Rate Of Recurrent Events Research Articles

Trends in Recurrent Coronary Heart Disease After Myocardial Infarction Among US Women and Men Between 2008 and 2017.

Rates for recurrent coronary heart disease (CHD) events have declined in the United States. However, few studies have assessed whether this decline has been similar among women and men. Data were used from 770 408 US women and 700 477 US men <65 years of age with commercial health insurance through MarketScan and ≥66 years of age with government health insurance through Medicare who had a myocardial infarction (MI) hospitalization between 2008 and 2017. Women and men were followed up for recurrent MI, recurrent CHD events (ie, recurrent MI or coronary revascularization), heart failure hospitalization, and all-cause mortality (Medicare only) in the 365 days after MI. From 2008 to 2017, age-standardized recurrent MI rates per 1000 person-years decreased from 89.2 to 72.3 in women and from 94.2 to 81.3 in men (multivariable-adjusted P interaction by sex <0.001). Recurrent CHD event rates decreased from 166.3 to 133.3 in women and from 198.1 to 176.8 in men (P interaction <0.001). Heart failure hospitalization rates decreased from 177.4 to 158.1 in women and from 162.9 to 156.1 in men (P interaction=0.001). All-cause mortality rates decreased from 403.2 to 389.5 in women and from 436.1 to 417.9 in men (P interaction=0.82). In 2017, the multivariable-adjusted rate ratios comparing women with men were 0.90 (95% CI, 0.86-0.93) for recurrent MI, 0.80 (95% CI, 0.78-0.82) for recurrent CHD events, 0.99 (95% CI, 0.96-1.01) for heart failure hospitalization, and 0.82 (95% CI, 0.80-0.83) for all-cause mortality. Rates of recurrent MI, recurrent CHD events, heart failure hospitalization, and mortality in the first year after an MI declined considerably between 2008 and 2017 in both men and women, with proportionally greater reductions for women than men. However, rates remain very high, and rates of recurrent MI, recurrent CHD events, and death continue to be higher among men than women.

The preablation monocyte/ high density lipoprotein ratio predicts the late recurrence of paroxysmal atrial fibrillation after radiofrequency ablation

BackgroundThe monocyte/high-density lipoprotein ratio (MHR) has emerged as a promising alternative biomarker in the fields of cardiovascular disease and atrial fibrillation (AF). This retrospective study was aimed to explore the predictive value of the MHR for the late recurrence of AF after radiofrequency ablation.MethodsFrom April 2015 to October 2018, patients with paroxysmal AF who had undergone radiofrequency catheter ablation at Subei People’s Hospital of Jiangsu Province were enrolled in our study. All the participants were observed until November 2019 after the procedure. During the postoperative follow up, the patients were categorized into the recurrence group and maintenance of sinus rhythm group based on who had experienced AF recurrence.ResultsOne hundred twenty-five patients were diagnosed with paroxysmal AF, with an average age of 61.2 ± 9.3 years. Forty-seven patients had developed late recurrence during a mean follow up of 25.1 ± 12.0 months. The AF recurrence event rates were significantly increased in the highest MHR tertile compared with those in the lowest MHR tertile (22.0% vs. 57.1%; P < 0.05). On multivariate logistic regression analysis, the preablation MHR (OR = 1.34; 95% CI = 1.12 ~ 1.60; P = 0.001) and left atrial diameter (LAD) (OR = 1.21, 95% CI = 1.08 ~ 1.35; P = 0.001) were independent risk factors predicting the recurrence of AF after radiofrequency ablation. Furthermore, receiver operating characteristic (ROC) curve analysis revealed that the area under the curve (AUC) of the MHR was 0.712 (95% CI = 0.618 ~ 0.806; P = 0.000) and that of LAD was 0.739 (95% CI = 0.653 ~ 0.814; P = 0.000). Z-test found no significant difference between the MHR and LAD regarding the AUC (Z = 0.451; P = 0.652).ConclusionAn elevated preablation MHR was associated with an increased risk of the postoperative recurrence of AF. Additionally, the MHR independently predicted the late recurrence of paroxysmal AF after radiofrequency ablation, with the same predictive value as LAD.

