Lower Long-term Mortality Research Articles

Type of Anemia, Chronic Non-cardiovascular Illnesses, and Outcomes of Patients with ST-segment Elevation Myocardial Infarction.

ObjectivesTo assess the impact of different types of anemia and of concomitant non-cardiovascular chronic illnesses on outcomes of patients with ST-segment elevation myocardial infarction (STEMI) and baseline anemia admitted to the Intensive Cardiac Care Unit.MethodsBased on the mean corpuscular volume, anemia was stratified into: microcytic (<80 fL), normocytic (≥80, <96 fL), and macrocytic (≥96 fL). Data on concomitant chronic non-cardiovascular illnesses including malignancies were carefully collected. Endpoints included in-hospital bleeding as well as all-cause mortality at long-term follow-up.ResultsOf 1,390 patients with STEMI, 294 patients had baseline anemia (21.2%), in whom normocytic, microcytic, and macrocytic anemia was present in 77.2%, 17.0%, and 5.8% patients, respectively. In-hospital bleeding occurred in 25 (8.5%) of the study population without significant differences between the three groups. At a mean follow-up of 5.5±3.5 years, 104 patients (35.4%) had died. Mortality was the highest in patients with macrocytic anemia, followed by patients with normocytic anemia and microcytic anemia (58.8%, 37.0%, and 20.0%, respectively; P=0.009). Chronic non-cardiovascular condition was identified as an independent predictor of both in-hospital bleeding (odds ratio=2.57, P=0.01) and long-term mortality (hazard ratio [HR] 1.54, P=0.019). Performance of coronary angiography within index hospitalization was associated with lower long-term mortality (HR 0.38, P=0.001). Mean corpuscular volume did not predict either in-hospital bleeding or mortality.ConclusionsChronic non-cardiovascular illnesses are highly prevalent among patients with STEMI and baseline anemia, and are strongly associated with higher in-hospital bleeding and long-term mortality. Type of anemia is not related to prognosis post-STEMI.

Survival benefit of revascularization versus optimal medical therapy alone for chronic total occlusion management in patients with diabetes.

Chronic total occlusion (CTO) is common in patients with diabetes mellitus. Data on the long-term outcomes after treatment of CTOs in this high-risk population are scarce. To compare the long-term clinical outcomes of CTO revascularization either by coronary artery bypass graft (CABG) or successful percutaneous coronary intervention (PCI) versus optimal medical treatment (MT) alone in patients with diabetes. A total of 538 consecutive patients with diabetes and at least one CTO were identified from 2010 to 2014 in our center. In the present analysis, patients were stratified according to the CTO treatment strategy that was selected. MT was selected in 61% of patients whereas revascularization in the remaining 39%. Patients undergoing revascularization were younger, had higher left ventricular ejection fraction (LVEF), lower ACEF score, and more positive myocardial ischemia detection results compared to the MT group (p < .001).Patients referred for CABG had higher rates of left main disease compared to the PCI and MT groups (32% vs. 3% and 11%, respectively; p < .001). Complete revascularization was more often achieved in the CABG group, compared to the PCI group (62% vs. 32% p < .001). Multivariable analysis showed that revascularization with CABG was associated with lower rates of all-cause and cardiac mortality rates compared to MT, [hazard ratio (HR) 0.41, 95% confidence interval (CI) 0.25-0.70, p < .001 and HR 0.40, 95% CI 0.20-81, p = .011, respectively]. Successful CTO-PCI showed a trend towards benefit in all-cause mortality (HR 0.58, 95% CI 0.33-1.04, p = .06). In our registry, CTO revascularization in diabetic patients, especially with CABG, was associated with lower long-term mortality rates as compared to MT alone.

Hydrocortisone with fludrocortisone for septic shock: a systematic review and meta-analysis.

AimCombined hydrocortisone and fludrocortisone therapy for septic shock has not been evaluated with an independent systematic review. We aimed to elucidate the beneficial effects of a dual corticosteroid treatment regime involving both hydrocortisone and fludrocortisone for adult patients with septic shock on mortality.MethodsWe searched the Medline, Cochrane CENTRAL, and ICHUSHI databases for reports published before April 2019. We included randomized controlled trials that compared the use of both hydrocortisone and fludrocortisone with either corticosteroid‐free or hydrocortisone‐only treatments on adult patients with septic shock. Three researchers independently reviewed the studies. The meta‐analyses were undertaken to assess primary outcome (28‐day mortality) and secondary outcomes (in‐hospital mortality, long‐term mortality, shock reversal, and adverse events).ResultsAmong the four studies eligible for data synthesis, we included 2,050 patients from three studies for quantitative synthesis. All studies used similar regimens (hydrocortisone and fludrocortisone for 7 days without tapering). The 28‐day mortality rate was reduced after dual corticosteroid treatment (risk ratio, 0.88; 95% confidence intervals [CI], 0.78–0.99). The heterogeneity between the studies was low (I 2 = 0%). Patients who underwent dual corticosteroid treatment had lower long‐term mortality rates (risk ratio, 0.90; 95% CI, 0.83–0.98) and higher rate of shock reversal after 28 days (odds ratio, 1.06; 95% CI, 1.01–1.12) than control patients. Adverse events (except for hyperglycemia) were similar among the treatment groups.ConclusionsThe available evidence suggests that a combination of fludrocortisone and hydrocortisone is more effective than adjunctive therapy and could be recommended for septic shock.

