Mortality In 30-day Survivors Research Articles

Characteristics, management and outcomes of active cancer patients with cardiogenic shock.

Characteristics, management, and outcomes of patients with active cancer admitted for cardiogenic shock remain largely unknown. This study aimed to address this issue and identify the determinants of 30-day and 1-year mortality in a large cardiogenic shock cohort of all etiologies. FRENSHOCK is a prospective multicenter observational registry conducted in French critical care units between April and October 2016. "Active cancer" was defined as a malignancy diagnosed within the previous weeks with planned or ongoing anticancer therapy. Among the 772 enrolled patients (mean age 65.7 ± 14.9 years; 71.5% male), 51 (6.6%) had active cancer. Among them, the main cancer types were solid cancers (60.8%), and hematological malignancies (27.5%). Solid cancers were mainly urogenital (21.6%), gastrointestinal (15.7%), and lung cancer (9.8%). Medical history, clinical presentation, and baseline echocardiography were almost the same between groups. In-hospital management significantly differed: patients with cancers received more catecholamines or inotropes (norepinephrine 72 vs 52%, p=0.005 and norepinephrine-dobutamine combination 64.7 vs 44.5%, p=0.005), but had less mechanical circulatory support (5.9 vs 19.5%, p=0.016). They presented similar 30-day mortality rate (29 vs 26%) but a significantly higher mortality at one-year (70.6 vs 45.2%, p<0.001). In multivariable analysis, active cancer was not associated with 30-day mortality but was significantly associated with 1-year mortality in 30-day survivors (HR 3.61 [1.29 - 10.11], p=0.015). Active cancer patients accounted for almost 7% of all cases of cardiogenic shock. Early mortality was the same regardless active cancer or not, whereas long-term mortality was significantly increased in patients with active cancer.

Long-Term Survival, Causes of Death, and Trends in 5-Year Mortality After Intracerebral Hemorrhage: The Tromsø Study.

Data on long-term survival after intracerebral hemorrhage (ICH) are scarce. In a population-based nested case-control study, we compared long-term survival and causes of death within 5 years in 30-day survivors of first-ever ICH and controls, assessed the impact of cardiovascular risk factors on 5-year mortality, and analyzed time trend in 5-year mortality in ICH patients over 2 decades. We included 219 participants from the population-based Tromsø Study, who after the baseline participation had a first-ever ICH between 1994 to 2013 and 1095 age- and sex-matched participants without ICH. Cumulative survival was presented using the Kaplan-Meier method. Hazard ratios (HRs) for mortality and for the association between cardiovascular risk factors and 5-year mortality in 30-day survivors were estimated by stratified Cox proportional hazards models. Trend in 5-year mortality was assessed by logistic regression. Risk of death during follow-up (median time, 4.8 years) was increased in the ICH group compared with controls (HR, 1.62 [95% CI, 1.27-2.06]). Cardiovascular disease was the leading cause of death, with a higher proportion in ICH patients (22.9% versus 9.0%; P<0.001). Smoking increased the risk of 5-year mortality in cases and controls (HR, 1.59 [95% CI, 1.15-2.19]), whereas serum cholesterol was associated with 5-year mortality in cases only (HR, 1.39 [95% CI, 1.04-1.86]). Use of anticoagulants at ICH onset increased the risk of death (HR, 2.09 [95% CI, 1.09-4.00]). There was no difference according to ICH location (HR, 1.15 [95% CI, 0.56-2.37]). Five-year mortality did not change during the study period (odds ratio per calendar year, 1.01 [95% CI, 0.93-1.09]). Survival rates were significantly lower in cases than in controls, driven by a 2-fold increased risk of cardiovascular death. Smoking, serum cholesterol, and use of anticoagulant drugs were associated with increased risk of death in ICH patients. Five-year mortality rates in ICH patients remained stable over time.

Long-term prognosis after intracerebral haemorrhage.

