Significant Reduction In All-cause Mortality Research Articles

Increased short- and long-term mortality in 8146 hospitalised peptic ulcer patients.

Incidence and complications of peptic ulcer disease (PUD) have declined, but mortality from peptic ulcer bleeding has remained unchanged. The few recent studies on mortality associated with both uncomplicated and complicated patients with peptic ulcer disease provide contradictory results. To evaluate short- and long-term mortality, and the main causes of death in peptic ulcer disease. In this retrospective epidemiologic cohort study, register data on 8146 adult patients hospitalised with peptic ulcer disease during 2000-2008 were collected in the capital region of Finland. All were followed in the National Cause of Death Register until the end of 2009. The data were linked with the nationwide Drug Purchase Register of the Finnish Social Insurance Institution. Mean follow-up time was 4.9 years. Overall mortality was substantially increased, standardised mortality ratio 2.53 (95% CI: 2.44-2.63); 3.7% died within 30 days, and 11.8% within 1 year. At 6 months, the survival of patients with perforated or bleeding ulcer was lower compared to those with uncomplicated ulcer; hazard ratios were 2.06 (1.68-2.04) and 1.32 (1.11-1.58), respectively. For perforated duodenal ulcers, both the short- and long-term survival was significantly impaired in women. The main causes of mortality at 1 year were malignancies and cardiovascular diseases. Previous use of statins was associated with significant reduction in all-cause mortality. One-year mortality in patients hospitalised with peptic ulcer disease remained high with no change. This peptic ulcer disease cohort had a clearly decreased survival rate up to 10 years, especially among women with a perforated duodenal ulcer, most likely explained by poorer survival due to underlying comorbidity.

Safety and efficacy of oral factor-Xa inhibitors versus Vitamin K antagonist in patients with non-valvular atrial fibrillation: Meta-analysis of phase II and III randomized controlled trials

BackgroundAim of our study was to assess the safety and efficacy on factor-Xa inhibitors (FXIs) in patients with non-valvular atrial fibrillation (NVAF) as compared to Vitamin K antagonist (VKA). MethodsPhase II and III randomized controlled trials that reported clinical safety and efficacy of FXI in patients with NVAF were identified from MEDLINE, Embase, and Cochrane Central Register of Controlled Trials through December 10, 2015. The primary safety outcome of our study was composite of stroke and systemic embolic event. Secondary outcomes studied were individual endpoints of primary safety outcome, major bleeding, clinically relevant non-major bleed (CRNMB), and all-cause mortality. ResultsWe included 11 RCTs with a total of 59,164 participants, of which 34,231 patients received oral FXI and 24,933 patients were on VKA with a mean follow-up of 369days. There was a significant reduction in primary outcome with FXI compared to VKA, 1,112 (3.4%) versus 816 (3.6%) events, respectively (OR 0.82; 95% CI 0.68–0.99). Use of FXI significantly reduced major bleeding events compared to VKA, OR 0.74, 95% CI 0.58–0.96, test for heterogeneity (I2=74%). Incidence of CRNMB was not different between FXI and VKA groups, OR 0.84, 95% CI 0.68–1.04. There was a significant reduction in all-cause mortality in FXI group compared to VKA group, OR 0.88, 95% CI 0.83–0.94 with no significant heterogeneity. ConclusionUse of FXI was associated with a significant reduction in major bleeding events and all-cause mortality without increased risk of stroke or SEE compared to VKA.

Tumor-Infiltrating Lymphocytes, Crohn's-Like Lymphoid Reaction, and Survival From Colorectal Cancer.