Antecedent cancer in Takotsubo syndrome predicts both cardiovascular and long-term mortality

BackgroundTakotsubo syndrome (TTS), primarily an acute myocardial inflammatory condition engendered by catecholamine exposure, is associated with similar long-term mortality rates to those of patients with acute myocardial infarction. However, there is increasing evidence of a nexus between TTS and underlying malignancies:- many patients have antecedent cancer (A/Ca), while incremental risk of late cancer-related death has also been reported.PurposeTo evaluate potential interactions between A/Ca among TTS patients and both early and late clinical course.MethodsThree hundred forty-six consecutive TTS patients [aged 69 ± 13 (SD) years, males: 8.2%] were prospectively followed up for a median duration of 4.1 (IQR 2.2–6.4) years. Associations between A/Ca and severity of acute attacks, in-hospital complications and long-term death rates were sought utilising univariate analyses followed by multiple logistic regression analysis.ResultsA/Ca (present in 16.8% of patients) was associated with (i) greater elevation of hs-CRP and NT-proBNP concentrations (p = 0.01 and 0.04, respectively), (ii) more complicated in-hospital clinical course, with major adverse cardiac events (MACE) in 30.9% of patients, compared to 18.2% in non-A/Ca patients (p = 0.04). Long-term all-cause mortality rate was also greater [hazard ratio (HR) = 2.4, p = 0.0001] in A/Ca patients, with an excess cardiovascular (CVS) fatality rate (HR = 3.1, p = 0.001). On multivariate analysis, male gender, peak plasma concentrations of normetanephrine and hs-CRP, early arrhythmias and development of shock, but not A/Ca per se, were all independently associated with increased long-term mortality rate. Furthermore, patients discharged on β-adrenoceptor antagonists (βBl) or angiotensin converting enzyme inhibitors/ angiotensin receptor blockers (ACEi/ARB) had lower long-term mortality rates (β = − 0.2, p = 0.01; β = − 0.14, p = 0.05, respectively).Conclusions(1) A/Ca is associated with greater clinical severity of initial TTS attacks and substantially greater long-term CVS-related as well as all-cause mortality.(2) Post-discharge therapy with either βBl or ACEi/ARB is associated with reductions in long-term mortality rates.Overall, the current data suggest operation of substantial interactions between neoplasia and TTS, both at the level of pathogenesis and of outcomes.

6029Invasive versus medical management for non-ST elevation myocardial infarction in the elderly (SENIOR-NSTEMI study)

Abstract Background Trials and registry studies suggest lower long-term mortality after invasive than medical management among patients with non-ST elevated myocardial infarction (NSTEMI), but elderly patients were underrepresented. Purpose To estimate the effect of invasive compared with medical management on survival in patients with NSTEMI aged ≥80 years, using routine clinical data. Methods We used National Institute for Health Research Health Informatics Collaborative data to identify eligible patients admitted during 2010–2017 at five tertiary centres. We compared patients who did and did not have invasive management within 3 days of their peak troponin level. To limit the effect of immortal time bias, follow-up started 3 days after peak troponin: deaths within three days were excluded. We conducted intention-to-treat analyses. Propensity scores were derived from a logistic regression model based on pre-treatment variables: patient demographics, blood test results, cardiovascular risk factors, history of cardiovascular disease and other comorbidities. We modelled non-linear relationships using splines. Patients with high probability (based on propensity score) of medical or invasive intervention were excluded. We used Cox models to estimate hazard ratios (HR) comparing invasive with medical management. Three methods were used to control confounding; multivariable-adjusted, multivariable-adjusted additionally for continuous propensity score (primary analysis), and inverse-probability-of-treatment (IPT) weighting. Kaplan-Meier survival curves were plotted. The robustness of the results to unmeasured confounding was assessed in sensitivity analyses. Results The 2,239 patients (61.3% medical management) included in analyses had a median age of 85 (IQR 82–89) years. During a median follow-up of 32.1 (IQR 11.1–54.3) months, there were 1,015 (45.3%) deaths. At 3-years, cumulative survival was 78.9% and 50.3% in the invasive and medical management groups, respectively (Figure 1). The crude HR comparing invasive with medical management was 0.34 (95% CI 0.29–0.40). The multivariable-adjusted HR was 0.44 (95% CI 0.36–0.53), was unchanged with additional adjustment for propensity score, and was 0.46 (95% CI 0.39–0.56) in the IPT-weighted model (all p&lt;0.0001). The E-value for the point estimate was 2.91: this implies that residual confounding could explain the association if there is an unmeasured covariate with a relative risk of at least 2.91 for both mortality and undergoing invasive management. The highest mortality HR for comorbidities included in our model were aortic stenosis 1.66 (95% CI 1.28–2.14) and obstructive lung disease 1.50 (95% CI 1.16–1.94). Figure 1. Kaplan-Meier survival curves Conclusion This study provides evidence that the survival advantage from invasive management may extend to elderly patients with NSTEMI. Future research should address the possibility of unmeasured confounding, including by post-admission prognostic factors that affect choice of invasive or medical management. Acknowledgement/Funding Funded by NIHR Imperial Biomedical Research Centre (BRC) using NIHR Health Informatics Collaborative data service, supported by OUH, GSTT &amp; UCLH BRCs

