Propensity-matched Studies Research Articles

Transfemoral, transapical and transcatheter aortic valve implantation and surgical aortic valve replacement: a meta-analysis of direct and adjusted indirect comparisons of early and mid-term deaths.

Clinical outcomes of transfemoral-transcatheter aortic valve implantation (TF-TAVI) versus surgical aortic valve replacement (SAVR) or transapical (TA)-TAVI are limited to a few randomized clinical trials (RCTs). Because previous meta-analyses only included a limited number of adjusted studies or several non-adjusted studies, our goal was to compare and summarize the outcomes of TF-TAVI vs SAVR and TF-TAVI vs TA-TAVI exclusively with the RCT and propensity-matched cohort studies with direct and adjusted indirect comparisons to reach more precise conclusions. We hypothesized that TF-TAVI would offer surgical candidates a better outcome compared with SAVR and TA-TAVI because of its potential for fewer myocardial injuries. A literature search was conducted through PUBMED and EMBASE through June 2016. Only RCTs and propensity-matched cohort studies were included. A direct meta-analysis of TF-TAVI vs SAVR, TA-TAVI vs SAVR and TF-TAVI vs TA-TAVI was conducted. Then, the effect size of an indirect meta-analysis was calculated from the direct meta-analysis. The effect sizes of direct and indirect meta-analyses were then combined. A random-effects model was used to calculate the hazards ratio and the odds ratio with 95% confidence intervals. Early (in-hospital or 30 days) and mid-term (≥1 year) all-cause mortality rates were assessed. Our search resulted in 4 RCTs (n = 2319) and 14 propensity-matched cohort (n = 7217) studies with 9536 patients of whom 3471, 1769 and 4296 received TF, TA and SAVR, respectively. Direct meta-analyses and combined direct and indirect meta-analyses of early and mid-term deaths with TF-TAVI and SAVR were similar. Early deaths with TF-TAVI vs TA-TAVI were comparable in direct meta-analyses (odds ratio 0.64, P = 0.35) and direct and indirect meta-analyses combined (odds ratio 0.73, P = 0.24). Mid-term deaths with TF-TAVI vs TA-TAVI were increased (hazard ratio 0.83, P = 0.07) in a direct meta-analysis and became significant after addition of the indirect meta-analysis (hazard ratio 0.78, 95% confidence interval 0.67-0.92, P = 0.003). In conclusion, TF-TAVI was associated with similar early and mid-term deaths compared with SAVR. The number of early deaths was not significantly different between TF-TAVI and TA-TAVI, whereas there were fewer mid-term deaths with TF-TAVI than with TA-TAVI.

Endoscopic versus open radial artery harvesting: A meta-analysis of randomized controlled and propensity matched studies.

We sought to investigate the impact of radial artery harvesting techniques on clinical outcomes using a meta-analytic approach limited to randomized controlled trials and propensity-matched studies for clinical outcomes, in which graft patency was analyzed. A systematic literature review was conducted using PubMed and MEDLINE to identify publications containing comparisons between endoscopic radial artery harvesting (ERAH) and open harvesting (ORAH). Only randomized controlled trials and propensity-matched series were included. Data were extracted and analyzed with RevMan. The primary endpoint was wound complication rate, while secondary endpoints were patency rate, early mortality, and long-term cardiac mortality. Six studies comprising 743 patients were included in the meta-analysis. Of them 324 (43.6%) underwent ERAH and 419 (56.4%) ORAH. ERAH was associated with a lower incidence of wound complications (odds ratio: 0.33, confidence interval 0.14-0.77; p = 0.01). There were no differences in graft patency, and early and long-term cardiac mortality between the two techniques. ERAH reduces wound complications and does not affect graft patency, or short- and long-term mortality compared to ORAH.

Preface to the book This is life: the journey of uniportal VATS

Thoracoscopic lobectomy was introduced without the support of prospective randomized trials; however, the advantages of thoracoscopic lobectomy were demonstrated through multi-institutional and propensity-matched studies, proving the quality of life advantages, safety advantages, and cost advantages, compared to thoracotomy. Prospective randomized trials would now be difficult to complete to due lack of equipoise. Thoracoscopic lobectomy has emerged as the standard of care for early stage lung cancer and is utilized extensively for locally advanced lung cancer in centers of excellence. Throughout the investigation of the potential for thoracoscopic lobectomy to improve outcomes, the focus on technical aspects centered on limiting the size of the access incision, but more importantly, avoiding rib spreading with a retractor. Surgeons may have used 4 ports, or 3 ports or 2 ports, and robotic procedures may have employed with up to 5 ports, but the difference in the number of ports was never considered in assessing outcomes.