While clinical outcomes from colorectal cancer (CRC) are influenced by stage at diagnosis and treatment, mounting evidence suggests that an enhanced lymphocytic reaction to a tumor may also be an informative prognostic indicator. The roles of intratumoral T lymphocyte infiltration (TIL), peritumoral Crohn's-like lymphoid reaction (CLR), microsatellite instability (MSI), and clinicopathological characteristics in survival from CRC were examined using 2369 incident CRCs from a population-based case-control study in northern Israel. Cox proportional hazards regression was used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for CRC-specific and all-cause mortality in multivariable models adjusted for age, sex, ethnicity, grade, stage, and MSI. All statistical tests were two-sided. Tumors with TIL/high-powered field (HPF) of 2 or greater were associated with a statistically significant increase in CRC-specific (P < .001) and overall survival (P < .001) compared with tumors with TIL/HPF of less than 2. Similarly, tumors with a prominent CLR experienced better CRC-specific (P < .001) and overall survival (P < .001) as compared with those with no response. High TILs (HR = 0.76, 95% CI = 0.64 to 0.89, P < .001) and a prominent CLR (HR = 0.71, 95% CI = 0.62 to 0.80, P < .001), but not MSI, were associated with a statistically significant reduction in all-cause mortality after adjustment for established prognostic factors. TILs and CLR are both prognostic indicators for CRC after adjusting for traditional prognostic indicators.

The impact of oophorectomy on survival after breast cancer in BRCA1-positive breast cancer patients.

The aim of the study is to identify treatments which predict survival for women with a BRCA1 mutation, including oophorectomy and chemotherapy. 476 women with stage I to stage III breast cancer who carried a BRCA1 mutation were followed from diagnosis until April 2015. Information on treatment was obtained from chart review and patient questionnaires. Dates of death were obtained from the Poland vital statistics registry. Survival curves were compared for different subgroups according to treatment received. Predictors of overall survival were determined using the Cox proportional hazards model. The ten-year overall survival was 78.3% (95% CI 74.2-82.6%) and the ten-year breast cancer-specific survival was 84.2% (95% CI 80.5-88.0%). Sixty-two patients died of breast cancer, 14 patients died of ovarian cancer, and 2 patients died of peritoneal cancer. Oophorectomy was associated with a significant reduction in all-cause mortality in the entire cohort (adjusted HR=0.41; 95% CI 0.24-0.69; p=0.0008) and in breast cancer-specific mortality among ER-negative breast cancer patients (HR=0.44; 95% CI 0.22-0.89; p=0.02). Among women with breast cancer and a BRCA1 mutation, survival is greatly improved by oophorectomy due to the prevention of deaths from both breast and ovarian cancer.

Extended anticoagulation and mortality in venous thromboembolism. A meta-analysis of six randomized trials

Data on all-cause mortality in patients with venous thromboembolism (VTE) and prolonged anticoagulation are inconclusive. The aim of this study was to compare the incidence of all-cause mortality in patients with VTE at intermediate risk of recurrence, i.e. without transient risk factors or cancer, exposed to shorter (at least three months) or longer anticoagulation.We did a systematic revue and meta-analysis of randomized clinical trials searching MEDLINE and COCHRANE bibliographic databases. A random-effects model was used to pool study results. I2 testing was used to test for heterogeneity.Six studies (5920 patients) entered in the final analysis. Mean course of anticoagulation was 7.5months in the shorter and 18.6months in the longer treatment arm. Prolonged anticoagulation was associated with a statistically significant reduction in all-cause mortality (RR 0.47, 95% CI 0.29 to 0.75; 0.8% vs 1.8%). Pulmonary embolism-related death was also lowered in the longer anticoagulation arm (RR 0.32, 95% CI 0.12 to 0.83; 0.2% vs 0.6%).Longer compared with shorter anticoagulation significantly reduced all-cause mortality in patients with VTE at intermediate risk of recurrence.

Effect of antiplatelet therapy on mortality and acute lung injury in critically ill patients: A systematic review and meta-analysis.

Aim:Platelet function is intricately linked to the pathophysiology of critical Illness, and some studies have shown that antiplatelet therapy (APT) may decrease mortality and incidence of acute respiratory distress syndrome (ARDS) in these patients. Our objective was to understand the efficacy of APT by conducting a meta-analysis.Materials and Methods:We conducted a meta-analysis using PubMed, Central, Embase, The Cochrane Central Register, the ClinicalTrials.gov Website, and Google Scholar. Studies were included if they investigated critically ill patients receiving antiplatelet therapy and mentioned the outcomes being studied (mortality, duration of hospitalization, ARDS, and need for mechanical ventilation).Results:We found that there was a significant reduction in all-cause mortality in patients on APT compared to control (odds ratio [OR]: 0.83; 95% confidence interval [CI]: 0.70–0.97). Both the incidence of acute lung injury/ARDS (OR: 0.67; 95% CI: 0.57–0.78) and need for mechanical ventilation (OR: 0.74; 95% CI: 0.60–0.91) were lower in the antiplatelet group. No significant difference in duration of hospitalization was observed between the two groups (standardized mean difference: −0.02; 95% CI: −0.11–0.07).Conclusion:Our meta-analysis suggests that critically ill patients who are on APT have an improved survival, decreased incidence of ARDS, and decreased need for mechanical ventilation.