IntroductionThe aim of this study was to determine the risk of recurrent intracerebral haemorrhage (ICH), ischaemic stroke, all stroke, any vascular event and all-cause mortality in 30-day survivors of ICH, according to age and sex.Patients and methodsWe linked national hospital discharge, population and cause of death registers to obtain a cohort of Dutch 30-day survivors of ICH from 1998 to 2010. We calculated cumulative incidences of recurrent ICH, ischaemic stroke, all stroke and composite vascular outcome, adjusted for competing risk of death and all-cause mortality. Additionally, we compared survival with the general population.ResultsWe included 19,444 ICH-survivors (52% male; median age 72 years, interquartile range 61–79; 78,654 patient-years of follow-up). First-year cumulative incidence of recurrent ICH ranged from 1.5% (95% confidence interval 0.9–2.3; men 35–54 years) to 2.4% (2.0–2.9; women 75–94 years). Depending on age and sex, 10-year risk of recurrent ICH ranged from 3.7% (2.6–5.1; men 35–54 years) to 8.1% (6.9–9.4; women 55–74 years); ischaemic stroke 2.6% to 7.0%, of all stroke 9.9% to 26.2% and of any vascular event 15.0% to 40.4%. Ten-year mortality ranged from 16.7% (35–54 years) to 90.0% (75–94 years). Relative survival was lower in all age-groups of both sexes, ranging from 0.83 (0.80–0.87) in 35- to 54-year-old men to 0.28 (0.24–0.32) in 75- to 94-year-old women.DiscussionICH-survivors are at high risk of recurrent ICH, of ischaemic stroke and other vascular events, and have a sustained reduced survival rate compared to the general population.ConclusionThe high risk of recurrent ICH, other vascular events and prolonged reduced survival-rates warrant clinical trials to determine optimal secondary prevention treatment after ICH.

Population-based stroke surveillance using big data: state-wide epidemiological trends in admissions and mortality in New South Wales, Australia

ABSTRACT Objectives Epidemiological trends for major causes of death and disability, such as stroke, may be monitored using administrative data to guide public health initiatives and service delivery. Methods We calculated admissions rates for ischaemic stroke, intracerebral haemorrhage and subarachnoid haemorrhage between 1 January 2005 and December 31st, 2013 and rates of 30-day mortality and 365-day mortality in 30-day survivors to 31 December 2014 for patients aged 15 years or older from New South Wales, Australia. Annual Average Percentage Change in rates was estimated using negative binomial regression. Results Of 81,703 eligible admissions, 64,047 (78.4%) were ischaemic strokes and 13,302 (16.3%) and 4,778 (5.8%) were intracerebral and subarachnoid haemorrhages, respectively. Intracerebral haemorrhage admissions significantly declined by an average of 2.2% annually (95% Confidence Interval = −3.5% to −0.9%) (p < 0.001). Thirty-day mortality rates significantly declined for ischaemic stroke (Average Percentage Change −2.9%, 95% Confidence Interval = −5.2% to −1.0%) (p = 0.004) and subarachnoid haemorrhage (Average Percentage Change = −2.6%, 95% Confidence Interval = −4.8% to −0.2%) (p = 0.04). Mortality at 365-days amongst 30-day survivors of ischaemic stroke and intracerebral haemorrhage was stable over time and increased in subarachnoid haemorrhage (Annual Percentage Change 6.2%, 95% Confidence Interval = −0.1% to 12.8%), although not significantly (p = 0.05). Discussion Improved prevention may have underpinned declining intracerebral haemorrhage rates while survival gains suggest that innovations in care are being successfully translated. Mortality in patients surviving the acute period is unchanged and may be increasing for subarachnoid haemorrhage warranting investment in post-discharge care and secondary prevention.