Are adjunct subvalvular techniques more effective than isolated restrictive annuloplasty for treating ischemic mitral regurgitation?

This review focused on whether subvalvular techniques are more effective than isolated restrictive annuloplasty in addressing ischemic mitral regurgitation (MR). Searching identified 445 papers and, following a selection process, we ended up with 10 articles. Two were propensity-matched studies, four retrospective and four prospective, non-randomized studies. The end points of interest were late recurrence of MR, other early echocardiographic outcomes of mitral function and early mortality. All studies focusing on echocardiographic measurements showed improved results in the groups where subvalvular repair techniques were used. In almost all studies, the recurrence of MR postoperatively was less when subvalvular techniques were used. No difference in early or in-hospital mortality was demonstrated in all four studies that included comparisons. We conclude that subvalvular techniques in combination with annuloplasty are safe and may better address ischemic MR than the use of annuloplasty ring alone.

Impact of initial dialysis modality on mortality: a propensity-matched study.

BackgroundWhether the choice of dialysis modality in patients with end stage renal disease may impact mortality is undecided. No randomized controlled trial has properly addressed this issue. Propensity-matched observational studies could give important insight into the independent effect of peritoneal (PD) opposed to haemodialysis (HD) on all-cause and cardiovascular mortality.MethodsTo correct for case-mix differences between patients treated with PD and HD, propensity-matched analyses were utilized in all patients who initiated dialysis as first renal replacement therapy in Norway in the period 2005–2012. PD patients were matched in a 1:1 fashion with HD patients, creating 692 pairs of patients with comparable baseline variables. As-treated and intention-to treat analyses were undertaken to assess cardiovascular and all-cause mortality. Interaction analyses were used to assess differences in the relationship between initial dialysis modality and mortality, between strata of age, gender and prevalent diabetes mellitus.ResultsIn the as-treated analyses, initial dialysis modality did not impact 2-year (PD vs. HD: HR 0.87, 95 % CI 0.67–1.12) or 5-year all-cause mortality (HR 0.95, 95 % CI 0.77–1.17). In patients younger than 65 years, PD was superior compared to HD with regard to both 2-year (HR 0.39, 95 % CI 0.19–0.81), and 5-year all-cause mortality (HR 0.49, 95 % CI 0.27–0.89). Cardiovascular mortality was also lower in the younger patients treated with PD (5-year HR 0.38, 95 % CI 0.15–0.96). PD was not associated with impaired prognosis in any of the prespecified subgroups compared to HD. The results were similar in the as-treated and intention-to-treat analyses.ConclusionSurvival in PD was not inferior to HD in any subgroup of patients even after five years of follow-up. In patients below 65 years, PD yielded superior survival rates compared to HD. Increased use of PD as initial dialysis modality in ESRD patients could be encouraged.

Post-cardiac arrest extracorporeal life support.

Sudden cardiac arrest is a complex, life-threatening event involving a multidisciplinary approach. Despite the use of conventional cardiopulmonary resuscitation, survival rate continues to be low for both in-hospital and out-of-hospital cardiac arrest. In refractory cardiac arrest, defined by the absence of return of spontaneous circulation despite resuscitation manoeuvres, mortality approaches 100%. In the last years, an increasing number of case series, and few propensity-matched cohort studies have reported encouraging results on the use of venoarterial extracorporeal membrane oxygenation for refractory cardiac arrest. Extracorporeal circulation ensures an adequate blood flow, to perform diagnostic and therapeutic interventions even before a return of spontaneous circulation is achieved and to rest the heart by unloading the ventricle while ensuring myocardial perfusion after return of spontaneous circulation. This study reviews the rational, indications, evidence and management of extracorporeal support for cardiac arrest.

Safety and efficacy of digoxin: systematic review and meta-analysis of observational and controlled trial data

Objective To clarify the impact of digoxin on death and clinical outcomes across all observational and randomised controlled trials, accounting for study designs and methods.Data sources and study selection Comprehensive...