Abstract 16704: Role of Statins in Heart Transplant Recipients: A Meta-analysis

Introduction: Statins, through their immunomodulatory effects, may prevent cardiac allograft dysfunction in heart transplant recipients. Current International Society of Heart and Lung Transplantation (ISHLT) guidelines recommend the use of statins in these patients. Though several studies have demonstrated significant survival benefit with statin use, a pooled analysis evaluating the role of statins in heart transplant recipients has not been performed to date. We conducted a meta-analysis to study the effect of statins on outcomes in heart transplant recipients. Methods: We searched PubMed for all published studies comparing statins with controls in heart transplant recipients. Outcomes studied included all-cause mortality and hemodynamically significant / fatal rejection. All studies reporting these outcomes were included in the pooled analysis. Random effects model with Mantel-Haenszel method was used to analyze the outcomes. Results: We identified 9 studies (n = 2062) which compared outcomes in heart transplant recipients receiving statins (n = 1449) with that of those not receiving statins (n = 613). Of the 9 studies, 4 were randomized controlled trials and 5 were retrospective studies. There was no heterogeneity across the studies (mortality - I2 = 0%, rejection - I2 = 19%). The use of statins was associated with a significant reduction in all-cause mortality (OR 0.28, 95% CI 0.21-0.37, p &lt; 0.0001). Statins also significantly decreased hemodynamically significant / fatal rejections (OR 0.41, 95% CI 0.25-0.69, p &lt; 0.0001) Conclusion: Statins provide significant survival benefit and reduce cardiac allograft rejection in heart transplant recipients.

Abstract 19486: Does the Association Between Adherence to Statin Medications and Mortality Depend on the Measurement Approach? A Retrospective Cohort Study

Background: Optimal adherence to statin medications is associated with reduced mortality rates. However, it is not clear if the estimated benefits of statin adherence are influenced by the method used to measure adherence. Objective: To contrast the association between all-cause mortality and statin adherence when two different measurement approaches are used: (i.e., fixed summary measurement versus repeated measurement). Methods: A retrospective cohort study was conducted using administrative data from Saskatchewan, Canada between 1994 and 2008. Eligible individuals received a statin prescription following discharge from a hospitalization for acute coronary syndrome (ACS). Adherence was measured using proportion of days covered (PDC) expressed either as: 1) a fixed summary measure, or 2) as a repeatedly measured covariate. Cox proportional hazards models were used to test the association between each adherence measure and mortality after covariate adjustment. Results: Among 9,051 eligible individuals, optimal adherence (≥80%) modeled with a fixed summary measure was not associated with mortality (adjusted HR 0.97, 95% CI 0.86 to 1.09). In contrast, optimal adherence defined by the repeated measures approach was associated with a 25% reduction in the risk of death (adjusted HR 0.75, 95% CI 0.67 to 0.85). Conclusions: Unlike summary measure, the repeated measures approach appears to provide a significant reduction of all-cause mortality of adherence to statins. This effect may be a result of the repeated measures approach being more sensitive, or more prone to survival bias. Therefore, we recommend comparing different measurement approaches whenever possible.

O-050: Incidence of benzodiazepine and related drug use in persons with and without Alzheimer's disease: the MEDALZ study

Results: 3901 patients were included in the study; 74.2% were women. The mean age was 84.6 years. 82.1% and 27.9% received influenza and pneumococcal vaccination, respectively. Overall 727 (20.71%) residents died during the 1 year follow up period. After adjusting for potential confounders, which included age, sex, comorbilities, depression and ADL, both influenza (HR=0.75, 95%CI 0.62– 0.90) and pneumococcal vaccination (HR=0.79, 95%CI 0.67–0.95) were associated with a significant reduction in all cause mortality. Conclusions: In a population of older adult living in nursing home influenza and pneumococcal vaccination were associated with a reduction in all cause mortality.