Return to Play After Medial Patellofemoral Ligament Reconstruction: A Systematic Review

Background: Medial patellofemoral ligament (MPFL) reconstruction is being performed more frequently in athletes experiencing recurrent patellar instability. Purpose/Hypothesis: The purpose was to systematically review the evidence in the orthopaedic sports medicine literature to determine both the rate and timing of return to play after MPFL reconstruction and the rate of further patellar instability. Our hypothesis was that there would be a high rate of return to play after MPFL reconstruction. Study Design: Systematic review. Methods: A systematic literature search was performed based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, which utilized EMBASE, MEDLINE, and the Cochrane Library databases. Inclusion criteria for literature included clinical studies reporting on return to play after MPFL reconstruction. Rate of return to play, level of return, timing of return, rate of recurrent instability, and patient-reported outcomes were evaluated. Statistical analysis was performed using SPSS. Results: Our review found 27 studies including 1278 patients meeting our inclusion criteria. The majority of patients were women (58%), and the total group had a mean age of 22.0 years and a mean follow-up of 39.3 months. The overall rate of return to play was 85.1%, with 68.3% returning to the same level of play. The average time to return to play was 7.0 months postoperatively. The rate of recurrent instability events following reconstruction was 5.4%. There was an improvement in both mean visual analog scale, pain scores (preoperative: 4.3, postoperative: 1.6) and Tegner activity scores (preoperative: 4.8, postoperative: 5.5). Conclusion: The overall rate of return to play was high after MPFL reconstruction for the treatment of recurrent patellar instability. However, a relatively high percentage of those patients were unable to return to their preoperative level of sport. Additionally, there was a moderate time taken to return to play, at approximately 7 months after the procedure.

Coronavirus 2019 Disease (COVID-19), Systemic Inflammation, and Cardiovascular Disease.

Acute respiratory failure associated with the Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2), has rapidly spread worldwide and presents critical challenges for the public health and medical communities The World Health Organization (WHO) has declared SARS-CoV-2 a public health emergency of international concern, with a global estimate of over 7 million human infections and more than 400000 deaths worldwide as of June 12, 2020 A 2020 report by the China Medical Treatment Expert Group for Coronavirus disease 2010 (COVID-19) (2) showed that the clinical spectrum of the viral infection is dominated by fever (up to 88 7% of patients during hospitalization) and cough (67 8% of patients) followed by symptoms such as headache, fatigue, or shortness of breath

Anticoagulation Type and Early Recurrence in Cardioembolic Stroke: The IAC Study.

In patients with acute ischemic stroke and atrial fibrillation, treatment with low molecular weight heparin increases early hemorrhagic risk without reducing early recurrence, and there is limited data comparing warfarin to direct oral anticoagulant (DOAC) therapy. We aim to compare the effects of the treatments above on the risk of 90-day recurrent ischemic events and delayed symptomatic intracranial hemorrhage. We included consecutive patients with acute ischemic stroke and atrial fibrillation from the IAC (Initiation of Anticoagulation after Cardioembolic) stroke study pooling data from stroke registries of 8 comprehensive stroke centers across the United States. We compared recurrent ischemic events and delayed symptomatic intracranial hemorrhage between each of the following groups in separate Cox-regression analyses: (1) DOAC versus warfarin and (2) bridging with heparin/low molecular weight heparin versus no bridging, adjusting for pertinent confounders to test these associations. We identified 1289 patients who met the bridging versus no bridging analysis inclusion criteria and 1251 patients who met the DOAC versus warfarin analysis inclusion criteria. In adjusted Cox-regression models, bridging (versus no bridging) treatment was associated with a high risk of delayed symptomatic intracranial hemorrhage (hazard ratio, 2.74 [95% CI, 1.01-7.42]) but a similar rate of recurrent ischemic events (hazard ratio, 1.23 [95% CI, 0.63-2.40]). Furthermore, DOAC (versus warfarin) treatment was associated with a lower risk of recurrent ischemic events (hazard ratio, 0.51 [95% CI, 0.29-0.87]) but not delayed symptomatic intracranial hemorrhage (hazard ratio, 0.57 [95% CI, 0.22-1.48]). Our study suggests that patients with ischemic stroke and atrial fibrillation would benefit from the initiation of a DOAC without bridging therapy. Due to our study limitations, these findings should be interpreted with caution pending confirmation from large prospective studies.

