Lower Risk Of Early Mortality Research Articles

Preoperative statin therapy decreases early mortality in patients undergoing isolated valve surgery: result from a meta-analysis.

The purpose of this meta-analysis was to assess the role of preoperative statin therapy on adverse cardiovascular events in patients undergoing valve surgery. Meta-analysis of 10 observational studies. Hospital. 22,158 patients. None. The Medline, Cochrane, and Embase databases were searched for clinical studies published up to June 2014. Studies that evaluated the effects of preoperative statin therapy on valve surgery were included. After a literature search in the major databases, 10 observational studies with 22,518 patients were identified. Pool analysis indicated that preoperative statin therapy was associated with a significantly lower risk of early all-cause mortality (Odds ratio [OR]: 0.69; 95% confidence interval [CI] 0.50-0.95, p = 0.03). The benefits of preoperative statin therapy were more obvious in studies with isolated valve surgery, resulting in a 1.9% absolute risk and a 38% odds reduction of early mortality (2.4 v 4.3%; OR: 0.62; 95% CI 0.49-0.77, p<0.0001). A significant reduction by statin therapy also was observed for atrial fibrillation (OR 0.88, 95% CI: 0.80-0.98, p = 0.02). However, statin therapy was not associated with a lower risk of postoperative stroke (OR: 0.74; 95% CI 0.46-1.19, p = 0.21), myocardial infarction (OR: 1.02; 95% CI 0.78-1.34, p = 0.87), and renal failure (OR: 0.91; 95% CI 0.57-1.44, p = 0.68). Preoperative statin therapy was associated with a significantly lower risk of early mortality in patients undergoing isolated valve surgery. A prospective, randomized, controlled trial is warranted.

Elderly patients (&gt;75 years) with intermediate risk pulmonary embolism and acute right ventricle pressure overload treated with systemic thrombolysis: 6 years experience of a single center

Purpose: The benefits of extending thrombolysis (TBL) to clinically stable elderly patients (pts) with acute pulmonary embolism (PE) and excessive right ventricular (RV) pressure overload remains controversial. The aim of this study was to assess the effect of TBL plus unfractionated heparin (UFH) versus UFH alone on echocardiographically detected pulmonary systolic pressure (PsP) and short-term clinical outcome in haemodynamically stable elderly pts (>75 years old) with PE and PsP> 50 mmHg in absence of RV hypertrophy (RV free wall thickness < 5mm). Methods: According to the European Society of Cardiology PE guidelines (2008), pts were classified into high, intermediate and low risk of early mortality. A shock index, defined as heart rate divided by systolic blood pressure, was calculated in all pts on admission. Echocardiography was performed at the time of EP diagnosis and repeated 24 hours after the starter of therapy. TBL (tPA, 100 mg) and UFH were infused at approved regimens for PE. Results: Between January 2007 and December 2012, 95 pts were referred to our institute for objectively confirmed acute PE, 66 (69.3%) were > 75 years old (age 83.8±4.5 years, 58 females). In this subgroup of pts there were 3 high (4,5%), 46 intermediate (69,7%) and 17 low risk pts (25,8%); PsP> 50 mmHg without RV hypertrophy was detected in 30 elderly pts with intermediate risk PE; the shock index was > 1 in 84% and in 57% of intermediate risk elderly pts, with or without PsP >50 mmHg, respectively. 15 pts received TBL plus UFH (group A, age 82.9±4.9 years) and 15 were treated with UFH alone (group B, age 84.8.±3.9 years). Both groups were well matched with regard to features and clinical presentation. The PsP decreased from a pretreatment value of 64±14mmHg to 37±14 mmHg at 24 hours for group A and from 62±14 mmHg to 46±15 mmHg for group B pts (p<0.001). There were no fatal bleeding episodes or intracerebral hemorrhage in both treatment groups. One patient of the group B developed a cardiogenic shock and died during hospitalization. Conclusions: Our study shows that pts with PE are more often elderly pts with intermediate risk of early death. Echocardiographic evidence of PsP > 50 mmHg and normal RV free wall thickness selects pts at increased risk for adverse clinical outcome. For those pts, TBL results safe and effective, leading to a significant early reduction in the PsP.