Normalization of testosterone level is associated with reduced incidence of myocardial infarction and mortality in men.

There is a significant uncertainty regarding the effect of testosterone replacement therapy (TRT) on cardiovascular (CV) outcomes including myocardial infarction (MI) and stroke. The aim of this study was to examine the relationship between normalization of total testosterone (TT) after TRT and CV events as well as all-cause mortality in patients without previous history of MI and stroke. We retrospectively examined 83 010 male veterans with documented low TT levels. The subjects were categorized into (Gp1: TRT with resulting normalization of TT levels), (Gp2: TRT without normalization of TT levels) and (Gp3: Did not receive TRT). By utilizing propensity score-weighted Cox proportional hazard models, the association of TRT with all-cause mortality, MI, stroke, and a composite endpoint was compared between these groups. The all-cause mortality [hazard ratio (HR): 0.44, confidence interval (CI) 0.42-0.46], risk of MI (HR: 0.76, CI 0.63-0.93), and stroke (HR: 0.64, CI 0.43-0.96) were significantly lower in Gp1 (n = 43 931, median age = 66 years, mean follow-up = 6.2 years) vs. Gp3 (n = 13 378, median age = 66 years, mean follow-up = 4.7 years) in propensity-matched cohort. Similarly, the all-cause mortality (HR: 0.53, CI 0.50-0.55), risk of MI (HR: 0.82, CI 0.71-0.95), and stroke (HR: 0.70, CI 0.51-0.96) were significantly lower in Gp1 vs. Gp2 (n = 25 701, median age = 66 years, mean follow-up = 4.6 years). There was no difference in MI or stroke risk between Gp2 and Gp3. In this large observational cohort with extended follow-up, normalization of TT levels after TRT was associated with a significant reduction in all-cause mortality, MI, and stroke.

Impact of advanced age on management and prognosis in atrial fibrillation: insights from a population-based study in general practice.

to examine the use of antithrombotic therapy and predictors of stroke and death in very elderly (≥85 years) atrial fibrillation (AF) patients in a general practice cohort from the UK. retrospective, observational cohort study; 12-month follow-up period. eleven general practices serving the town of Darlington, England representing a population of 105,000 patients. two thousand two hundred and fifty-nine patients with a history of AF, 561 (24.8%) aged ≥85 years. use of antithrombotic therapy by age group and predictors of stroke and death. five hundred and sixty-one (24.8%) AF patients aged ≥85 years (mean (SD) age 89 (4) years; 66% female) identified with a mean CHA2DS2-VASc score of 4.6 (SD 1.4). Thirty-six per cent received oral anticoagulation (OAC) compared with 57% in the 75-84 years age group. Forty-nine per cent of the very elderly received antiplatelet (AP) monotherapy; recorded OAC contraindications and declines were greatest among those aged ≥85 years. Stroke risk was highest among the very elderly (5.2% per annum), despite anticoagulation (3.9%). Multivariate analyses demonstrated an increased risk of stroke with AP monotherapy (odds ratio (OR) 2.45, 95% confidence intervals (CIs) 1.05-5.70) and a significant reduction in all-cause mortality with OAC therapy (OR 0.59, 95% CI 0.36-0.99). the majority of very elderly AF patients in general practice do not receive OAC despite their higher stroke risk; almost half received AP monotherapy. AP use independently increased the risk of stroke, signifying that effective stroke prevention requires OAC regardless of age, except where true contraindications exist.

Is self-monitoring an effective option for people receiving long-term vitamin K antagonist therapy? A systematic review and economic evaluation

ObjectivesTo investigate the clinical and cost-effectiveness of self-monitoring of coagulation status in people receiving long-term vitamin K antagonist therapy compared with standard clinic care.DesignSystematic review of current evidence and economic...