Anticoagulation Timing in Cardioembolic Stroke and Recurrent Event Risk.

Guidelines recommend initiating anticoagulation within 4 to 14 days after cardioembolic stroke. Data supporting this did not account for key factors potentially affecting the decision to initiate anticoagulation, such as infarct size, hemorrhagic transformation, or high-risk features on echocardiography. We pooled data from stroke registries of 8 comprehensive stroke centers across the United States. We included consecutive patients admitted with ischemic stroke and atrial fibrillation. The primary predictor was timing of initiating anticoagulation (0-3 days, 4-14 days, or >14 days), and outcomes were recurrent stroke/transient ischemic attack/systemic embolism, symptomatic intracerebral hemorrhage (sICH), and major extracranial hemorrhage (ECH) within 90 days. Among 2,084 patients, 1,289 met the inclusion criteria. The combined endpoint occurred in 10.1% (n = 130) subjects (87 ischemic events, 20 sICH, and 29 ECH). Overall, there was no significant difference in the composite endpoint between the 3 groups (0-3 days: 10.3%, 64/617; 4-14 days: 9.7%, 52/535; >14 days: 10.2%, 14/137; p = 0.933). In adjusted models, patients started on anticoagulation between 4 and 14 days did not have a lower rate of sICH (vs 0-3 days; odds ratio [OR] = 1.49, 95% confidence interval [CI] = 0.50-4.43), nor did they have a lower rate of recurrent ischemic events (vs >14 days; OR = 0.76, 95% CI = 0.36-1.62, p = 0.482). In this multicenter real-world cohort, the recommended (4-14 days) time frame to start oral anticoagulation was not associated with reduced ischemic and hemorrhagic outcomes. Randomized trials are required to determine the optimal timing of anticoagulation initiation. ANN NEUROL 2020;88:807-816.

Risk of recurrent venous thromboembolism related to prior risk situations: re-evaluation of a cohort study with a longer follow-up.

: Venous thromboembolism (VTE) is a chronic disease. Strategies to assess groups at a high risk of recurrence are needed. We reported that patients without prior risk situation for VTE had an incidence rate ratio (IRR) three times higher when compared with those with this history. The aim of this study was to re-evaluate the cohort, with a longer follow-up and evaluated the association between the absence of a prior risk situation for VTE with an increased risk for recurrence. A total of 289 patients with a previous VTE were followed for 116 months. Patients were advised to attend the outpatients' clinic in case of suspected VTE recurrence. Incidence rates of recurrent thrombotic events were calculated as the number of events over the accumulated observation time. Recurrent VTE occurred in 52 (18%) patients. Patients with a provoked first event and positive prior risk situations for VTE had an incidence rate for recurrence of 1.2 [95% confidence interval (95% CI), 0.7-1.9] per 100 patient-years. The IRR of this subgroup compared with patients with a provoked event without prior risk situations for VTE was 0.9 (95% CI 0.4-2.4). IRR was 2.5 (95% CI, 1.3-4.9) in patients with an unprovoked event and positive prior risk situations and 5.9 (95% CI, 32.8-12.5) in patients with an unprovoked event and no prior risk situations compared with patients with a provoked event without other prior risk situations for VTE. Exposure to prior risk situations for VTE was a protective factor among those patients whose first VTE event was unprovoked.

EUS-guided gallbladder drainage versus laparoscopic cholecystectomy for acute cholecystitis: a propensity score analysis with 1-year follow-up data