Incidence of cardiovascular events and gastrointestinal bleeding in patients receiving clopidogrel with and without proton pump inhibitors: an updated meta-analysis

BackgroundDual antiplatelet therapy is the standard of care after coronary stent placement but increases the bleeding risk. The effects of proton pump inhibitors (PPIs) on clopidogrel metabolism have been described,...

Venoarterial Extracorporeal Membrane Oxygenation in Adults With Cardiac Arrest.

Cardiac arrest (CA) is a major cause of morbidity and mortality worldwide. Despite the use of conventional cardiopulmonary resuscitation (CPR), rates of return of spontaneous circulation and survival with minimal neurologic impairment remain low. Utilization of venoarterial extracorporeal membrane oxygenation (ECMO) for CA in adults is steadily increasing. Propensity-matched cohort studies have reported outcomes associated with ECMO use to be superior to that of conventional CPR alone in in-hospital patients with CA. In this review, we discuss the mechanism, indications, complications, and evidence for ECMO in CA in adults.

Lobectomy by Video-Assisted Thoracic Surgery vs Muscle-Sparing Thoracotomy for Stage I Lung Cancer: A Critical Evaluation of Short- and Long-Term Outcomes

Propensity-matched studies have shown lobectomy by VATS to be superior to thoracotomy. However, these studies do not control for institution or surgeon expertise and do not compare VATS strictly with muscle-sparing thoracotomy (MST). From a single surgeon experienced in both VATS and MST, patients undergoing lobectomy for clinical stage I non-small cell cancer were evaluated. Video-assisted thoracic surgery was chosen if the patient requested this approach, otherwise MST was used. Short-term and long-term outcomes were compared. From 2007 to 2012, two hundred and ninety-eight patients were evaluated, 74 (25%) VATS and 224 (75%) MST. There were no statistically significant differences in demographics, chest tube days, and postoperative complications between the 2 surgical groups. Operative time was longer for VATS (median 130 minutes for VATS vs 90 minutes for MST; p<0.001). Hospital length of stay was longer for MST (median 4.5 days for VATS vs 5 days for MST; p=0.007). There was no difference in disease-free survival (5-year: 76% for VATS vs 78% for MST; p=0.446) and overall survival (5-year: 80% for VATS vs 79% for MST; p=0.840) for clinical stage I disease. Results were unchanged using propensity score matching of 60 VATS and 60 MST patients for postoperative complications, disease-free survival, and overall survival between the 2 matched groups. Our current comparison of VATS vs MST, from a single surgeon experienced with both approaches, found operative time (favoring MST) and hospital days (favoring VATS) to be the only difference between the 2 groups; and major outcomes, such as postoperative complications, disease-free survival, and overall survival, were not different. A multi-institution randomized trial should be considered before deeming any one approach to be superior.

Conventional versus minimally invasive aortic valve replacement: pooled analysis of propensity-matched data.

Minimally invasive aortic valve replacement (mAVR) is increasingly preferred over conventional AVR (cAVR). However, data comparing these procedures present conflicting results. Hence, we conducted a systematic review and meta-analysis comparing clinical results in these cohorts. Only randomized controlled trials (RCT) and propensity-matched observational studies (POS) (1998-2013) comparing clinical outcome of patients subjected to mAVR or cAVR were pooled. Continuous data was compared using mean/standardized mean difference (MD/SMD) while categorical results were pooled to obtain an odds ratio (OR) with a 95% confidence interval. A total of 18 studies (6 RCT and 12 POS) (1973 mAVR patients; 2697 cAVR patients) were analyzed. The mean ischemic time was significantly longer with mAVR (MD 9.42 minutes [4.25-14.59]; p < 0.01). However, early mortality (mAVR [1.8%] and cAVR [3%]) was comparable (OR 0.70 [0.46-1.06]; p = 0.09). Postoperative ventilation time was slightly shorter after mAVR (7.5 vs 11.1 hours; p = 0.07), and hospital discharge was earlier after mAVR (MD -1.05 [-1.64 to -0.46]; p < 0.01). However, mAVR failed to reduce transfusion requirement (OR 0.77 [0.51-1.14]; p = 0.19) or pain scores (SMD -0.25 [-0.65 to 0.13]; p = 0.20). Postoperative atrial fibrillation (p = 0.67) and stroke (p = 0.79) rates were comparable. Pooled rate of conversion to full sternotomy was 2.5%. Cosmetic satisfaction could not be pooled due to reporting heterogeneity. Minimally invasive aortic valve replacement can be performed safely despite the longer ischemic time. While minimally invasive surgery does demonstrate some advantages in postoperative recovery, we failed to find any other substantial improvement in outcome over conventional aortic valve replacement.