Abstract 354: The Effect Of Early Surgery on Outcomes in Infective Endocarditis- A Meta- Analysis of 25,732 Patients

Despite a rising incidence of infective endocarditis (IE), its associated mortality remains high. It is estimated that at least 30% of patients with IE undergo surgery, however data on outcomes of outcomes associated with timing of surgical intervention in this setting is limited. Existing literature mainly consists of observational studies with conflicting results, and current guidelines (ACC/ AHA and Society of Thoracic Surgeons) base recommendations largely on small retrospective studies and expert opinion. We sought to determine the effect of early surgery on outcomes after IE by performing the first comprehensive meta- analysis on the subject. A comprehensive literature search using PubMed (MEDLINE) was performed using keywords “endocarditis”, “surgery”, “mortality” and “outcome”. Early surgery was defined as surgical intervention performed during index hospitalization. Primary outcome of interest was all-cause mortality. Secondary outcomes included incidence of recurrent endocarditis and embolic phenomenon. Of 117 identified studies, 36 met the inclusion criteria (25,732 patients). Data on baseline characteristics and outcomes of interest were extracted. Meta-analysis was performed using Review Manager Version 5.0 (Cochrane Collaboration). Effect sizes for outcomes of interest were estimated using odds ratio (OR) and 95% confidence intervals (CI). Given the inherent heterogeneity among included studies, results from the random effects model are reported. Of the included 25,732 patients, 7,835 underwent early surgery compared to 17,537 who received conventional treatment. A significant reduction in both, short and long term mortality in patients who underwent early surgery OR 0.58 (95% CI 0.47-0.70; p = &lt;0.001) and OR 0.49 (95% CI 0.37-0.65; p = 0.001) respectively was seen. The incidence of recurrent endocarditis or embolic phenomenon did not differ between the two groups. This is the first comprehensive meta-analysis to examine the impact of early surgery on outcomes in patients with IE. Our results indicate that early surgery is associated with a significant reduction in all-cause mortality in patients with IE, without an increase in incidence of recurrent endocarditis. These findings are of clinical significance given paucity of quality data on the subject.

Bivalirudin Versus Heparin Plus Glycoprotein IIb/IIIa Inhibitors in Patients with Diabetes Mellitus Undergoing Percutaneous Coronary Intervention: A Meta-Analysis of Randomized Controlled Trials.

Diabetes mellitus (DM) is a pro-thrombotic state with enhanced thrombin generation and platelet reactivity. For most patients undergoing percutaneous coronary intervention (PCI), bivalirudin demonstrates efficacy comparable with that of heparin and glycoprotein IIb/IIIa inhibitors (GPIs). Yet, because of their pro-thrombotic condition, we hypothesized that patients with DM may benefit from more aggressive dual antithrombin and antiplatelet therapy. The aim of this paper was to provide a systematic review comparing outcomes of PCI with bivalirudin versus heparin plus GPI in patients with DM using meta-analytical techniques. Eligible studies needed to have reported a subgroup analysis of outcomes among diabetic patients. Six trials comprising 5924 diabetic patients were eligible. At 30 days, bivalirudin was associated with a reduction in net adverse cardiac events [relative risk (RR) 0.81, 95% confidence interval (CI) 0.70-0.93, p=0.002] and major bleeds (RR 0.68, 95% CI 0.49-0.95; p=0.02), with no difference in composite ischemia (RR 0.92, 95% CI 0.74-1.14; p=0.43) or mortality (RR 0.71, 95% CI 0.45-1.13; p=0.15). At 1 year, bivalirudin was associated with a significant reduction in all-cause mortality (RR 0.73, 95% CI 0.54-1.00, p=0.05) despite similar composite ischemia (RR 1.02, 95% CI 0.56-1.21, p=0.811). In conclusion, thrombin inhibition with bivalirudin alone was associated with reduced 30-day major bleeding and 1-year all-cause mortality compared with heparin plus GPI in diabetic patients undergoing PCI.

Meta-Analysis of Randomized Controlled Trials Comparing Multivessel Versus Culprit-Only Revascularization for Patients With ST-Segment Elevation Myocardial Infarction and Multivessel Disease Undergoing Primary Percutaneous Coronary Intervention