EUS-guided gallbladder drainage (EUS-GBD) is a safe alternative to percutaneous cholecystostomy (PT-GBD) for acute cholecystitis. How the procedure compares with laparoscopic cholecystectomy (LC) is uncertain. The aim of the current study is to compare the outcomes of EUS-GBD with LC for acute cholecystitis. This was propensity score analysis of all patients admitted for acute cholecystitis between 2012 and 2018. Consecutive patients who received EUS-GBD or LC were included. Patients were matched for age, sex, and age-adjusted Charlson score. Outcome measurements included 30-day adverse events, mortality, recurrent cholecystitis, recurrent biliary events, reinterventions, and readmissions. During the study period, 60 patients were selected (30 EUS-GBD vs 30 LC) after propensity score matching. Technical success rates (100% vs 100%), clinical success rates (93.3% vs 100%, P= 1), lengths of hospital stay (6.8 [8.1] vs 5.5 [2.7], P= 1), 30-day adverse events (4 [13.3%] vs 4 [13.3%], P= 1), and mortality rates (2 [6.7%] vs 0 [0%], P= .492) were similar. The rates of recurrent biliary events (3 [10%] vs 3 [10%], P= .784), reinterventions (4 [13.3%] vs 3 [10%], P= 1), and unplanned readmissions (3 [10%] vs 3 [10%], P= .784) in 1 year were also similar. The outcomes of EUS-GBD for acute cholecystitis were comparable with LC with acceptable rates of recurrent acute cholecystitis. These results support the role of EUS-GBD as an alternative to LC in patients who may or may not be surgically fit to undergo definitive cholecystectomy.

729 EUS-GUIDED GALLBLADDER DRAINAGE VERSUS LAPAROSCOPIC CHOLECYSTECTOMY FOR ACUTE CHOLECYSTITIS. A PROPENSITY SCORE ANALYSIS

EUS-guided gallbladder (EUS-GBD) is an effective and safe alternative to percutaneous drainage (PT-GBD) for acute cholecystitis. The procedure has been shown by meta-analysis to be associated with lower rates of post-procedure adverse events, shorter hospital stays, and fewer reinterventions and readmissions. However, how the procedure compares to laparoscopic cholecystectomy is unknown. The aim of the current study is to compare the long-term outcomes of EUS-GBD with laparoscopic cholecystectomy (LC) for acute cholecystitis using propensity score matching. This was retrospective study of all patients admitted for acute cholecystitis between 2012 to 2018 in the Prince of Wales Hospital in Hong Kong. Consecutive patients that received EUS-GBD or LC were included. Since patients that were included for EUS-GBD were at very-high risk for cholecystectomy, to make the two groups more comparable, they were matched for age, sex and age-adjusted charlson score using propensity score matching. Outcome measurements included 30-day adverse events, mortality, recurrent cholecystitis, recurrent biliary events, reinterventions and readmissions. During the study period, a total of 144 patients were identified and after propensity score matching, 62 patients were selected (31 EUS-GBD vs 31 LC). There were no statistically significant differences in the background demographics (Table 1). The technical success rates (100% vs 100%, P = 1), clinical success rates (90.3% vs 100%, P = 0.238) and mean (S.D.) lengths of hospital stays [6.6 (8.0) vs 5.9 (3.5), P = 0.169] were similar between the groups. The 30 adverse events [5 (16.1%) vs 5 (16.1%), P = 1] and mortality rates [3 (9.7%) vs 0 (0%), P = 0.238] were similar. None of the patients in the LC group required conversion to open surgery. The rates of recurrent biliary events [4 (12.9%) vs 3 (9.7%), P = 1], re-interventions [5 (16.1%) vs 3 (9.7%), P = 0.707] and unplanned readmissions [4 (12.9%) vs 3 (9.7%), P = 1] were also similar. Most of the patients with recurrent biliary events were due to common bile duct stones that required ERCP. One patient in the EUS-GBD group had recurrent acute cholecystitis. The duration of follow-up was significantly longer in the EUS-GBD group [561.9 (470.3) vs 278.5 (364.5), P = 0.003]. The outcomes of EUS-GBD for acute cholecystitis were comparable to LC in the longer term with acceptable rates of recurrent acute cholecystitis. This suggests that the procedure can be an alternative to LC in a selected group of surgically fit patients.Figure 1A) X-ray imaging of EUS-GBD after stenting. B) Operative photo of laparoscopic cholecystectomy.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

378-P: Real-Time Inpatient Hypoglycemia Intervention Reduces the Rate of Recurrent Severe Hypoglycemia