Statin therapy is associated with improved survival in patients with ventricular tachyarrhythmias

ObjectivesThe study sought to assess the impact of statin therapy on survival in patients presenting with ventricular tachyarrhythmias.BackgroundData regarding the outcome of patients with statin therapy presenting with ventricular tachyarrhythmias is limited.MethodsA large retrospective registry was used including all consecutive patients presenting with ventricular tachycardia (VT) or fibrillation (VF) from 2002 to 2016. Patients with statin were compared to patients without statin therapy (non-statin). The primary prognostic endpoint was long-term all-cause death at 3 years. Uni- and multivariable Cox regression analyses were applied in propensity-score matched cohorts.ResultsA total of 424 matched patients was included. The rates of VT and VF were similar in both groups (VT: statin 71% vs. non-statin 68%; VF: statin 29% vs. 32%; p = 0.460). Statin therapy was associated with lower all-cause mortality at long-term follow-up (mortality rates 16% versus 33%; log rank, p = 0.001; HR = 0.438; 95% CI 0.290–0.663; p = 0.001), irrespective of the underlying type of ventricular tachyarrhythmia (VT/VF), left ventricular ejection fraction (LVEF) > 35%, presence of an activated implantable cardioverter defibrillator (ICD), cardiogenic shock or cardiopulmonary resuscitation (CPR).ConclusionStatin therapy is independently associated with lower long-term mortality in patients presenting with ventricular tachyarrhythmias on admission.Trial registrationClinicaltrials.gov, NCT02982473, 11/29/2016, Retrospectively registered.

Usefulness of skeletal muscle area detected by computed tomography to predict mortality in patients undergoing transcatheter aortic valve replacement: a meta-analysis study.

Measures of sarcopenia, such as low muscle mass measured from the readily available preoperative computed tomography (CT) images, have been recently suggested as a predictor of outcomes in patients undergoing transcatheter aortic valve replacement (TAVR). However, results of these studies are variable and, therefore, we performed a systematic review of current literature to evaluate sarcopenia as a predictor of outcome post TAVR. The search was carried out in electronic databases between 2008 and 2018. We identified studies that reported CT-derived skeletal muscle area (SMA) and survival outcomes post TAVR. Studies were evaluated for the incidence of early (≤ 30days) and late all-cause mortality (> 30days) post TAVR. Eight studies with 1881 patients were included (mean age of 81.8years ± 12, 55.9% men). Mean body mass index was (28.2kg/m2 ± 1.1), mean Society of Thoracic Surgeons risk score (7.0 ± 0.6), and mean albumin level was (3.8g/dL ± 0.1). Higher SMA was associated with lower long-term mortality [odds ratio (OR) 0.49, 95% confidence interval (CI) 0.28-0.83, p = 0.049], compared with low SMA. Also, higher SMA was associated with lower early mortality but was not statistically significant (OR 0.72; 95% CI 0.44-1.18; p = 0.285). CT-derived SMA provides value in predicting post-TAVR long-term outcomes for patients undergoing TAVR. This is a simple risk assessment tool that may help in making treatment decisions and help identifying and targeting high-risk patients with interventions to improve muscle mass prior to and following the procedures.

What is the best graft to supplement the bilateral internal thoracic artery to the left coronary system? A meta-analysis.

This meta-analysis was designed to assess the effect of the use of arterial conduits (ACs) versus great saphenous vein (GSV) grafts as a third conduit for revascularization of the right coronary artery system, in addition to the bilateral internal mammary artery on the left coronary artery. PubMed and OVID's version of MEDLINE were searched from January 2000 to September 2017 for relevant publications. The primary end point was the long-term mortality rate. The secondary end point was early mortality, defined as either in-hospital death or death within 30 days after the operation. Meta-regression was used to evaluate the effect of female gender and diabetes on the primary and secondary outcomes. A total of 10 studies (4121 patients) were selected for the systematic review and meta-analysis comparing ACs (1619) versus the GSV (2502), 6 (2548) comparing the GSV (2548) versus the right gastroepiploic artery (1023) and 5 comparing the GSV (2548) versus the radial artery (596). The pooled analysis did not show any difference between ACs and the GSV in terms of long-term mortality rates [hazard ratio (HR) = 0.75, 95% confidence interval (CI) = 0.56-1.01; P = 0.061]. When using the leave-one-out analysis, after the exclusion of 1 study (outlier), ACs were significantly associated with lower long-term mortality rates (HR = 0.67, 95% CI = 0.54-0.83; P < 0.001). When the results were stratified according to the type of study, no differences with regard to long-term results were found between ACs and the GSV, either in the pooled analysis of the 6 propensity score-matched studies (HR = 0.69, 95% CI = 0.43-1.08; P = 0.107) or in the pooled analysis of the 4 non-propensity score-matched studies (HR = 0.88, 95% CI = 0.62-1.23; P = 0.438). Again, when the outlier was excluded, the pooled analysis of the propensity score-matched studies confirmed that ACs were associated with lower long-term mortality rates (HR = 0.58, 95% CI = 0.43-0.80; P < 0.001). Comparisons between the GSV and either the right gastroepiploic artery or the radial artery showed similar results. No publication bias was found. This meta-analysis is the first to compare the GSV to the radial artery and the right gastroepiploic artery for right coronary artery grafting in patients receiving a bilateral internal mammary artery to left coronary artery. The choice of a third AC seems to be preferable in order to achieve better long-term survival.