Invited Commentary

This report by Chaudhry and colleagues [1] compares results of off-pump coronary artery bypass grafting (OPCAB) with those of on-pump coronary artery bypass grafting (ONCAB), including midterm and long-term survival rates and major adverse cardiac and cerebrovascular events, by performing a meta-analysis on 52,783 patients in 32 studies. The authors conclude that midterm mortality and morbidity are comparable between OPCAB and ONCAB. However, long-term survival is improved in ONCAB compared with OPCAB, although this is not evident when analyzing only randomized controlled trials and propensity-matched studies.

Off-Pump Versus On-Pump Coronary Revascularization: Meta-Analysis of Mid- and Long-Term Outcomes

Early outcomes for off-pump coronary artery bypass grafting (OPCAB) have been extensively compared with on-pump coronary revascularization (ONCAB); however, the long-term effects of OPCAB continue to be debated. This study aims to compare the mid-term (>1year; ≤5 years) and long-term (>5 years) survival and major adverse cardiovascular and cerebrovascular events of OPCAB versus ONCAB. A systematic search identified 32 studies meeting our inclusion criteria. These were analyzed using random effects modeling, with subgroup evaluation according to study type. Primary outcomes were mid- and long-term survival over a follow-up period greater than 1 year. Secondary outcomes were mid- and long-term events including repeat revascularization, myocardial infarction, angina, heart failure, and cerebrovascular accidents. Off-pump coronary artery bypass grafting confers similar overall mid-term survival when compared with ONCAB (hazard ratio, 1.06; 95% confidence interval, 0.95 to 1.19; p=0.31). On-pump coronary artery bypass grafting was associated with a significant trend towards a long-term survival advantage (hazard ratio, 1.06; 95% confidence interval, 1.00 to 1.13; p=0.05); however, this was no longer present when subgroup analysis of only randomized controlled trials, registry-based studies, and propensity-matched studies was performed. There was an increase in angina recurrence among two studies after OPCAB, but no difference was seen in 11 other studies reporting data as odds ratio. No significant differences were observed in other secondary outcomes. This analysis demonstrates comparable mid-term mortality and mid- to long-term morbidity between OPCAB and ONCAB. On-pump coronary artery bypass grafting may be associated with improved long-term survival when all study types are analyzed; however, analysis of only randomized controlled trials and propensity-matched studies demonstrates comparable long-term mortality between OPCAB and ONCAB.

Should chloride-rich crystalloids remain the mainstay of fluid resuscitation to prevent ‘pre-renal’ acute kidney injury?: con

The high chloride content of 0.9% saline leads to adverse pathophysiological effects in both animals and healthy human volunteers, changes not seen after balanced crystalloids. Small randomized trials confirm that the hyperchloremic acidosis induced by saline also occurs in patients, but no clinical outcome benefit was demonstrable when compared with balanced crystalloids, perhaps due to a type II error. A strong signal is emerging from recent large propensity-matched and cohort studies for the adverse effects that 0.9% saline has on the clinical outcome in surgical and critically ill patients when compared with balanced crystalloids. Major complications are the increased incidence of acute kidney injury and the need for renal replacement therapy, and that pathological hyperchloremia may increase postoperative mortality. However, there are no large-scale randomized trials comparing 0.9% saline with balanced crystalloids. Some balanced crystalloids are hypo-osmolar and may not be suitable for neurosurgical patients because of their propensity to cause brain edema. Saline may be the solution of choice used for the resuscitation of patients with alkalosis and hypochloremia. Nevertheless, there is evidence to suggest that balanced crystalloids cause less detriment to renal function than 0.9% saline, with perhaps better clinical outcome. Hence, we argue that chloride-rich crystalloids such as 0.9% saline should be replaced with balanced crystalloids as the mainstay of fluid resuscitation to prevent ‘pre-renal' acute kidney injury.