Hypoglycemic events are a common inpatient safety issue; over half are preventable. There are no studies of real-time detection/response to prevent recurrence of hypoglycemia. We evaluated the effectiveness of real-time electronic hypoglycemia surveillance program (REHSP) to reduce the rate of recurrent severe hypoglycemic events (RHE) in hospitalized patients. REHSP is driven by a multidisciplinary team of endocrinologists and nurse practitioners who review an electronic database of all inpatient hypoglycemia events in the last 24hrs. Recommendations to reduce RHE are given to primary teams and appropriate response is monitored. We compared recurrence rates of severe hypoglycemia (BG &amp;lt;50 mg/dL) in inpatients with at least one severe hypoglycemic event (index event) 1 year Pre-REHSP vs. 1 year Post-REHSP implementation. RHE were defined as severe hypoglycemia occurring 20 hours and more after the index event (based on CMS criteria). The primary outcomes were rates of RHE and appropriate response by the primary teams. The Table shows that demographic and clinical characteristics were similar in both groups. In the Post-REHSP group the rates of RHE and length of stay declined significantly and the appropriate response of the teams significantly increased. This study highlights the potential of reducing recurrent hypoglycemia through real-time intervention. Disclosure Y. Gorantla: None. S.T. Yap: None. Y. Guerra: None. L. Fogelfeld: Research Support; Self; Bayer Healthcare Pharmaceuticals Inc., Gan &amp; Lee Pharmaceuticals, Gilead Sciences, Inc., Merck &amp; Co., Inc., Sanofi.

1417-P: Lipoprotein(a)-Associated Residual Atherosclerotic Cardiovascular Disease Risk in Patients with Cardiovascular Disease on Statin Therapy by Diabetes Status

Background: The relation between elevated lipoprotein(a) [Lp(a)] and future atherosclerotic cardiovascular disease (ASCVD) in those with vs. without diabetes mellitus (DM) but known cardiovascular disease (CVD) is not clear. We examined recurrent ASCVD event risk by DM status in persons with known CVD on statin therapy. Methods: We studied 1,354 patients with and 2,005 patients without DM, all with prior CVD on statin therapy in the AIM-HIGH cohort. First and total recurrent ASCVD event rates were calculated by Lp(a) levels and the PWP model provided hazard ratios (HRs) for events over a mean follow-up of 3.3 years, adjusted for age, sex, trial treatment, LDL-C, and other risk factors. Results: ASCVD event rates (per 1000 person years) increased with Lp(a) levels ranging from &amp;lt;15 mg/dl to ≥70 mg/dL in non-DM: 39.7 to 74.1 for first and 48.5 to 87.3 for total recurrent events and in DM: 51.1 to 79.5 for first and 69.8 to 100.3 for total recurrent events. The Table shows HRs by Lp(a) categories for first and total recurrent ASCVD events. A higher risk for first recurrent events is noted at lower Lp(a) levels in those with vs. without DM. Conclusions: Higher Lp(a) levels predict residual ASCVD risk. However, ASCVD event risk may occur at lower levels of Lp(a) in those with vs. without DM. Future investigations in larger cohorts are needed to confirm these findings. Disclosure Y. Zhao: None. J.C. Sung: Employee; Self; Novartis Pharmaceuticals Corporation. A. Browne: Employee; Self; Novartis Pharmaceuticals Corporation. N.D. Wong: Advisory Panel; Self; Esperion Therapeutics, Inc. Research Support; Self; Amarin Corporation, Amgen, Boehringer Ingelheim Pharmaceuticals, Inc., Novartis AG, Novo Nordisk Inc. Speaker’s Bureau; Self; Amarin Corporation, Sanofi.

Adherence to and persistence with direct oral anticoagulant therapy among patients with new onset venous thromboembolism receiving extended anticoagulant therapy and followed by a centralized anticoagulation service

