Prognostic significance of mitral regurgitation in long-term all-cause mortality in patients aged ≥ 80 years with acute coronary syndrome

Background

Mitral regurgitation (MR) has been shown to be associated with a poor prognosis in the patients with acute myocardial infarction, whether or not percutaneous coronary intervention (PCI) is employed. However, the long-term prognostic significance of MR in octogenarian patients with acute coronary syndrome (ACS) remains unknown. We sought to determine the impact of MR on long-term all-cause mortality and to further reveal whether PCI could influence the prognosis in octogenarian MR patients with ACS.

Methods

In this study, we included a total of 353 consecutive hospitalized patients, aged ≥ 80 years, with ACS during the period of 5-year follow-up. Association between MR and long-term all-cause mortality was analyzed both in a overall cohort and in a matched cohort developed from a propensity score analysis.

Results

MR was independently associated with long-term all-cause mortality in the overall and matched cohorts (hazard ratio (HR) 1.58, 95% CI 1.01–2.47, P = 0.043; HR 1.90, 95% CI 1.15–3.13, P = 0.013). In the subgroup treated with PCI, MR also exhibited higher long-term all-cause mortality, PCI remained an independent determinant of improving long-term survival rate by reducing the mortality by 15.1% in ACS patients with MR aged ≥ 80 years.

Conclusions

Our study demonstrates that MR is independently associated with long-term all-cause mortality, and PCI is an independent determinant for improving the long-term survival rate in the octogenarian ACS patients with MR.     

Health-related quality of life predicts unplanned rehospitalization following coronary revascularization

Background

Health-related quality of life (HRQL) is an increasingly well-recognized measure of health outcome in cardiology. We examined HRQL as a predictor of unplanned rehospitalization for cardiac reasons in patients after coronary revascularization over a period of 3 years.

Patients and methods

Out of 791 patients enrolled in the study, 743 completed the MacNew HRQL questionnaire after coronary revascularization. MacNew HRQL scores were used as predictors of unplanned rehospitalization.

Results

Within the 3-year follow-up period, 125 patients (16.8?%) were rehospitalized. After adjustment for age, gender, and myocardial infarction as the initiating event, there were significant differences in unplanned rehospitalization rates between patients with low or moderate vs. high MacNew HRQL global scores (HR: 1.8, 95?% CI: 1.2–2.7) and both physical (HR: 2.2, 95?% CI: 1.4–3.5) and social (HR: 1.8, 95?% CI: 1.2–2.7) subscale scores.

Conclusion

Poor HRQL assessed after coronary revascularization appears to be a powerful predictor of rehospitalization over a 3-year period.

     

Renin–angiotensin system inhibition is not associated with increased sudden cardiac death,cardiovascular mortality or all-cause mortality in patients with aortic stenosis

Background

Renin–angiotensin system inhibition (RASI) is frequently avoided in aortic stenosis (AS) patients because of fear of hypotension. We evaluated if RASI with angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) increased mortality in patients with mild to moderate AS.

Methods

All patients (n = 1873) from the Simvastatin and Ezetimibe in Aortic Stenosis study: asymptomatic patients with AS and preserved left ventricular (LV) ejection fraction were included. Risks of sudden cardiac death (SCD), cardiovascular death and all-cause mortality according to RASI treatment were analyzed by multivariable time-varying Cox models and propensity score matched analyses.

Results

769 (41%) patients received RASI. During a median follow-up of 4.3 ± 0.9 years, 678 patients were categorized as having severe AS, 545 underwent aortic valve replacement, 40 SCDs, 103 cardiovascular and 205 all-cause deaths occurred. RASI was not associated with SCD (HR: 1.19 [95%CI: 0.50–2.83], p = 0.694), cardiovascular (HR: 1.05 [95%CI: 0.62–1.77], p = 0.854) or all-cause mortality (HR: 0.81 [95%CI: 0.55–1.20], p = 0.281). This was confirmed in propensity matched analysis (all p > 0.05). In separate analyses, RASI was associated with larger reduction in systolic blood pressure (p = 0.001) and less progression of LV mass (p = 0.040).

Conclusions

RASI was not associated with SCD, cardiovascular or all-cause mortality in asymptomatic AS patients. However, RASI was associated with a potentially beneficial decrease in blood pressure and reduced LV mass progression.     