Association of Stroke Among Adults Aged 18 to 49 Years With Long-term Mortality

Stroke remains the second leading cause of death worldwide. Approximately 10% to 15% of all strokes occur in young adults. Information on prognosis and mortality specifically in young adults is limited. To determine short- and long-term mortality risk after stroke in young adults, according to age, sex, and stroke subtype; time trends in mortality; and causes of death. Registry- and population-based study in the Netherlands of 15 527 patients aged 18 to 49 years with first stroke between 1998 and 2010, and follow-up until January 1, 2017. Patients and outcomes were identified through linkage of the national Hospital Discharge Registry, national Cause of Death Registry, and the Dutch Population Register. First stroke occurring at age 18 to 49 years, documented using International Classification of Diseases, Ninth Revision, and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, codes for ischemic stroke, intracerebral hemorrhage, and stroke not otherwise specified. Primary outcome was all-cause cumulative mortality in 30-day survivors at end of follow-up, stratified by age, sex, and stroke subtype, and compared with all-cause cumulative mortality in the general population. The study population included 15 527 patients with stroke (median age, 44 years [interquartile range, 38-47 years]; 53.3% women). At end of follow-up, a total of 3540 cumulative deaths had occurred, including 1776 deaths within 30 days after stroke and 1764 deaths (23.2%) during a median duration of follow-up of 9.3 years (interquartile range, 5.9-13.1 years). The 15-year mortality in 30-day survivors was 17.0% (95% CI, 16.2%-17.9%). The standardized mortality rate compared with the general population was 5.1 (95% CI, 4.7-5.4) for ischemic stroke (observed mortality rate 12.0/1000 person-years [95% CI, 11.2-12.9/1000 person-years]; expected rate, 2.4/1000 person-years; excess rate, 9.6/1000 person-years) and the standardized mortality rate for intracerebral hemorrhage was 8.4 (95% CI, 7.4-9.3; observed rate, 18.7/1000 person-years [95% CI, 16.7-21.0/1000 person-years]; expected rate, 2.2/1000 person-years; excess rate, 16.4/1000 person-years). Among young adults aged 18 to 49 years in the Netherlands who were 30-day survivors of first stroke, mortality risk compared with the general population remained elevated up to 15 years later.

Epidemiology of heart failure in myocardial infarction treated with primary angioplasty: Analysis of the Codi IAM registry

Introduction and objectivesThe epidemiology of heart failure (HF) that complicates ST-segment elevation myocardial infarction (STEMI) is not well defined. Our aim was to analyze the epidemiology and prognosis of HF that complicates STEMI treated with primary percutaneous coronary intervention (PCI). MethodsMulticentre registry of 14070 patients with STEMI treated with primary PCI from January 2010 to December 2015. ResultsPatients with HF were older, more frequently female, and diabetic and had chronic ischaemic heart disease. Only 10.3% of patients with STEMI treated with primary PCI had HF on admission and the majority of them had the mildest form (Killip–Kimball II 77.8%). HF was associated with high mortality (30-day mortality was 2.9% of patients in Killip–Kimball I, 9.5% of Killip–Kimball II and 17.4% in Killip–Kimball III, P<.005, and 1-year mortality in patients who survived 30 days was 2.9%, 9.3% and 14.3%, P<.005, respectively). Both the presence of Killip–Kimball class II and III were independently associated with 30-day and 1-year mortality in 30-day survivors. Up to 6% and 15% of patients in Killip–Kimball II and III on admission worsened to cardiogenic shock, and the onset of cardiogenic shock during hospitalization was independently associated with mortality at 30-day and 1-year follow-up. ConclusionsHF complicates 10.3% of patients with STEMI treated with primary PCI and it was associated with a higher risk of developing cardiogenic shock and with 30-day and 1-year mortality in 30-day survivors. In this high-risk population, primary PCI and posterior medical treatment should be prioritized to avoid worsening of HF.

Short- and long-term mortality due to sepsis in patients with rheumatoid arthritis.