New Prospective for the Management of Low-Risk Pulmonary Embolism: Prognostic Assessment, Early Discharge, and Single-Drug Therapy with New Oral Anticoagulants

Patients with pulmonary embolism (PE) can be stratified into two different prognostic categories, based on the presence or absence of shock or sustained arterial hypotension. Some patients with normotensive PE have a low risk of early mortality, defined as <1% at 30 days or during hospital stay. In this paper, we will discuss the new prospective for the optimal management of low-risk PE: prognostic assessment, early discharge, and single-drug therapy with new oral anticoagulants. Several parameters have been proposed and investigated to identify low-risk PE: clinical prediction rules, imaging tests, and laboratory markers of right ventricular dysfunction or injury. Moreover, outpatient management has been suggested for low-risk PE: it may lead to a decrease in unnecessary hospitalizations, acquired infections, death, and costs and to an improvement in health-related quality of life. Finally, the main characteristics of new oral anticoagulant drugs and the most recent published data on phase III trials on PE suggest that the single-drug therapy is a possible suitable option. Oral administration, predictable anticoagulant responses, and few drug-drug interactions of direct thrombin and factor Xa inhibitors may further simplify PE home therapy avoiding administration of low-molecular-weight heparin.

Surgical closure of patent foramen ovale in patients with suspected paradoxical embolism: long‐term results

Objective—It is thought that a patent foramen ovale (PFO) is the crucial mechanism in patients with suspected paradoxical embolism and cryptogenic stroke. It has been hypothesized that closure of the PFO would prevent further cerebrovascular incidents. We describe our early and late experience with surgical closure of PFO in patients with paradoxical embolism.Patients and methods—Between May 1994 and December 2001, 33 patients (26 men, 7 women; mean age, 55.2 ± 8.7 years; range, 37–74 years) underwent surgical closure of a PFO at our institution. All patients had preoperatively suffered from a stroke and/or a transient ischemic attack, after which echocardiography showed a PFO. Mean follow‐up at 99 ± 30 months (range, 10–111 months) was 100% complete.Results—All patients survived the operative procedure. Early complications occurred in four patients (12%). Actuarial survival at 1, 5 and 8 years was 97 ± 3%, 97 ± 5% and 94 ± 8%, respectively. At long‐term follow‐up all but two patients were alive. The deaths of these two patients were related to malignancy and ischemic heart disease, respectively. Two patients (6%) had suffered a residual cerebrovascular event after successful surgery.Conclusion—Surgical closure of PFO in patients with paradoxical embolism can safely be performed with a low risk of early mortality. Residual thromboembolic events were rare and in those few it occurred it did so with the interatrial septum being closed, indicating that in those patients the PFO was not the mechanism of the thromboembolic event in the first place.

Role of age and sex in short-term and long term mortality after a first Q wave myocardial infarction

STUDY OBJECTIVEThe objective of this study was to analyse whether the risk of death within 28 days and three years after a first Q wave myocardial infarction was higher in...

Preferences for Home vs Hospital Care Among Low-Risk Patients With Community-Acquired Pneumonia

To measure preferences for initial outpatient vs hospital care among low-risk patients who were being actively treated for community-acquired pneumonia (CAP). Study patients included 159 patients with CAP, 57 (36%) initially hospitalized, who were identified as being at low risk for early mortality using a validated prediction model. Subjects were enrolled from university and community health care facilities located in Boston, Mass, Halifax, Nova Scotia, and Pittsburgh, Pa, participating in the Pneumonia Patient Outcome Research Team prospective cohort study of CAP. Three utility assessment techniques (category scaling, standard gamble, and willingness to pay) were used to measure the strength of patient preferences for the site of care for low-risk CAP. At the time of initial therapy or during the early recuperative period, patient preferences were assessed across a spectrum of potential clinical outcomes using 7 standardized pneumonia clinical vignettes. Responses to the 7 pneumonia scenarios indicated that most patients consistently preferred outpatient-based therapy. This pattern was observed regardless of whether patients had actually been treated initially at home or in a hospital. Patients (74%) who stated that they generally preferred home care for low-risk CAP were willing to pay a mean of 24% of 1 month's household income to be assured of this preference. Preference for home care, as measured by the category scaling and the willingness to pay, persisted after adjustment for sociodemographic and baseline health status covariates. Sixty nine percent of interviewed patients said that their physician alone determined whether they would be treated in the hospital or at home. Only 11% recalled being asked if they had a preference for either site of care. Most patients, even those treated initially in a hospital, who were at low risk for mortality from CAP prefer outpatient treatment. However, most physicians appear not to involve patients in the site-of-care decision. More explicit discussion of patient preferences for the location of care would likely yield more highly valued care by patients as well as less costly treatment for CAP.