Low plasma DHEA-S increases mortality risk among male hemodialysis patients

Objective

The incidence of chronic kidney disease (CKD) is on the rise. CKD patients are at high risk of cardiovascular (CVD) and all-cause mortality. CKD patients have several endocrine disorders, including low levels of dehydroepiandrosterone sulfate (DHEA-S). In the general population, low levels of DHEA-S are associated with high CVD and all-cause mortality. The aim of this study was to analyze the prognostic value of plasma DHEA-S on the survival of CKD patients on hemodialysis.

Method

This was a single-center prospective cohort study on two hundred CKD patients on hemodialysis, which assessed the prognostic value of plasma DHEA-S on their survival.

Result

We found that plasma DHEA-S levels were negatively associated with age, and positively associated with dialysis duration and plasma creatinine, albumin, and phosphate levels in hemodialysis men. Elderly patients with co-morbidities (i.e. diabetes mellitus, congestive heart failure, and chronic obstructive pulmonary disease), poorer fluid control which was evaluated by higher cardiothoracic ratio, and low plasma creatinine and albumin levels seemed to have poor prognosis in hemodialysis men. Furthermore, low plasma DHEA-S levels were significantly associated with CVD-related [hazard ratio (HR) = 3.877; P = 0.021], non-CVD-related (HR = 3.522; P = 0.016), and all-cause mortality (HR = 3.667; P = 0.001) in hemodialysis men. But low plasma DHEA-S levels were not significantly associated with CVD-related, non-CVD-related, and all-cause mortality in hemodialysis women. Multivariate Cox regression analysis suggested that low plasma DHEA-S levels are significantly and independently associated with all-cause mortality in hemodialysis men (HR = 2.933; P = 0.033).

Conclusion

The study suggested that low plasma DHEA-S was independently and significantly associated with all-cause mortality in CKD hemodialysis men.     

Digoxin Reduces 30-day All-cause Hospital Admission in Older Patients with Chronic Systolic Heart Failure

Background

Heart failure is a leading cause of hospital admission and readmission in older adults. The new United States healthcare reform law has created provisions for financial penalties for hospitals with higher than expected 30-day all-cause readmission rates for hospitalized Medicare beneficiaries aged ≥65 years with heart failure. We examined the effect of digoxin on 30-day all-cause hospital admission in older patients with heart failure and reduced ejection fraction.

Methods

In the main Digitalis Investigation Group trial, 6800 ambulatory patients with chronic heart failure (ejection fraction ≤45%) were randomly assigned to digoxin or placebo. Of these, 3405 were aged ≥65 years (mean age, 72 years; 25% were women; 11% were nonwhite). The main outcome in the current analysis was 30-day all-cause hospital admission.

Results

In the first 30 days after randomization, all-cause hospitalization occurred in 5.4% (92/1693) and 8.1% (139/1712) of patients in the digoxin and placebo groups, respectively, (hazard ratio {HR} when digoxin was compared with placebo, 0.66; 95% confidence interval {CI}, 0.51-0.86; P = .002). Digoxin also reduced both 30-day cardiovascular (3.5% vs 6.5%; HR, 0.53; 95% CI, 0.38-0.72; P < .001) and heart failure (1.7 vs 4.2%; HR, 0.40; 95% CI, 0.26-0.62; P < .001) hospitalizations, with similar trends for 30-day all-cause mortality (0.7% vs 1.3%; HR, 0.55; 95% CI, 0.27-1.11; P = .096). Younger patients were at lower risk of events but obtained similar benefits from digoxin.

Conclusions

Digoxin reduces 30-day all-cause hospital admission in ambulatory older patients with chronic systolic heart failure. Future studies need to examine its effect on 30-day all-cause hospital readmission in hospitalized patients with acute heart failure.     

Long-term prognostic value of elevated heart rate one year after heart transplantation

Background

Elevated heart rate (HR) is associated with adverse cardiovascular outcome in the general population and in patients with cardiovascular disease. Elevated HR due to graft denervation is often found in heart transplantation (HTx) patients; the effect on graft survival and vasculopathy is unclear. Thus, the aim of this study was to evaluate the role of elevated HR at 12 months post-HTx and its power to predict HTx long-term outcome.