Severe infections and sepsis are common among patients with rheumatoid arthritis (RA) and are associated with increased morbidity and mortality risks. To determine whether RA is an independent risk factor for short- and long-term mortality in patients admitted to an Intensive Care Unit (ICU) with sepsis. A retrospective age- and sex-matched cohort study, based on data of the SEPSIS-ISR Registry, an ongoing study that collects data on all patients admitted with the diagnosis of sepsis to the ICUs of 7 large hospitals during the period 2002-2012. The primary outcomes of the study were the 30-day and 3-years survival rates. A total of 124 RA patients and 248 non-RA patients (mean age 71 years; 64.5% female) were included. Primary site of infection as well as pathogens distributions were similar between the two groups. Severe sepsis and septic shock were diagnosed in 92% vs. 84% (p = 0.03) and 50% versus 39% (p = 0.06) of the RA patients and non-RA, respectively. 30-day survival rates were similar between groups, whereas 3-year survival rate in 30-day survivors was significantly lower among RA patients (34.9%) compared to non-RA patients (55.7%) (p = 0.01). In multivariate Cox proportional hazards regression, RA was found to be a significant independent risk factor for 3-year mortality in 30-day survivors (hazard ratio 1.63 95% confidence interval 1.03-1.63; p = 0.04). RA is an independent risk factor for 3-year mortality, but not short-term mortality following ICU admission with sepsis.

Three-year mortality in 30-day survivors of critical care with acute kidney injury: data from the prospective observational FINNAKI study.

BackgroundThe role of an episode of acute kidney injury (AKI) in long-term mortality among initial survivors of critical illness is controversial. We aimed to determine whether AKI is independently associated with decreased survival at 3 years among 30-day survivors of intensive care.ResultsWe included 2336 30-day survivors of intensive care enrolled in the FINNAKI study conducted in seventeen medical–surgical ICUs in Finland during a 5-month period in 2011–2012. The incidence of AKI, defined by the Kidney Disease: Improving Global Outcomes criteria, was 34.6%, and 192 (8.3%) commenced RRT. The 3-year mortality among AKI patients was 23.5% (95% CI 20.6–26.4%) compared to 18.9% (17.0–20.9%) of patients without AKI, p = 0.01. However, after adjustments using Cox proportional hazards regression, AKI was not associated with decreased 3-year survival (HR 1.05; CI 95% 0.86–1.27), whereas advanced age, poor pre-morbid functional performance, and presence of several comorbidities were. Additionally, we matched AKI patients to non-AKI patients 1:1 according to age, gender, presence of severe sepsis, and a propensity score to develop AKI. In the well-balanced matched cohort, 3-year mortality among AKI patients was 136 of 662 (20.5%; 17.5–23.6%) and among matched non-AKI patients 143 of 662 (21.6%; 18.5–24.7%), p = 0.687. Neither AKI nor RRT was associated with decreased survival at 3 years in the sensitivity analyses that excluded patients (1) with chronic kidney disease, (2) with AKI not commenced renal replacement therapy (RRT), and (3) with estimated pre-admission creatinine, chronic kidney disease, or AKI stage 1.ConclusionAKI was not an independent risk factor for 3-year mortality among 30-day survivors. Increased 3-year mortality among patients with AKI who survive critical illness may not be related to AKI per se, but rather to advanced age and pre-existing comorbidities.Electronic supplementary materialThe online version of this article (doi:10.1186/s13613-016-0218-5) contains supplementary material, which is available to authorized users.

Prognostic Value of the Age, Creatinine, and Ejection Fraction Score for 1-Year Mortality in 30-Day Survivors Who Underwent Percutaneous Coronary Intervention After Acute Myocardial Infarction

Few simple and effective tools are available for determining the prognosis of 30-day survivors after acute myocardial infarction. We aimed to assess whether the simple age, creatinine, and ejection fraction (ACEF) score could predict 1-year mortality of 12,000 post-myocardial infarction 30-day survivors who underwent percutaneous coronary intervention. The ACEF score was computed as follows: (age/ejection fraction)+1, if the serum creatinine was >2 mg/dl. Accuracy was defined through receiver-operating characteristics analysis and area under the curve (AUC) evaluation. Twelve risk factors were selected and ranked according to their AUC value. Age, ejection fraction, and serum creatinine levels indicated the best AUC value. The ACEF score was significantly higher in the nonsurvivors (1.95±0.82 vs 1.28±0.50; p<0.001) and was an independent predictor of 1-year mortality (adjusted hazard ratio 2.26; p<0.001). The best accuracy was achieved by a prediction model including 12 risk factors (AUC=0.80), but this did not significantly differ compared with the AUC (0.79) of the ACEF score (p=ns). Adjusted hazard ratios for 1-year mortality were 1 (reference), 3.11 (p<0.001), and 10.38 (p<0.001) for the ACEFLOW (ACEF score<1.0), ACEFMID (ACEF score 1.0 to 1.39), and ACEFHIGH (ACEF score≥1.4) groups, respectively. The ACEF score may be a novel valid model to stratify the 1-year mortality risk in 30-day survivors who underwent percutaneous coronary intervention after acute myocardial infarction.