BackgroundExtended direct oral anticoagulant (DOAC) therapy may be required for patients with a venous thromboembolism (VTE); thus, DOAC adherence may impact the risk of recurrent VTE or bleeding. Materials and methodsThis was a retrospective cohort study. Adult patients with a VTE who were initiated on a DOAC between January 1, 2010 and December 31, 2017 for a cumulative >90 days of therapy were included. Adherence, measured with the proportion of days covered (PDC), was assessed during the six, 12, and 18 months after initiation. Patients were assigned to PDC ≥ 80% (adherent) or PDC < 80% (non-adherent) groups during the 1- to 6-month follow-up period. Rates of recurrent VTE and hemorrhagic events were compared between the groups. ResultsA total of 305 patients were included. The mean PDC were 96.0% (±8.0%), 94.7% (±8.2%), and 94.4% (±7.7%) during the 6-, 12-, and 18-month follow-ups, respectively, with 17 (5.6%) and 288 (94.4%) patients classified as non-adherent and adherent, respectively. Patients in the non-adherent group were more likely to have had a recurrent VTE during the 1- to 6-month (11.8% vs. 1.0%, p = 0.007) and 1- to 12-month follow-ups (16.6% vs. 3.6%, p = 0.030). There were no statistically significant differences between the groups in the rates of bleeding during any follow-up periods (all p > 0.05). ConclusionsIn patients who had >90 days of initial DOAC therapy, adherence to DOAC therapy was high throughout the 18-month follow-up while DOAC non-adherence (i.e., PDC < 80%) increased the risk of recurrent VTE.

A flexible additive-multiplicative transformation mean model for recurrent event data

Recurrent event data frequently occur in longitudinal studies, and it is often of interest to estimate the effects of covariates on the recurrent event rate. This paper considers a flexible semi-parametric additive-multiplicative transformation mean model for recurrent event data, which includes the multiplicative model and additive transformation model as special cases. The new model is flexible in that they allow for both additive and multiplicative covariates effects, and additive effects are allowed to be time-varying. The estimation of regression parameters in the model is given by using the idea of estimating equations, and the asymptotic properties of the resulting estimators are established. Numerical studies under different settings were conducted for assessing the proposed methodology and an application to a bladder cancer study is illustrated. The results suggest that they work well.

The relation between healthy lifestyle changes and decrease in systemic inflammation in patients with stable cardiovascular disease

Background and aimsPharmacological lowering of inflammation has proven effective in reducing recurrent cardiovascular event rates. Aim of the current study is to evaluate lifestyle changes (smoking cessation, weight loss, physical activity level increase, alcohol moderation, and a summary lifestyle improvement score) in relation to change in plasma C-reactive protein (CRP) concentration in patients with established cardiovascular disease. MethodsIn total, 1794 patients from the UCC-SMART cohort with stable cardiovascular disease and CRP levels ≤10 mg/L, who returned for a follow-up study visit after median 9.9 years (IQR 5.4–10.8), were included. The relation between changes in smoking status, weight, physical activity, alcohol consumption, a summary lifestyle improvement score and change in plasma CRP concentration was evaluated with linear regression analyses. ResultsSmoking cessation was related to a 0.40 mg/L decline in CRP concentration (β-coefficient −0.40; 95%CI -0.73,-0.07). Weight loss (per 1SD = 6.4 kg) and increase in physical activity (per 1 SD = 48 MET hours per week) were related to a decrease in CRP concentration (β-coefficients −0.25; 95%CI -0.33,-0.16 and −0.09; 95%CI -0.17,-0.01 per SD). Change in alcohol consumption was not related to CRP difference. Every point higher in the summary lifestyle improvement score was related to a decrease in CRP concentration of 0.17 mg/L (β-coefficient −0.17; 95%CI -0.26,-0.07). ConclusionsSmoking cessation, increase in physical activity, and weight loss are related to a decrease in CRP concentration in patients with stable cardiovascular disease. Patients with the highest summary lifestyle improvement score have the most decrease in CRP concentration. These results may indicate that healthy lifestyle changes contribute to lowering systemic inflammation, potentially leading to a lower cardiovascular risk in patients with established cardiovascular disease.

Recurrent Stroke Risk in Pilots with Atrial Fibrillation.