Methylene Blue: Between Scylla (Meta-Analysis) and Charybdis (Propensity)

Methylene Blue: Between Scylla (Meta-Analysis) and Charybdis (Propensity)

Intravascular Ultrasound-Guided Implantation of Drug-Eluting Stents to Improve Outcome: A Meta-Analysis

The aim of this study was to systematically review and perform a meta-analysis of randomized trials and observational studies of intravascular ultrasound (IVUS)-guided versus angiography-guided implantation of drug-eluting stents (DES). Although studies in the bare-metal stents era suggested that there were clinical benefits to IVUS guidance, it is still controversial whether percutaneous coronary intervention (PCI) with DES guided by IVUS leads to better clinical outcomes. Relevant studies published through March 31, 2013, were searched for and identified in the electronic databases. Summary estimates were obtained using a random-effects model. From 138 initial citations, 3 randomized trials and 12 observational studies with 24,849 patients (11,793 IVUS-guided and 13,056 angiography-guided) were included in this study. Comparison of IVUS- versus angiography-guided PCI disclosed odds ratios (ORs) for major adverse cardiac events of 0.79 (95% confidence interval [CI]: 0.69 to 0.91; p= 0.001). IVUS-guided PCI was also associated with significantly lower rates of all-cause mortality (OR: 0.64; 95% CI: 0.51 to 0.81; p< 0.001), myocardial infarction (OR: 0.57; 95% CI: 0.42 to 0.78; p < 0.001), target vessel revascularization (OR: 0.81; 95% CI: 0.68 to 0.95; p= 0.01), and stent thrombosis (OR: 0.59; 95% CI: 0.42 to 0.82; p= 0.002). Ameta-analysis of propensity-matched studies demonstrated similar results in terms of clinical outcomes, but not repeat revascularization. IVUS-guided DES implantation is associated with significantly lower rates of adverse clinical events compared with angiography guidance. Further study is needed to clarify which subgroups of subjects with IVUS guidance will have greater benefit.

Total arterial coronary revascularization

Arterial coronary grafts can be used in the majority of patients and have better patencies than saphenous vein grafts (SVGs), resulting in excellent perioperative and superior long-term outcomes. Barriers to their extensive use include potential for trauma and spasm, extra-operating time, unfamiliarity, concerns over hypoperfusion and deep sternal wound infection in patients in whom bilateral internal thoracic arteries are used-especially diabetics. This presentation addresses these concerns with particular attention to the radial artery, and skeletonized right internal thoracic artery harvest and construction of the proximal anastomoses of these grafts to the ascending thoracic aorta. The facile handling of these grafts and techniques identical to SVG grafting are emphasized. Avoidance of competitive flow and the importance of spasm prophylaxis cannot be overstated. Arterial grafts have patencies >90% at 10 years (SVG 50-60% at 10 years) and once functioning normally, remain free of atheroma. Long-term results are excellent, especially freedom from recurrent cardiac events and reoperations, even in patients with significant preoperative comorbidities such as diabetes and renal dysfunction. Depending on age, long-term survival is between 85 and 90% at 10 years and 75 and 80% at 15 years, and is always better than for one arterial graft plus SVG in all long-term risk-adjusted or propensity-matched studies.

Comparison of intravascular ultrasound versus angiography-guided drug-eluting stent implantation: a meta-analysis of one randomised trial and ten observational studies involving 19,619 patients

The impact of intravascular ultrasound (IVUS) guided coronary drug-eluting stent (DES) implantation on clinical outcomes remains controversial. A meta-analysis of the currently available clinical trials investigating IVUS-guided DES implantation was undertaken. We searched Medline, the Cochrane Library and other internet sources, without language or date restrictions, for published articles comparing clinical outcomes between IVUS-guided and angiography-guided DES implantation. Clinical studies with both adjusted and unadjusted data were included. Eleven studies were identified (one randomised controlled trial and 10 registries) and included in the meta-analysis with a weighted follow-up time of 20.7±11.5 months. Compared with angiography guidance, IVUS-guided DES implantation was associated with a reduced incidence of death (hazard ratio [HR]: 0.59, 95% confidence interval [CI]: 0.48-0.73, p<0.001), major adverse cardiac events (HR: 0.87, 95% CI: 0.78-0.96, p=0.008) and stent thrombosis (HR: 0.58, 95% CI: 0.44-0.77, p<0.001). The incidence of myocardial infarction (HR: 0.82, 95% CI: 0.63-1.06, p=0.126), target lesion (HR: 0.90, 95% CI: 0.73-1.11, p=0.316) and target vessel (HR: 0.90, 95% CI: 0.77-1.05, p=0.195) revascularisation was comparable between the angiography and IVUS-guided arms. A repeat meta-analysis of propensity-matched studies only (six studies, n=5,300) yielded broadly similar results in terms of clinical outcomes. IVUS-guided coronary DES implantation is associated with a significant reduction in death, MACE and stent thrombosis compared to angiography guidance. Appropriately powered randomised trials are necessary to confirm the findings from this meta-analysis.