One-year clinical impact of cardiac arrest in patients with first onset acute ST-segment elevation myocardial infarction

BackgroundCardiac arrest complicating acute ST elevation myocardial infarction (STEMI) is known to be associated with increased in-hospital mortality. However, little is known about the long-term outcomes after cardiac arrest complicating first onset STEMI in contemporary percutaneous coronary intervention (PCI) era. MethodsWe analyzed 7942 consecutive patients who were diagnosed with STEMI and had no previous history of MI. They were divided into two groups according to the presence of cardiac arrest (group I, patients with cardiac arrest; n=481, group II, patients without cardiac arrest; n=7641). ResultsIn a stepwise multivariate model, previous history of chronic kidney disease, high serum level of glucose and low high density lipoprotein-cholesterol was an independent predictor of cardiac arrest complicating STEMI. Group I had significantly higher in-hospital mortality (adjusted hazard ratio [HR] 3.06, 95% confidence interval [CI] 2.08–4.51, p<0.001) and 30-day mortality after hospital discharge (adjusted HR 2.92, 95% CI 1.86–4.58, log-rank p<0.001). However, there was no significant increase in mortality beyond 30days (6-month, adjusted HR 1.46, 95% CI 0.45–4.77, log rank p=0.382; 1-year, adjusted HR 1.84, 95% CI 0.83–4.05, log-rank p=0.107). Also, there were no significant differences in 6-month and 1-year major adverse cardiac events in 30-day survivors. Performing PCI was associated with decreased 12-month mortality in 30-day survivors. ConclusionsAlthough patients with cardiac arrest complicating first onset STEMI had higher in-hospital and 30-day mortality after hospital discharge, cardiac arrest itself did not have any residual impact on mortality as well as clinical outcomes.

TCT-252 Prognostic value of ACEF (age, creatinine, ejection fraction) score of one year mortality in 30-day survivors undergoing percutaneous coronary intervention after acute myocardial infarction

Predictors of one year mortality in 30-day survivors after acute myocardial infarction (AMI) has not been elucidated yet. Recently, several studies reported that ACEF (age, creatinine, ejection fraction) score could provide a prognostic information in patients undergoing percutaneous coronary

Influence of hospitalization for cardiovascular versus noncardiovascular reasons on subsequent mortality in patients with chronic heart failure across the spectrum of ejection fraction

Purpose: Noncardiovascular (non-CV) comorbidities may contribute to hospitalizations in patients with heart failure (HF). We examined the incidence of mortality following hospitalization for cardiovascular (CV) versus non-CV reasons in patients with reduced or preserved ejection fraction (EF) in the CHARM Program. Methods: CHARM randomized 7,599 subjects (4576 with EF≤40% and 3023 with EF>40%) with NYHA class II-IV HF and prior history of cardiac hospitalization to treatment with candesartan or placebo. First hospitalizations for CV or non-CV reasons were related to subsequent risk of all-cause death over median 36.6 month follow up using time-updated proportional hazards models. Results: 4792 patients experienced a classifiable incident first hospitalization, including 2806 (58.5%) for CV reasons and 1986 (41.4%) for non-CV reasons, while 2802 were not hospitalized. Rates of CV hospitalization were higher for those with EF≤40% than those with EF>40% (p<0.001), but rates of non-CV hospitalization did not vary by EF (p=0.88, Table). The death rate (per 100-patient years) amongst those not hospitalized was 2.7 compared with 18.3 after CV and 16.2 after non-CV hospitalization (both p<0.001). Mortality at 30-days was higher after CV than non-CV hospitalization (p<0.001, Table). However, amongst 30-day survivors of CV and non-CV hospitalization, rates of subsequent mortality were similar (14.7 vs. 14.3, p=0.62). Low EF patients were at higher risk for mortality than high EF patients after both CV and non-CV hospitalization. (both p<0.001). View this table: Table 1. Incidence of Hospitalization for CV and non-CV Reasons in the CHARM trial and subsequent rates of mortality Conclusions: Non-CV reasons for hospitalization are common in HF patients across the spectrum of EF. Hospitalization for any reason is associated with high risk for subsequent mortality, with higher risk in low than preserved EF patients. Early mortality is higher after CV than non-CV hospitalization, but rates of mortality in 30-day survivors are unrelated to the cause of hospitalization.