Lower long-term mortality in obese patients with community-acquired pneumonia: possible role of CRP

OBJECTIVE:The present study aimed to investigate the relationship between obesity and mortality in patients with community-acquired pneumonia (CAP) in China.METHODS:In total, 909 patients with CAP were recruited for this study from January 2010 to June 2015. All patients were selected and divided into 4 groups according to their body mass index (BMI) values. All patients' clinical information was recorded. The associations among mortality; BMI; the 30-day, 6-month and 1-year survival rates for different BMI classes; the etiology of pneumonia in each BMI group; and the risk factors for 1-year mortality in CAP patients were analyzed.RESULT:With the exception of the level of C-reactive protein (CRP), no other clinical indexes showed significant differences among the different BMI groups. No significant differences were observed among all groups in terms of the 30-d and 6-month mortality rates (p>0.05). There was a significantly lower risk of 1-year mortality in the obese group than in the nonobese group, (p<0.05). Logistic regression analysis showed that there were seven independent risk factors for 1-year mortality in CAP patients, namely, age, cardiovascular disease, cerebrovascular disease, obesity, APACHE II score, level of CRP and CAP severity.CONCLUSION:Compared with nonobese patients with CAP, obese CAP patients may have a lower mortality rate, especially with regard to 1-year mortality, and CRP may be associated with the lower mortality rate in obese individuals than in nonobese individuals.

Effect of early physician follow-up on mortality and subsequent hospital admissions after emergency care for heart failure: a retrospective cohort study.

The 1-year mortality rate in patients with heart failure who are discharged from an emergency department is 20%. We sought to determine whether early follow-up after discharge from the emergency department was associated with decreased mortality or subsequent admission to hospital. This retrospective cohort study conducted in Ontario, Canada, included adult patients who were discharged from 1 of 163 emergency departments between April 2007 and March 2014 with a primary diagnosis of heart failure. Using a propensity score-matched landmark analysis, we assessed follow-up in relation to mortality and admissions to hospital for cardiovascular conditions. Of 34 519 patients, 16 274 (47.1%) obtained follow-up care within 7 days and 28 846 (83.6%) within 30 days. Compared with follow-up between day 8 and 30, patients with follow-up care within 7 days had a lower rate of mortality over 1 year (hazard ratio [HR] 0.92; 95% confidence interval [CI] 0.87-0.97), and a reduced rate of admission to hospital over 90 days (HR 0.87, 95% CI 0.80-0.94) and 1 year (HR 0.92; 95% CI 0.87-0.97); the mortality rate over 90 days in this group trended to a lower rate (HR 0.90, 95% CI 0.10-1.00). Follow-up care within 30 days, compared with patients without 30-day follow-up, was associated with a reduction in 1-year mortality (HR 0.89, 95% CI 0.82-0.97) but not admission to hospital (HR 1.02, 95% CI 0.94-1.10). In this group, there was a trend toward an increase in 90-day admission to hospital (HR 1.14, 95% CI 1.00-1.29). Follow-up care within 7 days of discharge from the emergency department was associated with lower rates of long-term mortality, as well as subsequent hospital admissions, and a trend to lower short-term mortality rates. Timely access to longitudinal care for patients with heart failure who are discharged from the emergency setting should be prioritized.

Meta-Analysis Comparing Outcomes of Drug Eluting Stents Versus Single and Multiarterial Coronary Artery Bypass Grafting

Relative benefits of coronary artery bypass (CABG) using single and multiple arterial grafting (SAG, MAG) and drug eluting stent (DES) in multivessel coronary disease remain uncertain. We compared SAG, MAG, and DES in a pairwise and network meta-analysis. Randomized trials and adjusted observational studies comparing CABG versus DES were included (primary end point: long-term mortality; secondary end points: operative mortality, perioperative stroke, and follow-up repeated revascularization [RR]). Studies with ≥1.7 arterial grafts and/or patient were classified as MAG. Bayesian network meta-analyses and random-model pairwise meta-analyses were performed. A total of 53,239 patients (8 randomized, 17 observational studies) were included (26,306 DES; 26,933 CABG). In pairwise comparison (mean follow-up: 5.42 years), CABG (MAG + SAG) was associated with lower long-term mortality (incident rate ratio [IRR] 0.77, 95% confidence interval [CI] 0.66 to 0.90), lower RR (IRR 0.37, 95% CI 0.27 to 0.51), increased perioperative stroke (odds ratio [OR] 3.18, 95% CI 1.70 to 5.97), and similar operative mortality (OR 1.04, 95% CI 0.64 to 1.70) compared with DES. There was a nonsignificant trend toward lower long-term mortality for studies with higher mean number of arterial grafts. In network meta-analyses, compared with DES, MAG was associated with lower long-term mortality (IRR 0.72, 95% credible interval [CrI] 0.57 to 0.92) and late RR (IRR 0.32, 95% CrI 0.21 to 0.49), SAG was associated with lower long-term mortality and RR (IRR 0.80, 95% CrI 0.66 to 0.97 and IRR 0.42, 95% CrI 0.29 to 0.61, respectively). In conclusion, CABG was associated with reduced 5-year mortality and need for RR compared with DES. MAG was ranked as the best treatment for the primary and all secondary outcomes.