Abstract 8493: Lack of Association between Discharge Prescription of Aldosterone Antagonists and Outcomes in Medicare Beneficiaries with Heart Failure and Preserved Ejection Fraction: A Propensity-Matched Study of the OPTIMIZE-HF

Background: Aldosterone antagonists reduce mortality in systolic heart failure (HF). However, their effect in HF patients with preserved ejection fraction (HF-PEF) remains unclear. Propensity-matched studies can assemble balanced cohorts while remaining blinded to outcomes, and are suitable when RCTs are difficult or unethical. We examined the association of aldosterone antagonist with outcomes in a propensity-matched cohort of older HF-PEF patients. Methods: Of the 26,376 OPTIMIZE-HF (Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure) patients linked to Medicare outcomes data (through Dec 2008), 10429 patients age ≥65 years with HF-PEF (LVEF ≥40%) were discharged alive. Of these, 866 (8.3%) received a discharge prescription for aldosterone antagonists. Propensity scores for aldosterone antagonist use, estimated for each of the 10429 patients, were used to assemble a cohort of 864 pairs of patients receiving and not receiving these drugs who were balanced on 116 baseline characteristics. Results: Patients (n=1728) had a mean (±SD) age of 80 (±8) years, a mean (±SD) LVEF of 54% (±9%), 63% were women, and 8% African American. During ∼6 years of follow-up, all-cause mortality occurred in 71% and 70% of matched patients receiving and not receiving aldosterone antagonists (hazard ratio, 1.01; 95% CI, 0.90-1.24; p=0.929; Figure). A similar propensity-adjusted association was observed in the 10429 pre-match patients (hazard ratio, 0.99; 95% CI, 0.91-1.08; p=0.800). Aldosterone antagonist use also had no significant association with HF or all-cause hospitalization. Conclusions: Discharge prescription of aldosterone antagonists had no association with mortality or hospitalization in a propensity-matched balanced cohort of older HF-PEF patients. Whether these results differ from younger RCT-eligible patients will await results of the ongoing TOPCAT trial.

Effects of Peripheral Arterial Disease on Outcomes in Advanced Chronic Systolic Heart Failure

Background— The effect of peripheral arterial disease (PAD) on outcomes in patients with chronic heart failure (HF) has not been examined in propensity-matched studies. Methods and Results— Of the 2689 patients with advanced chronic systolic HF in the Beta-Blocker Evaluation of Survival Trial, 441 had a history of PAD. Propensity scores for a history of PAD, calculated for each patient using a multivariable logistic regression model, were used to assemble a matched cohort of 299 and 1015 patients, respectively, with and without PAD who were well balanced on 65 measured baseline characteristics. Cox regression models were used to estimate hazard ratios and 95% CIs for associations between PAD and outcomes during 4.1 years of follow-up. Patients had a mean age of 63±11 years, 19% were women, and 19% were black. All-cause mortality occurred in 43% and 33% of patients with and without a history of PAD, respectively (hazard ratio when PAD was compared with no history of PAD, 1.40; 95% CI, 1.14 to 1.72; P =0.001). All-cause hospitalization occurred in 75% and 63% of patients with and without PAD, respectively (hazard ratio when PAD was compared with no history of PAD, 1.36; 95% CI, 1.16 to 1.58; P &lt;0.0001). PAD-associated hazard ratios for cardiovascular mortality, HF mortality, and HF hospitalization were 1.31 (95% CI, 1.04 to 1.63; P =0.019), 1.40 (95% CI, 0.97 to 2.02; P =0.076), and 1.05 (95% CI, 0.86 to 1.29; P =0.635), respectively. Conclusions— In a well-balanced propensity-matched population of chronic systolic HF patients, a history of PAD was independently associated with increased mortality and hospitalization.