Preponderant role of reduced early mortality in the reduction of one-year mortality in STEMI from 1995 to 2010: data from 4 French nationwide surveys over 15 years

Background and aim: Early mortality of STEMI patients has considerably decreased. We used the 1-year follow-up data from 4 nationwide French surveys conducted 5 years apart from 1995 to 2010 to determine whether survival also improved beyond the acute stage. Methods: USIK 1995, USIC 2000, FAST-MI 2005 and FAST-MI 2010 included patients with STEMI <48 hrs from symptom onset, over a 1-month period of time in most French cardiology centres (60 to 80% of all centres taking care of STEMI patients). In all, 6,704 patients participated (1995: 1,536; 2000: 1,841; 2005: 1,611; 2010: 1,716). Results: Mean age (66±14 to 63±15 years) and the overall risk profile of the population decreased. Reperfusion therapy use increased from 49% to 80%, with an increase in primary PCI (12% to 65%). Early use of antiplatelet agents (92 to 97%), LMWH (27% to 62%), beta-blockers (65% to 81%), ACE-I (48 to 60%), statins (10% to 90%), increased. One-year survival increased from 81.5% to 85.8% to 88.6% to 91.8% (adjusted HR, 95% CI for death 2010 vs 1995: 0.45, 0.36-057, P<0.001). This was mostly related to a major decrease in 30-day mortality (13.7% to 4.4%), while one-year mortality in 30-day survivors decreased to a much lesser extent (5.6% to 4.2%, adjusted HR 95% CI: 0.81, 0.56-1.17, P= 0.27) (Figure). Improvement in late mortality was more marked in patients with primary PCI (5.4% to 2.8%) and fibrinolytic therapy (5.4% to 2.2%) while it tended to deteriorate in patients with no reperfusion treatment (7.5% to 9.3%). ![Figure][1] Evolution of 1-year survival in STEMI Conclusion: Improvement in early mortality in STEMI patients is maintained at one year. Beyond the acute phase, however, the gain in survival (-25%) is more limited than the gain achieved in the first month (-65%), in spite of improved use of secondary prevention medications. [1]: pending:yes

Leukoaraiosis is Associated with Short- and Long-term Mortality in Patients with Intracerebral Hemorrhage

There are few recent European studies of mortality after intracerebral hemorrhage (ICH), particularly long-term follow-up studies. No previous European studies have included information on leukoaraiosis. We studied all consecutive patients hospitalized with a first-ever intracerebral hemorrhage between 2005 and 2009 in a well-defined area and assessed the prognostic value of various baseline clinical and radiologic factors. Leukoaraiosis was scored on the baseline computed tomographic (CT) scan as described by van Swieten et al, with an overall score from 0 to 4. One hundred thirty-four patients were followed up for a median of 4.7 years (interquartile range 2.5-6.6). Overall mortality was 23% at 2 days, 30% at 7 days, 37% at 30 days, 46% at 1 year, and 53% at 2 years. Factors independently associated with increased 30-day mortality were warfarin use, leukoaraiosis score, intraventricular hemorrhage, and Glasgow Coma Scale (GCS) score. Factors independently associated with long-term mortality in the 85 patients who survived the first 30 days were leukoaraiosis score, coronary heart disease, and initial GCS score. Recurrent ICH occurred in 4.5% and was significantly more frequent after lobar ICH than after ICH in other locations (11.1% v 0%; P = .025). In unselected patients in Southern Norway with first-ever ICH, severe leukoaraiosis is independently associated with both 30-day and long-term mortality in 30-day survivors. Warfarin is independently associated with 30-day mortality and coronary heart disease with long-term mortality in 30-day survivors. Recurrent ICH is more frequent after lobar ICH than after ICH in other locations.

