the effects of general vs regional anesthesia on cerebral function reported to date, with more than 99% power to detect a clinically significant difference on any of the neuropsychological tests.

Cardiovascular complications of outpatient cardiac rehabilitation programs.

To determine the incidence of major cardiovascular complications in outpatient cardiac rehabilitation programs, we obtained data from 167 randomly selected cardiac rehabilitation programs via mailed questionnaires and follow-up telephone calls. These 167 programs reported that 51 303 patients exercised 2 351 916 hours from January 1980 through December 1984. Twenty-one cardiac arrests (18 in which the patient was successfully resuscitated and three fatal) and eight nonfatal myocardial infarctions were reported. The incidence rates per million patient hours of exercise were 8.9 for cardiac arrests (one per 111 996 patient-hours), 3.4 for myocardial infarctions (one per 293 990 patient-hours), and 1.3 for fatalities (one per 783 972 patient-hours). There was no statistically significant difference in frequency of these events among programs of varying size or extent of electrocardiographic monitoring. These data indicate that current cardiac rehabilitation practice allows for prescribed supervised exercise by patients with cardiovascular disease to be performed at a low risk of major cardiovascular complications.

Cardiovascular Complications of Recreational Physical Activity.

In brief To evaluate the incidence of major cardiovascular complications (CVCs) during recreational activity the authors conducted a five-year retrospective survey of fatal and nonfatal CVCs that occurred in community recreation centers during or immediately after exercise. Forty-eight facilities reported 30 nonfatal and 38 fatal CVCs. Although most (57%) occurred during court games and jogging, the data are insufficient to infer any increased relative risk during these activities. There was one nonfatal and one fatal event every 1,124,200 and 887,526 hours of participation, respectively. These data suggest a small acute risk of CVC in the general public during recreational activity.