Refeeding syndrome: relevance for the critically ill patient.

To provide an overview of recent findings concerning refeeding syndrome (RFS) among critically ill patients and recommendations for daily practice. Recent literature shows that RFS is common among critically ill ventilated patients. Usual risk factors for non-ICU patients addressed on ICU admission do not identify patients developing RFS. A marked drop of phosphate levels (>0.16 mmol/l) from normal levels within 72 h of commencement of feeding, selects patients that benefit from hypocaloric or restricted caloric intake for at least 48 h resulting in lower long-term mortality. RFS is a potentially life-threatening condition induced by initiation of feeding after a period of starvation. Although a uniform definition is lacking, most definitions comprise a complex constellation of laboratory markers (i.e. hypophosphatemia, hypokalemia, hypomagnesemia) or clinical symptoms, including cardiac and pulmonary failure. Recent studies show that low caloric intake results in lower mortality rates in critically ill RFS patients compared with RFS patients on full nutritional support. Therefore, standard monitoring of RFS-markers (especially serum phosphate) and caloric restriction when RFS is diagnosed should be considered. Furthermore, standard therapy with thiamin and electrolyte supplementation is essential.

Long-Term Sirolimus for Primary Immunosuppression in Heart Transplant Recipients

BackgroundSmall studies have reported superiority of sirolimus (SRL) over calcineurin inhibitor (CNI) in mitigating cardiac allograft vasculopathy (CAV) after heart transplantation (HT). However, data on the long-term effect on CAV progression and clinical outcomes are lacking. ObjectivesThe aim of this study was to test the long-term safety and efficacy of conversion from CNI to SRL as maintenance therapy on CAV progression and outcomes after HT. MethodsA cohort of 402 patients who underwent HT and were either treated with CNI alone (n = 134) or converted from CNI to SRL (n = 268) as primary immunosuppression was analyzed. CAV progression was assessed using serial coronary intravascular ultrasound during treatment with CNI (n = 99) and after conversion to SRL (n = 235) in patients who underwent at least 2 intravascular ultrasound studies. ResultsThe progression in plaque volume (2.8 ± 2.3 mm3/mm vs. 0.46 ± 1.8 mm3/mm; p < 0.0001) and plaque index (plaque volume–to–vessel volume ratio) (12.2 ± 9.6% vs. 1.1 ± 7.9%; p < 0.0001) were significantly attenuated when treated with SRL compared with CNI. Over a mean follow-up period of 8.9 years from time of HT, all-cause mortality occurred in 25.6% of the patients and was lower during treatment with SRL compared with CNI (adjusted hazard ratio: 0.47; 95% confidence interval: 0.31 to 0.70; p = 0.0002), and CAV-related events were also less frequent during treatment with SRL (adjusted hazard ratio: 0.35; 95% confidence interval: 0.21 to 0.59; p < 0.0001). Further analyses suggested more attenuation of CAV and more favorable clinical outcomes with earlier conversion to SRL (≤2 years) compared with late conversion (>2 years) after HT. ConclusionsEarly conversion to SRL is associated with attenuated CAV progression and with lower long-term mortality and fewer CAV-related events compared with continued CNI use.

Outcomes after first-time lower extremity revascularization for chronic limb-threatening ischemia between patients with and without diabetes