Predictive Value of Plasma Glucose Level on Admission for Short and Long Term Mortality in Patients With ST-Elevation Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention

Published reports describe a strong association between plasma glucose levels on admission and mortality in patients who undergo primary percutaneous coronary intervention for ST-segment elevation myocardial infarction. The aim of this study was to assess the predictive value of admission glucose levels for early and late mortality. From 2005 to 2007, 1,646 patients underwent primary percutaneous coronary intervention for ST-segment elevation myocardial infarction and were stratified according to admission plasma glucose level in category 1 (<7.8 mmol/L; n = 747), category 2 (7.8 to 11.0 mmol/L; n = 620), or category 3 (>11 mmol/L; n = 279). Event rates were estimated using the Kaplan-Meier method. A landmark survival analysis to 3-year follow-up was performed, with a landmark set at 30 days. Time-extended Cox regression was used to assess the predictive value of admission glucose levels. Furthermore, a stratified analysis was performed for known diabetes mellitus status at admission. Thirty-day mortality was 2.4% in category 1, 6% in category 2, and 22% in category 3 (p <0.01). Three-year mortality in 30-day survivors was 5.9% in category 1, 8.2% in category 2, and 7.1% in category 3 (p = 0.27). Glucose level on admission was a strong predictor of 30-day mortality: for every 1 mmol/L increase, the hazard increased by 14% (hazard ratio 1.14, 95% confidence interval 1.09 to 1.19, p <0.01) in patients without diabetes, by 12% (hazard ratio 1.12, 95% confidence interval 1.05 to 1.19, p <0.01) in those with diabetes, and by 13% (hazard ratio 1.13, 95% confidence interval 1.09 to 1.17, p <0.01) in the total cohort. After 30 days, glucose level at admission lost its predictive value. In conclusion, in patients with and those without diabetes, glucose level at admission is an independent predictor of early but not late mortality.

Prediction of One-Year Survival in High-Risk Patients with Acute Coronary Syndromes: Results from the SYNERGY Trial

Despite advances in pharmacologic therapy and invasive management strategies for patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS), these patients still suffer substantial morbidity and mortality. The objective of this study was to analyze independent predictors of 1-year mortality in patients with high-risk NSTE ACS. A total of 9,978 patients were assigned to receive enoxaparin or unfractionated heparin (UFH) in this prospective, randomized, open-label, international trial. Vital status at 1 year was collected. Univariable and multivariable predictors of 1-year mortality were identified. Three different multivariable regression models were constructed to identify: (1) predictors of 30-day mortality; (2) predictors of 1-year mortality; (3) predictors of 1-year mortality in 30-day survivors. The last model is the focus of this paper. Overall, 9,922 (99.4%) of patients had 1-year follow-up. Of the 56 patients (37 UFH-assigned and 19 enoxaparin-assigned) without 1-year data, 11 patients were excluded because of withdrawal of consent, and 45 could not be located. One-year mortality was 7.5% (7.7% enoxaparin-assigned patients; 7.3% UFH-assigned patients; P = 0.4). In patients surviving 30 days after enrollment, independent predictors of 1-year mortality included factors known at baseline such as increased age, male sex, decreased weight, having ever smoked, decreased creatinine clearance, ST-segment depression, history of diabetes, history of angina, congestive heart failure, coronary artery bypass grafting, increased heart rate, rales, increased hematocrit, lowered hemoglobin, and higher platelet count. Factors predictive of mortality during the hospitalization and 30-day follow-up period were decreased weight at 30 days from baseline, atrial fibrillation, decreased nadir platelet, no use of beta-blockers and statins up to 30 days, and not receiving an intervention (c-index = 0.82). Easily determined baseline clinical characteristics can be used to predict 1-year mortality with reasonable discriminative power. These models corroborate prior work in a contemporary aggressively managed population. A model to predict 1-year mortality in patients surviving at least 30 days may be quite helpful to healthcare providers in setting expectations and goals with patients after ACS.