INTRODUCTION: Atrial fibrillation (AF) is one of the most common cardiac arrhythmias in the general population and is considered disqualifying aeromedically. This study is a unique examination of significant outcomes in aviators with previous history of both AF and stroke.METHODS: Pilots examined by the FAA between 2002 and 2012 who had had AF at some point during his or her medical history were reviewed, and those with an initial stroke or transient ischemic attack (TIA) during that time period were included in this study. All records were individually reviewed to determine stroke and AF history, medical certification history, and recurrent events. Variables collected included medical and behavior history, stroke type, gender, BMI, medication use, and any cardiovascular or neurological outcomes of interest. Major recurrent events included stroke, TIA, cerebrovascular accident, death, or other major events. These factors were used to calculate CHA₂DS₂-VASc scores.RESULTS: Of the 141 pilots selected for the study, 17.7% experienced a recurrent event. At 6 mo, the recurrent event rate was 5.0%; at 1 yr, 5.8%; at 3 yr 6.9%; and at 5 yr the recurrent event rate was 17.3%. No statistical difference between CHA₂DS₂-VASc scores was found as it pertained to number of recurrent events.DISCUSSION: We found no significant factors predicting risk of recurrent event and lower recurrence rates in pilots than the general population. This suggests CHA₂DS₂-VASc scores are not appropriate risk stratification tools in an aviation population and more research is necessary to determine risk of recurrent events in aviators with atrial fibrillation.Tedford J, Skaggs V, Norris A, Sahiar F, Mathers C. Recurrent stroke risk in pilots with atrial fibrillation. Aerosp Med Hum Perform. 2020; 91(4):352-357.

Abstract TMP54: A VA Observational Study Examining the Benefit of Various Post-Ischemic Stroke/Tia Hypertension Goals in Preventing Recurrent Vascular Events

Introduction: Joint National Committee (JNC)-8 goal blood pressure (BP) recommendation of &lt; 140/90 mmHg has been supplanted by 2017 ACC/AHA goal of &lt; 130/80 mmHg for patients with ischemic stroke/TIA. Understanding the potential benefit in preventing recurrent vascular events for patients reaching ACC/AHA BP goals is necessary to inform clinical care. Methods: This is a retrospective cohort of Veterans with stroke/TIA (N=39,053) who received their longitudinal outpatient primary care within a Veterans Administration Medical Center between 10/2014 and 9/2018. Patients were excluded (n=25,381) if they had missing or physiologically improbable BP values, died, or had less than 1 year of follow-up. Vascular events were defined as cerebrovascular-only, cardiovascular-only, and the composite of each. We calculated average SBP during 90 days after discharge and assessed it in categorical form (≤115 mmHg, 106-115 mmHg, 116-130, mmHg, 131-140 mmHg, and &gt;140 mmHg) and continuous form. Multivariate COX proportional hazard regression was used to examine the relationship between average SBP groups and time to recurrent event 90 days after discharge up to 1 year. In multivariate logistic regression, we used continuous SBP along with its quadratic term to predict 1-year recurrent vascular event rates. Results: A total of 12,337 eligible patients were included in the final analysis. Compared to those with SBP &gt; 140 mmHg, patients reaching ACC/AHA BP goal had significant lower risk of cerebrovascular recurrent events (HR=0.77, 95% CI=0.60-0.99) but not cardiovascular recurrence or both combined. Conclusions: In considering BP reached by 90-days, ACC/AHA BP guidelines showed protective effects on cerebrovascular event recurrence only.

Incidence of thrombotic events and complications associated to inferior vena cava filters in patients with and without anticoagulation therapy.

Anticoagulation is the primary management to prevent venous thromboembolism; inferior vena cava filters (IVCFs) provide a mechanical prophylactic alternative when anticoagulation is contraindicated. The aim of this study was to evaluate in IVCF patients, whether the initiation of anticoagulation therapy is associated with decreased rates of recurrent thrombotic events and device-related complications. This was a retrospective review of patients that underwent insertion of IVCF. Subjects with IVCF were studied in two groups: those initiated on anticoagulation (A) and without anticoagulation (NA). Variables as indications for IVCF, anticoagulation, recurrence of thrombosis, complications, and reinterventions were examined. From April 2007 to March 2014, 54 patients underwent IVCF placement; (61% of females), with mean age of 54 years (standard deviation ± 19). 28 (52%) were initiated on anticoagulation, during a mean follow-up period of 28 months, five experienced recurrent thrombosis and three were on the A group (p=0.5); when comparing patients that developed post-thrombotic syndrome, seven were in the A group and seven in the NA. Two patients with IVC rupture were in the A group (p=0.5), and the only case of IVCF migration occurred in the A group. 11 (20%) patients died from comorbidities nonrelated to the device or procedure (four in the A cohort). Patients with IVCF on anticoagulation have equivalent rates of thrombotic events and device-related complications than those patients NA.