Methods

We evaluated retrospectively a prospective database of 312 patients undergoing HTx at two centers. HR was registered at 12 months post-HTx. The median HR was used as a cutoff point. Cox regression analysis was performed with variables known to be clinically relevant to mortality and those selected from the univariate analysis.

Results

During a mean follow-up of 5.5 ± 2.8 years there were 58 deaths (19%). Patients with a HR ≥ 90 bpm (median HR) at 12 months had an increased risk for all-cause mortality (Hazard Ratio = 2.4, 95% CI 1.2 to 4.5, p = 0.009) and mortality related to coronary allograft vasculopathy (CAV) (Hazard Ratio = 3.0, 95% CI 1.25–7.14, p = 0.01). Multivariate analysis showed that a HR ≥ 90 bpm independently predicted mortality (HR 3.2, 95% CI 1.4–7.1, p = 0.004).

Conclusions

Elevated HR measured at 12 months after HTx is an independent predictor of all-cause mortality in HTx recipients. A HR ≥ 90 bpm identifies a group of patients at high risk of death and CAV-related mortality at mid- to long-term.     

Increased mortality after transcatheter aortic valve implantation (TAVI) in patients with severe aortic stenosis and low ejection fraction: A meta-analysis of 6898 patients

Background

There is conflicting evidence regarding the safety and efficacy of transcatheter aortic valve implantation (TAVI) procedures in patients with severe aortic stenosis and low left ventricular ejection fraction (EF). The primary aim of this study was to determine the impact of TAVI on short- and long-term mortality in patients with low EF (EF < 50%); the secondary aim was to analyze the impact of TAVI procedure on EF recovery in the same setting of patients.

Methods and results

Twenty-six studies enrolling 6898 patients with severe aortic stenosis undergoing TAVI procedure were included in the meta-analysis and analyzed for 30-day, 6-month and 1-year all-cause and cardiovascular mortality; a further meta-analysis was also performed in patients with low EF to assess EF changes post TAVI.In low EF patients, both all-cause and cardiovascular short- and long-term mortality were significantly higher when compared to patients with normal EF (30-day-all-cause mortality: 0.13; 95% confidence interval [CI]: 0.01 to 0.25, I² = 49.65, Q = 21.85; 1-year-all-cause mortality: 0.25; 95% [CI]: 0.16 to 0.34, I² = 25.57, Q = 16.12; 30-day-cardiovascular mortality: 0.03; 95% [CI]: − 0.31 to 0.36, I² = 66.84, Q = 6.03; 1-year-cardiovascular mortality: 0.29; 95% [CI]: 0.12 to 0.45, I² = 0.00, Q = 1.88). Nevertheless, in low EF patients TAVI was associated with a significant recovery of EF, which started at discharge and proceeded up to 1-year-follow-up.

Conclusions

Patients with low EF severe aortic stenosis have higher mortality following TAVI compared to normal EF patients, despite a significant and sustained improvement in EF.     

Temporal trends in all-cause mortality of smokers versus non-smokers hospitalized with ST-segment elevation myocardial infarction

Background/objectives

Over the past decade, the development of novel management strategies has resulted in improved outcomes among patients hospitalized with ST-segment myocardial infarction (STEMI). The aim of the present study was to compare temporal trends in the mortality of smokers versus non-smokers admitted with STEMI in a real world setting between 2000 and 2010.

Methods

We evaluated time-dependent changes in the clinical characteristics, management strategies, and one year all-cause mortality of STEMI patients who were enrolled in the biannual Acute Coronary Syndrome Israeli Survey (ACSIS) between 2000 and 2010, categorized as smokers (n = 2399) and non-smokers (n = 3069). We divided the survey periods into early (2000–2004) and late (2006–2010). The primary endpoint of the study was the occurrence of one-year all-cause mortality.

Results

A total of 4564 STEMI patients were enrolled in the study. Compared with non-smokers, smokers were significantly younger and displayed a significantly lower rate of all-cause mortality at 30 days and 1-year. Both smokers and non-smokers who were enrolled in the late survey period received more evidence-based therapies (primary PCI and guideline-based medications) (p < 0.001 for all). There was a significant reduction in the risk of 1-year all-cause mortality only among non-smokers (HR = 0.664 CI 95% 0.52–0.85, p = 0.0009), whereas smokers who were enrolled in more recent survey periods did not display a significant risk reduction (HR = 1.08 CI 95% 0.77–1.51, p = 0.67).