Stroke subtype and mortality: a follow-up study in 998 patients with a first cerebral infarct

The aim of this article was to study mortality following a first-ever cerebral infarct, accounting for ischemic stroke subtypes (lacunar, cardioembolic, atherothrombotic) and relevant prognostic variables. This study was done from s a hospital-based prospective registry of all patients with a first cerebral infarct, with a high case ascertainment of first and recurrent stroke by CT. We used a cross-sectional follow-up, using standardized methods. Analyses were performed using crude comparison of mortality data and death causes between stroke subtypes. We analyzed 30-day case fatality and 1-year mortality in 30-day survivors by means of logistic regression analysis, and mortality in 1-year survivors by means of Cox proportional hazard modeling. We also constructed Kaplan-Meier survival curves, and used log-rank testing for differences between stroke subtypes. Thirty-day case fatality was 10%, 1-year mortality 15%, and after 1-year mortality 16%. Mean follow-up was 691, SD 521 days. At the end of follow-up 36% of all patients had died. Mortality was at all three time points lowest in lacunar stroke (2, 12, and 14%, respectively), intermediate in atherothrombotic stroke (10, 16, and 15%, respectively), and highest in cardioembolic stroke (23, 22, and 21%, respectively). Death related to recurrent stroke was similar in all three stroke subtypes (13–16%). Although 30-day case fatality rate was low in lacunar stroke, a quarter of lacunar stroke patients had died at the end of follow-up. Diabetes mellitus, age, stroke subtype, and initial stroke severity were independent predictors of 30-day case fatality, but only diabetes and age were consistent independent predictors for later mortality. Recurrent stroke and heart failure were important death causes. Prognosis for (future) death following a first cerebral infarct differs between stroke subtypes; lacunar stroke patients have the lowest mortality. However, lacunar stroke cannot be regarded as a mild stroke type, as after 2 years more than a quarter of such stroke patients had died. Cardioembolic stroke patients have the grimmest prognosis: more than half of them had died within 1.5 years. Better prognosis for long-term survival following stroke may be achieved by therapies which lower the risk of stroke recurrence, provide better treatment of heart failure, or both.

Support for the open-artery hypothesis in survivors of acute myocardial infarction: analysis of 11,228 patients treated with thrombolytic therapy

We examined the possible benefits of achieving and maintaining infarct-related artery patency beyond the time when preservation of left ventricular function would be expected. The open-artery hypothesis suggests that a patent infarct-related artery confers a survival benefit greater than that expected from myocardial salvage alone, which extends beyond the time when preservation of left ventricular function is expected. We examined the survival experience of patients undergoing thrombolysis in the Global Utilization of Streptokinase and TPA for Occluded Arteries (GUSTO-I) trial for whom data on the patency of the infarct artery were available. Univariable analysis was used to determine the unadjusted relations of angiographic variables and revascularization procedures to both 30-day and 1-year mortality in 30-day survivors. Multivariable analysis was used to test for interactions between patency and each characteristic and to adjust both for all other variables and for baseline characteristics known to predict mortality.In both univariable and multivariable analysis, patients with an open rather than a closed infarct-related artery had significantly lower 30-day mortality (p <0.001). This benefit cannot be accounted for by myocardial salvage alone, because it remained after adjustment for left ventricular ejection fraction. Patency was also associated with lower 1-year mortality in 30-day survivors, but not after adjustment for other variables affecting late mortality. Having an open infarct-related artery at the time of first catheterization confers a survival advantage that extends beyond the benefit of myocardial salvage from thrombolytic therapy, and is independent of ejection fraction.