Current guidelines recommend against revascularization of the noninfarct artery during the index percutaneous coronary intervention (PCI) in hemodynamically stable patients with ST-segment elevation myocardial infarction (STEMI). This was based largely on observational studies with few data coming from randomized controlled trials (RCTs). Recently, several small-to-moderate sized RCTs have provided data, suggesting that a multivessel revascularization approach may be appropriate. We performed a meta-analysis of RCTs comparing multivessel percutaneous coronary intervention (MV PCI) versus culprit vessel-only revascularization (COR) during primary PCI in patients with STEMI and multivessel coronary disease (MVCD). We searched Medline, PubMed, and Scopus databases for RCTs comparing MV PCI versus COR in patients with STEMI and MVCD. The incidence of all-cause death, cardiac death, recurrent myocardial infarction, and revascularization during follow-up were extracted. Four RCTs fit our primary selection criteria. Among these, 566 patients underwent MV PCI (either at the time of the primary PCI or as a staged procedure) and 478 patients underwent COR. During long-term follow-up (range 1 to 2.5years), combined data indicated a significant reduction inall-cause mortality (relative risk [RR] 0.57, 95% confidence interval [CI] 0.36 to 0.92, p= 0.02) and in cardiac death (RR 0.38, 95% CI 0.20 to 0.73, p= 0.004) with MV PCI. In addition, there was a significantly lower risk of recurrent myocardial infarction (RR 0.41, 95% CI 0.23 to 0.75; p=0.004) and future revascularization (RR 0.37, 95% CI 0.27 to 0.52; p <0.00001). In conclusion, from the RCT data, MV PCI appears to improve outcomes in patients with STEMI and MVCD.

The efficacy and safety of plasma exchange in patients with sepsis and septic shock: a systematic review and meta-analysis.

IntroductionSepsis and septic shock are leading causes of intensive care unit (ICU) mortality. They are characterized by excessive inflammation, upregulation of procoagulant proteins and depletion of natural anticoagulants. Plasma exchange has the potential to improve survival in sepsis by removing inflammatory cytokines and restoring deficient plasma proteins. The objective of this study is to evaluate the efficacy and safety of plasma exchange in patients with sepsis.MethodsWe searched MEDLINE, EMBASE, CENTRAL, Scopus, reference lists of relevant articles, and grey literature for relevant citations. We included randomized controlled trials comparing plasma exchange or plasma filtration with usual care in critically ill patients with sepsis or septic shock. Two reviewers independently identified trials, extracted trial-level data and performed risk of bias assessments using the Cochrane Risk of Bias tool. The primary outcome was all-cause mortality reported at longest follow-up. Meta-analysis was performed using a random-effects model.ResultsOf 1,957 records identified, we included four unique trials enrolling a total of 194 patients (one enrolling adults only, two enrolling children only, one enrolling adults and children). The mean age of adult patients ranged from 38 to 53 years (n = 128) and the mean age of children ranged from 0.9 to 18 years (n = 66). All trials were at unclear to high risk of bias. The use of plasma exchange was not associated with a significant reduction in all-cause mortality (risk ratio (RR) 0.83, 95% confidence interval (CI) 0.45 to 1.52, I2 60%). In adults, plasma exchange was associated with reduced mortality (RR 0.63, 95% CI 0.42 to 0.96; I2 0%), but was not in children (RR 0.96, 95% CI 0.28 to 3.38; I2 60%). None of the trials reported ICU or hospital lengths of stay. Only one trial reported adverse events associated with plasma exchange including six episodes of hypotension and one allergic reaction to fresh frozen plasma.ConclusionsInsufficient evidence exists to recommend plasma exchange as an adjunctive therapy for patients with sepsis or septic shock. Rigorous randomized controlled trials evaluating clinically relevant patient-centered outcomes are required to evaluate the impact of plasma exchange in this condition.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-014-0699-2) contains supplementary material, which is available to authorized users.

Abstract 18567: Impact of Participation in Cardiac Rehabilitation on Long-term Survival after Coronary Artery Bypass Graft Surgery