ObjectiveThe effect of diabetes type and insulin dependence on short- and long-term outcomes after lower extremity revascularization for chronic limb-threatening ischemia (CLTI) warrants additional study and more targeted focus. We sought to address this paucity of information by evaluating outcomes in insulin-dependent and noninsulin-dependent patients after any first-time revascularization. MethodsWe reviewed all limbs undergoing first-time infrainguinal bypass grafting (BPG) or percutaneous transluminal angioplasty with or without stenting (PTA/S) for CLTI at our institution from 2005 to 2014. Based on preoperative medication regimen, patients were categorized as having insulin-dependent diabetes (IDDM), noninsulin-dependent diabetes (NIDDM), or no diabetes (NDM). Outcomes included wound healing; major amputation; RAS events (reintervention, major amputation, or stenosis); major adverse limb events; and mortality. Outcomes were evaluated using χ2, Kaplan-Meier, and Cox regression analyses. ResultsOf 2869 infrainguinal revascularizations from 2005 to 2014, 1294 limbs (646 BPG, 648 PTA/S) fit our criteria. Overall, our analysis included 703 IDDM, 262 NIDDM, and 329 NDM limbs. IDDM patients, compared with NIDDM and NDM patients, were younger (69 vs 73 vs 77 years; P < .001) and more often presented with tissue loss (89% vs 77% vs 67%; P < .001), coronary artery disease (57% vs 48% vs 43%; P < .001), and end-stage renal disease (26% vs 13% vs 12%; P < .001). Perioperative complications, including mortality (3% vs 2% vs 5%; P = .07), did not differ between groups; however, complete wound healing at 6-month follow-up was significantly worse among IDDM patients (41% vs 49% vs 61%; P < .001). IDDM patients had significantly higher 3-year major amputation rates (23% vs 11% vs 8%; P < .001). Multivariable analyses illustrated that compared with NDM, IDDM was associated with significantly higher risk of both major amputation and RAS events after any first-time intervention (hazard ratio, 2.0 [95% confidence interval, 1.1-4.1] and 1.4 [1.1-1.8], respectively). Similar associations between IDDM and both major amputation and RAS events were found in patients undergoing a PTA/S-first intervention (4.1 [1.3-12.6] and 1.5 [1.1-2.2], respectively), whereas IDDM in BPG-first patients was associated with only incomplete wound healing (2.0 [1.4-4.5]). Last, compared with NDM, NIDDM was associated with lower late mortality (0.7 [0.5-0.9]). ConclusionsCompared with NDM, IDDM is associated with similar perioperative and long-term mortality but a higher risk of incomplete wound healing, major amputation, and future RAS events, especially after a PTA/S-first approach. NIDDM, on the other hand, is associated with lower long-term mortality and few adverse limb events. Overall, these data demonstrate both the importance of distinguishing between diabetes types and the potential long-term benefit of a BPG-first strategy in appropriately selected IDDM patients with CLTI.

Superiority of Serum Cystatin C Over Creatinine in Prediction of Long-Term Prognosis at Discharge From ICU.

Renal outcomes after critical illness are seldom assessed despite strong correlation between chronic kidney disease and survival. Outside hospital, renal dysfunction is more strongly associated with mortality when assessed by serum cystatin C than by creatinine. The relationship between creatinine and longer term mortality might be particularly weak in survivors of critical illness. Retrospective observational cohort study. In 3,077 adult ICU survivors, we compared ICU discharge cystatin C and creatinine and their association with 1-year mortality. Exclusions were death within 72 hours of ICU discharge, ICU stay less than 24 hours, and end-stage renal disease. None. During ICU admission, serum cystatin C and creatinine diverged, so that by ICU discharge, almost twice as many patients had glomerular filtration rate less than 60 mL/min/1.73 m when estimated from cystatin C compared with glomerular filtration rate estimated from creatinine, 44% versus 26%. In 743 patients without acute kidney injury, where ICU discharge renal function should reflect ongoing baseline, discharge glomerular filtration rate estimated from creatinine consistently overestimated follow-up glomerular filtration rate estimated from creatinine, whereas ICU discharge glomerular filtration rate estimated from cystatin C well matched follow-up chronic kidney disease status. By 1 year, 535 (17.4%) had died. In survival analysis adjusted for age, sex, and comorbidity, cystatin C was near-linearly associated with increased mortality, hazard ratio equals to 1.78 (95% CI, 1.46-2.18), 75th versus 25th centile. Conversely, creatinine demonstrated a J-shaped relationship with mortality, so that in the majority of patients, there was no significant association with survival, hazard ratio equals to 1.03 (0.87-1.2), 75th versus 25th centile. After adjustment for both creatinine and cystatin C levels, higher discharge creatinine was then associated with lower long-term mortality. In contrast to creatinine, cystatin C consistently associated with long-term mortality, identifying patients at both high and low risk, and better correlated with follow-up renal function. Conversely, lower creatinine relative to cystatin C appeared to confer adverse prognosis, confounding creatinine interpretation in isolation. Cystatin C warrants further investigation as a more meaningful measure of renal function after critical illness.

In-hospital and long-term outcomes of percutaneous balloon aortic valvuloplasty with concomitant percutaneous coronary intervention in patients with severe aortic stenosis.

Severe aortic stenosis (AS) often coexists with significant coronary artery disease. To evaluate procedural complications and long-term outcomes of patients with severe AS undergoing balloon aortic valvuloplasty (BAV) and percutaneous coronary intervention (PCI). A total of 97 patients with severe AS underwent 104 BAVs as palliative procedure, bridge to definitive treatment, or before urgent non-cardiac surgery. Patients were followed-up for at least 12 months. Of the 97 patients, 34 (35.0%) underwent standalone BAV, 45 (46.4%) underwent BAV with coronary angiography, and 18 (18.6%) BAV with PCI. There were no differences in baseline characteristics and indications for BAV among the groups (P > 0.05). No higher risk of complications after BAV performed with concomitant coronary angiography/PCI was observed. Transcatheter aortic valve implantation was performed after BAV in 13 (13.4%) patients and surgical aortic valve replacement in three (3.1%) patients. In spite of no difference in in-hospital mortality (5.6% vs. 8.9%; P = 0.76), patients with BAV and concomitant PCI had lower long-term mortality than patients with BAV and concomitant coronary angiography (28.5% vs. 51.0%; P = 0.03). In multivariable Cox analysis adjusted for age, sex, and body mass index, the Society of Thoracic Surgeons Predicted Risk of Mortality score was identified as the only independent predictor of long-term mortality for all patients (HR: 1.09, 95%CI: 1.04-1.15, P = 0.0006). Concomitant PCI or coronary angiography performed with BAV may not increase the risk of major and vascular complications. Patients with BAV and concomitant PCI may have better survival than patients with BAV and concomitant coronary angiography.