Incidence of thrombotic events and complications associated to inferior vena cava filters in patients with and without anticoagulation therapy.

Anticoagulation is the primary management to prevent venous thromboembolism; inferior vena cava filters (IVCFs) provide a mechanical prophylactic alternative when anticoagulation is contraindicated. The aim of this study was to evaluate in IVCF patients, whether the initiation of anticoagulation therapy is associated with decreased rates of recurrent thrombotic events and device-related complications. This was a retrospective review of patients that underwent insertion of IVCF. Subjects with IVCF were studied in two groups: those initiated on anticoagulation (A) and without anticoagulation (NA). Variables as indications for IVCF, anticoagulation, recurrence of thrombosis, complications, and reinterventions were examined. From April 2007 to March 2014, 54 patients underwent IVCF placement; (61% of females), with mean age of 54 years (standard deviation ± 19). 28 (52%) were initiated on anticoagulation, during a mean follow-up period of 28 months, five experienced recurrent thrombosis and three were on the A group (p=0.5); when comparing patients that developed post-thrombotic syndrome, seven were in the A group and seven in the NA. Two patients with IVC rupture were in the A group (p=0.5), and the only case of IVCF migration occurred in the A group. 11 (20%) patients died from comorbidities nonrelated to the device or procedure (four in the A cohort). Patients with IVCF on anticoagulation have equivalent rates of thrombotic events and device-related complications than those patients NA.

A bivariate joint frailty model with mixture framework for survival analysis of recurrent events with dependent censoring and cure fraction.

In the study of multiple failure time data with recurrent clinical endpoints, the classical independent censoring assumption in survival analysis can be violated when the evolution of the recurrent events is correlated with a censoring mechanism such as death. Moreover, in some situations, a cure fraction appears in the data because a tangible proportion of the study population benefits from treatment and becomes recurrence free and insusceptible to death related to the disease. A bivariate joint frailty mixture cure model is proposed to allow for dependent censoring and cure fraction in recurrent event data. The latency part of the model consists of two intensity functions for the hazard rates of recurrent events and death, wherein a bivariate frailty is introduced by means of the generalized linear mixed model methodology to adjust for dependent censoring. The model allows covariates and frailties in both the incidence and the latency parts, and it further accounts for the possibility of cure after each recurrence. It includes the joint frailty model and other related models as special cases. An expectation-maximization (EM)-type algorithm is developed to provide residual maximum likelihood estimation of model parameters. Through simulation studies, the performance of the model is investigated under different magnitudes of dependent censoring and cure rate. The model is applied to data sets from two colorectal cancer studies to illustrate its practicalvalue.

Safety of direct-acting oral anticoagulants relative to warfarin in a matched cohort of liver transplant recipients.

Despite increasingly widespread utilization of direct-acting oral anticoagulants (DOACs), there remains limited experience with the use of these agents following liver transplantation. We performed a single-center, retrospective review of liver transplant recipients prescribed DOACs or warfarin between January 2014 and January 2018. Patients receiving DOACs were matched with warfarin-treated controls based on discrete clinical parameters and followed from the time of anticoagulant prescription, until treatment discontinuation or study conclusion. The primary endpoint for this review was the incidence of clinically relevant major or non-major bleeding among the treatment groups. Twenty-seven patients prescribed DOACs were identified for inclusion in the review, of which 20 could be matched with suitable warfarin controls. At the conclusion of the study, warfarin-treated patients had a significantly higher incidence of clinically relevant bleeding (45% vs 15%; P=.01). No statistically significant differences were found in the rate of new or recurrent thrombotic events. Multivariable logistic regression demonstrated that warfarin treatment was associated with a significantly higher odds of a bleeding event compared to treatment with a DOAC (OR=6.9; 95% CI, 1.1-44.6). DOAC use appears relatively safe compared with warfarin in select liver transplant recipients. Patient-specific factors still bear consideration when selecting between the various anticoagulant options.