Conclusion

Survival following STEMI among smokers has not improved over the past decade despite corresponding changes in management strategies. Future trials should focus on reducing the risk in smokers.     

Myocardial scar characteristics based on cardiac magnetic resonance imaging is associated with ventricular tachyarrhythmia in patients with ischemic cardiomyopathy

Objectives

We hypothesized that myocardial scar characterization using cardiac magnetic resonance imaging (CMR) may be associated with the occurrence of ventricular tachyarrhythmia (VT), appropriate implantable cardioverter-defibrillator (ICD) therapy and mortality.

Background

Since a minority of patients with prophylactic ICD implantation receive appropriate ICD therapy, there is a need for more effective risk stratification for primary prevention in patients with ischemic cardiomyopathy.

Methods and results

In 99 patients with ischemic cardiomyopathy, CMR was performed prior to ICD implantation. We assessed if CMR indices (cardiac mass, LVEF) and CMR scar characteristics (infarct core mass, peri-infarction mass and the ratio's between left ventricular mass, infarct core mass and peri-infarction mass) were associated with outcome. The primary endpoint was sustained VT and/or appropriate ICD therapy. The secondary endpoint was all-cause mortality. During a median follow-up of 5.4 years (IQR 4.5–6.6 years), 34 patients reached the primary end-point (17 appropriate ICD shocks) and 26 patients died. In multivariable Cox regression analysis, peri-infarction to core-infarction ratio (HR 2.01, 95%CI: 1.17–3.44, p = 0.01) was independently and significantly associated with the primary endpoint, whereas NYHA-class and lower LVEF were not. Conversely, age (HR 1.06, 95% CI: 1.01–1.12, p = 0.02) and lower LVEF (HR 0.95, 95% CI: 0.91–1.00, p = 0.04) were independently associated with all-cause mortality, mainly due to heart failure.

Conclusion

A relatively large peri-infarction mass is associated with sustained VT and/or appropriate ICD therapy, whereas age and lower LVEF are associated with mortality. CMR based tissue characterization could aid in the prediction of specific outcome measures and in clinical decision making.     

Changes in all-cause and cardiovascular disease mortality in three different Finnish population cohorts with and without diabetes

Background

We aimed to assess changes in cardiovascular (CVD) and all-cause mortality among diabetic and non-diabetic individuals between three large study cohorts with baseline assessments of 10 years apart and followed up for 10 years.

Methods

Six population surveys were carried out in 1972, 1977, 1982, 1987, 1992 and 1997 in Finland. For the analyses we combined the 1972 and 1977 cohorts (cohort 1), the 1982 and 1987 cohorts (cohort 2) and similarly also the 1992 and 1997 cohorts (cohort 3).

Results

Age-adjusted hazard ratio (HR) of all-cause mortality and CVD in men without diabetes showed that both had a statistically significant decreased risk of all-cause mortality compared to the first cohort. No statistically significant changes in all-cause mortality were observed in men and women with diabetes between the latter two cohorts compared with the first after controlling for several covariates. In both men and women without diabetes, cohort 2 (men, HR = 0.65; 95% CI 0.51–0.82; women, HR = 0.54; 95% CI 0.32–0.89) and cohort 3 (men, HR = 0.32; 95% CI 0.22–0.47; women, HR = 0.31; 95% CI 0.14–0.68) showed a statistically significant decreased risk of CVD mortality compared to cohort 1. Age-adjusted HRs in regard to CVD mortality in men (HR = 0.22; 95% CI 0.07–0.69) and women (HR = 0.22; 95% CI 0.05–0.99) with diabetes of cohort 3 were statistically significantly lower than in cohort 1.

Conclusions

There seems to be a decrease in CVD mortality in people with diabetes indicating that treatment of diabetes and cardiovascular risk factors in diabetes patients may have improved during the last decade.     

Impact of accelerated ventricular tachyarrhythmias on mortality in patients with implantable cardioverter-defibrillator therapy

Background

Anti-tachycardia pacing (ATP) and shock delivery may induce or accelerate tachyarrhythmias in patients with implantable cardioverter-defibrillator (ICD). We investigated the incidence, triggers and impact on mortality of accelerated ventricular tachyarrhythmias.