Background: Although cardiac rehabilitation (CR) is recommended after coronary artery bypass grafting (CABG) surgery, there are still deficient data about the long-term benefit of CR after CABG. Methods: We analyzed a single-center prospective registry, which included patients who had undergone CABG between 2000 and 2011. We evaluated the relationship between participation in CR and long-term survival. We identified 3975 patients (62.4±9.1 years old, 74.3% male) who survived for at least 3 months after surgery. Results: Of these, 2419 (60.9%) participated in phase I of CR while hospitalized, and 383 (9.6%) participated in phase II of CR at an outpatient clinic. During a median follow-up of 6.0 years (IQR, 4.3 to 9.5), the all-cause Kaplan-Meier mortality rate was 28.8% (616 deaths). Based on the propensity score matching method, participation in phase I CR was associated with a 20% relative risk reduction in all-cause mortality (hazard ratio [HR], 0.80; 95% confidence interval [CI], 0.64 to 0.98; p=0.043) and a 40% reduction in all-cause mortality after participation in phase II CR (HR, 0.60; 95% CI, 0.40 to 0.90; p=0.012). After multivariate Cox-proportional analysis, participation in any CR phase was associated with a significant reduction in mortality (HR, 0.77; 95% CI, 0.64 to 0.93; p=0.006 in phase I CR and HR, 0.57; 95% CI, 0.39 to 0.84, p=0.004 in phase II CR). Conclusions: CR participation is associated with a significant reduction in all-cause mortality after CABG. As well as outpatient CR participation, early CR during hospitalization has a beneficial impact in reducing mortality.

ST Elevation Myocardial Infarction After Tranexamic Acid

Antifibrinolytic agents, such as tranexamic acid (TA), aprotinin, and E-aminocaproic acid, have been extensively used in the past 2 decades to prevent blood loss from traumatic or postoperative bleeding. For example, the Clinical Randomization of an Antifibrinolytic in Significant Hemorrhage 2 (CRASH-2) trial demonstrated that there was a significant reduction in all-cause mortality in trauma patients treated with TA (relative risk=0.91, P=0.003) and death due to bleeding (relative risk=0.85, P=0.007). This article reports the case of a 56-year-old woman without any previous cardiac history who was admitted to the hospital for an elective right hip arthroplasty and who received 1 dose of 10 mg/kg of TA. Her immediate postoperative course was complicated by hypotension and chest pain, and an electrocardiogram showed ST segment elevation in the inferior leads. Emergent coronary angiography showed complete occlusion of the distal right coronary artery that was successfully treated with thrombectomy and percutaneous coronary intervention. An extensive literature search showed only 4 cases of myocardial infarction in the setting of TA administration, all of which were outside the United States.

TAVR Suitable Procedure for High-Risk AS Patients: 5-Year Results from the PARTNER Trial

One-, 2-, and 3-year data from the Placement of Aortic Transcatheter Valves study [PARTNER; NCT00530894] showed significant reductions in all-cause mortality, cardiac mortality, and rehospitalization [Kapadia SR et al. Circulation. 2014; Makkar RR et al. N Engl J Med. 2012; Leon MB et al. N Engl J Med. 2010]. This article reports the 5-year outcomes for the PARTNER trial.

Outcomes after first percutaneous coronary intervention for acute myocardial infarction according to patient funding source.

BackgroundDisparities in the use of invasive coronary artery revascularisation procedures to manage acute myocardial infarction (AMI) have been found in several developed economies. Factors such as socio-economic status, income and funding source may influence the use of invasive procedures and have also been associated with ongoing care. The objectives of this study were to determine whether outcomes for patients at one and five years after AMI treated with first-ever percutaneous coronary intervention (PCI) were the same for public and privately funded patients.MethodsRetrospective, population-based cohort study using linked data to identify 30-day survivors of AMI treated with PCI in the index admission between 1995 and 2008 in Western Australian hospitals. The main outcome measures were admission for another PCI, re-AMI, and all-cause and cardiac mortality at one and five years.ResultsAt one year, private patients were at greater adjusted risk for another PCI (HR 1.62 [1.36 – 1.94]; p < 0.001) than public patients, and more likely to have an additional revascularisation procedure from 90 days to 5 years (HR 1.33 [1.11 – 1.58]; p < 0.001). They were at less risk for all-cause death within five years (HR 0.69 [0.62–0.91]; p = 0.01) with a trend to reduced risk for cardiac death and re-AMI.ConclusionsTreatment as a private patient for AMI with first PCI is associated with an increased likelihood of additional coronary revascularisation procedure within 12 months and to five years, and a reduced risk for all-cause mortality to 5 years. While additional procedures were not associated with poorer outcomes, there was no clear relationship between better outcomes and additional procedures. Other lifestyle and health care factors may contribute to the significant reduction in all-cause mortality and the trends to reduced hazard for AMI and cardiac death among private patients.