Mortality after primary intracerebral hemorrhage in relation to post-stroke seizures

Seizures after intracerebral hemorrhage are repeatedly seen. Whether the development of seizures after intracerebral hemorrhage affects survival in the long term is unknown. This study aims to determine the relation between seizures (i.e., with and without anti-epileptic therapy) and long-term mortality risk in a large patient population with intracerebral hemorrhage. We retrospectively included patients with a non-traumatic ICH in all three hospitals in the South Limburg region in the Netherlands between January 1st 2004 and December 31st 2009, and we assessed all-cause mortality until March 14th 2016. Patient who did not survive the first seven days after intracerebral hemorrhage were excluded from analyses. We used Cox multivariate analyses to determine independent predictors of mortality. Of 1214 patients, 783 hemorrhagic stroke patients fulfilled the inclusion criteria, amongst whom 37 (4.7%) patients developed early seizures (within 7 days after hemorrhage) and 77 (9.8%) developed late seizures (more than 7 days after hemorrhage). Seizure development was not significantly related to mortality risk after correction for conventional vascular risk factors and hemorrhage severity. However, we found a small but independent relation between the use of anti-epileptic drugs and a lower long-term mortality (HR = 0.32, 95% CI 0.11–0.91). In our large population, seizures and epilepsy did not relate independently to an increased mortality risk after hemorrhage.

Effect of Shorter Door-to-Balloon Times Over 20 Years on Outcomes of Patients With Anterior ST-Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

Cardiovascular disease remains the most common cause of mortality. We studied the change in outcomes for anterior ST-elevation myocardial infarction (STEMI) between 1995 and 2014. Over the past 20 years, 1,658 patients presenting to our center with anterior STEMI underwent primary percutaneous coronary intervention within 12 hours of presentation. We divided these into 4 quartiles, 1995 to 1999 (n = 312), 2000 to 2004 (n = 408), 2005 to 2009 (n = 428), and 2010 to 2014 (n = 510). Across the 4 quartiles, mean age decreased (64.4, 62, 60.3, and 60 years, p <0.01). In all groups, there was a significant rise in prevalence of smoking, hypertension, and obesity. The median length of hospital stay decreased (6, 4.4, 4.2, and 3.6 days, p <0.01), as did the median door-to-balloon time (DBT) (217, 194, 135, and 38 minutes, p <0.01). Thirty-day and 1-year mortality improved over time (14.4%, 11.8%, 8.4%, and 7.8%; and 20.5%, 16.4%, 15.9%, and 13.9%) (p = 0.01 both). Also, 3-year mortality improved (25.3%, 21.6%, 21.3%, and 16.5%, p = 0.02). After adjusting for age, gender, co-morbidities, ejection fraction, clinical shock, and mitral regurgitation, shorter DBT was associated with lower long-term mortality (compared with DBT <60 minutes; 60 to 90 minutes hazard ratio [HR] 1.67, 95% confidence interval [CI] 0.93 to 3.00, p = 0.084; 90 to 120 minutes, HR 1.74, 95% CI 1.02 to 2.95, p = 0.04; >120 minutes, HR 1.91, 95% CI 1.23 to 2.96, p = 0.004). In conclusion, over the past 2 decades, long-term outcomes improved in patients presenting with anterior STEMI associated with shortening of DBT.

Impact of appropriate empirical antibiotic treatment on recurrence and mortality in patients with bacteraemia: a population-based cohort study

BackgroundData on the impact of empirical antibiotic treatment (EAT) on patient outcome in a population-based setting are sparse. We assessed the association between EAT and the risk of recurrence within one year, short-term- (2–30 days) and long-term (31–365 days) mortality in a Danish cohort of bacteraemia patients.MethodsA cohort study including all patients hospitalized with incident bacteraemia during 2007–2008 in the Copenhagen City and County areas and the North Denmark Region. EAT was defined as the antibiotic treatment given at the 1st notification of a positive blood culture. The definition of recurrence took account of pathogen species, site of infection, and time frame and was not restricted to homologous pathogens. The vital status was determined through the civil registration system. Association estimates between EAT and the outcomes were estimated by Cox and logistic regression models.ResultsIn 6483 eligible patients, 712 (11%) had a recurrent episode. A total of 3778 (58%) patients received appropriate EAT, 1290 (20%) received inappropriate EAT, while EAT status was unrecorded for 1415 (22%) patients. The 2–30 day mortality was 15.1%, 17.4% and 19.2% in patients receiving appropriate EAT, inappropriate EAT, and unknown EAT, respectively. Among patients alive on day 30, the 31–365 day mortality was 22.3% in patients given appropriate EAT compared to 30.7% in those given inappropriate EAT. Inappropriate EAT was independently associated with recurrence (HR 1.25; 95% CI = 1.03–1.52) and long-term mortality (OR 1.35; 95% CI = 1.10–1.60), but not with short-term mortality (OR 0.85; 95% CI = 0.70–1.02) after bacteraemia.ConclusionsOur data indicate that appropriate EAT is associated with reduced incidence of recurrence and lower long-term mortality following bacteraemia.

Modeling Long-Term Survival in Chemotherapy-Only Versus Combined Modality Therapy in Patients with Early Stage Unfavorable Hodgkin Lymphoma Involving the Mediastinum

Background: Optimal therapy for patients with early stage Hodgkin lymphoma (HL) is controversial. Combined modality therapy (CMT) utilizes chemotherapy plus consolidative radiotherapy (RT). CMT produces higher initial cure rates, but also increases the long-term risk of radiation toxicity. The most important risks include higher rates of breast and lung cancer, and ischemic heart disease due to mediastinal radiation exposure. Chemotherapy-only (CT) treatment with ABVD produces lower initial cure rates versus CMT, but also yields less long-term toxicity. Furthermore, those CT patients that fail initial therapy can often be salvaged with autologous stem cell transplant (ASCT). To help guide patient-specific strategies, we developed a Markov decision-analytic model to estimate long-term mortality in patients with early stage unfavorable HL involving the mediastinum treated with CMT vs. CT.Methods: We builta decision tree with Markov modeling to compare long-term mortality due to relapse, ischemic heart disease, and breast or lung cancer in hypothetical patients treated with CT or CMT using TreeAge Pro 2016. The model follows a hypothetical cohort of patients from primary therapy through 20-year follow-up. Patients transition between health states (Figure 1) based on probabilities extracted from 13 published studies. Patients that fail therapy then move to survival curves based on early vs. late relapse. The probability of toxicity was based on relative risks found in studies that used ABVD alone or ABVD with involved field or larger RT volumes. Patients who develop a toxicity move to a survival curve specific to that adverse effect. The model estimated 20-year survival in cohorts based on sex, upper vs. lower mediastinal disease, and age (20 y/o vs. 40 y/o) in non-smokers.Results: In 20 y/o patients, CMT showed better long-term survival than CT alone with slightly larger difference in mortality (1.6%) in males with upper mediastinal disease than in females (1.4%) (Table 1). In the cohort of 20 year old males, the causes of death in CMT vs. CT 20 years from starting therapy, respectively, were as follows: HL (4.7% vs. 6.6%); breast cancer (0% vs. 0%); lung cancer (0.1% vs. 0.1%); ischemic heart disease (0.6% vs. 0.3%). In 40 y/o patients, CT showed better long-term survival. The largest difference in mortality was 7.6% in 40 y/o females with lower mediastinal disease (19.9% in CMT vs. 12.3% in CT-only). In this cohort, the causes of death in CMT vs. CT, respectively were: HL (4.6% vs. 6.6%); breast cancer (4.7% vs. 1.0%); lung cancer (2.9% vs. 2.1%); ischemic heart disease (7.8% vs. 2.6%). CT-only also showed a survival benefit of 4.9% in 40 y/o males with lower mediastinal disease. Causes of death in CMT vs. CT, respectively: HL (4.6% vs. 6.6%); lung cancer (3.3% vs. 2.2%); ischemic heart disease (8.5% vs. 2.7%). At 20 years post treatment, CT-only tends to favor older patients, while CMT tends to favor younger patients due to lower baseline risks of dying from second cancers and ischemic heart disease in 40 y/o compared to 60 y/o survivors.Conclusions: This model may help multidisciplinary decision making when determining the optimum strategy for different types of patients based on disease location and risk factors for relapse and toxicity. In this study the benefits of radiation were erased by the higher rates of toxicities in older patients. Of note, the published relative risks used in this model were from studies using outdated large radiation fields rather than modern approaches. The impact of using much smaller "involved site" volumes, intensity modulated RT, and/or proton therapy is unknown but would likely lower long-term mortality from CMT. Further work using probabilistic sensitivity analyses can test these initial conclusions. [Display omitted] [Display omitted] DisclosuresHwang:Novartis: Research Funding. Nasta:Millennium Pharmaceuticals: Research Funding. Mato:Abbvie, Gilead Sciences, Pharmacyclics, TG Therapeutics: Consultancy; Abbvie, Acerta Pharma, Gilead Sciences, ProNAi, TG Therapeutics, Theradex: Research Funding. Schuster:Hoffman-LaRoche: Research Funding; Genentech: Consultancy, Honoraria; Gilead: Research Funding; Pharmacyclics: Consultancy, Research Funding; Merck: Research Funding; Celgene: Consultancy, Honoraria, Research Funding; Novartis: Consultancy, Honoraria, Research Funding; Nordic Nanovector: Consultancy, Honoraria, Membership on an entity’s Board of Directors or advisory committees; Janssen Research & Development: Research Funding. Svoboda:Celgene: Research Funding; Seattle Genetics: Research Funding; Pharmacyclics: Research Funding.