Methods

Database analysis concerning ventricular tachyarrhythmias accelerated by ATP or shock in 1275 ICD patients (age at implantation 59.7 ± 14.0 years; 81% male).

Results

Within a mean follow-up period of 5.3 ± 4.0 years, intracardiac electrograms were available in 1170 patients (91.8%). Overall 157 episodes of accelerated ventricular tachyarrhythmias were found in 100 of 1170 patients (8.5%). Termination of tachyarrhythmias was achieved by shock delivery in 153 episodes (96.8%). Triggers of accelerated tachyarrhythmias were appropriate ATP in 139 (88.5%) and inappropriate ATP in 14 (8.9%), as well as appropriate and inappropriate shocks in 2 (1.3%) episodes, respectively. Chronic heart failure was significantly correlated with the occurrence and recurrence of acceleration (p < 0.001). Patients with accelerated ventricular tachyarrhythmia and subsequent shock therapy revealed higher all-cause mortality (HR 1.760; 95% CI 1.286–2.410; p < 0.001) as well as higher cardiac mortality (HR 2.555; 95% CI 1.446–4.513; p = 0.001). The correlation between acceleration and all-cause mortality was independent of left ventricular function (HR 2.076; 95% CI 1.633–2.639; p < 0.001).

Conclusions

Ventricular ATP with arrhythmia acceleration and subsequent shock delivery is a frequent and serious complication of ICD therapy that predominantly occurs in patients with reduced left ventricular function. Finally, occurrence of accelerated ventricular tachyarrhythmias was associated with increased all-cause mortality.     

Coronary artery disease, coronary revascularization, and outcomes in chronic advanced systolic heart failure

Background

Associations between coronary artery disease (CAD) and outcomes in systolic heart failure (HF) and that between coronary artery bypass graft (CABG) surgery and outcomes in patients with HF and CAD have not been examined using propensity-matched designs.

Methods

Of the 2707 patients with advanced chronic systolic HF in the Beta-Blocker Evaluation of Survival Trial (BEST), 1593 had a history of CAD, of whom 782 had prior CABG. Using propensity scores for CAD we assembled a cohort of 458 pairs of CAD and no-CAD patients. Propensity scores for prior CABG in those with CAD were used to assemble 500 pairs of patients with and without CABG. Matched patients were balanced on 68 baseline characteristics.

Results

All-cause mortality occurred in 33% and 24% of matched patients with and without CAD respectively, during 26 months of median follow-up (hazard ratio {HR} when CAD was compared with no-CAD, 1.41; 95% confidence interval {CI}, 1.11-1.81; P = 0.006). HR's (95% CIs) for CAD-associated cardiovascular mortality, HF mortality, and sudden cardiac death (SCD) were 1.53 (1.17-2.00; P = 0.002), 1.44 (0.92-2.25; P = 0.114) and 1.76 (1.21-2.57; P = 0.003) respectively. CAD had no association with hospitalization. Among matched patients with HF and CAD, all-cause mortality occurred in 32% and 39% of those with and without prior CABG respectively (HR for CABG, 0.77; 95% CI, 0.62-0.95; P = 0.015).

Conclusions

In patients with advanced chronic systolic HF, CAD is associated with increased mortality, and in those with CAD, prior CABG seems to be associated with reduced all-cause mortality but not SCD.     

Female gender and contrast-induced nephropathy in primary percutaneous intervention for ST-segment elevation myocardial infarction

Background

Patients undergoing primary percutaneous coronary intervention (PCI) are at high risk for contrast-induced nephropathy (CIN), a complication that has been demonstrated to negatively affect outcomes. It has been suggested that, when compared to males, female patients present higher incidence of CIN and higher mortality after primary PCI. However, the specific role of gender in this setting remains ill-defined given its complex interplay with several co-morbidities and clinical characteristics. We investigated the relationship of patients' variables, including gender, with CIN and mortality after primary PCI.

Methods

In a single center study in 323 consecutive patients undergoing primary PCI, the development of CIN and mortality during an 18-month median follow-up period was assessed. CIN was defined as an increase in serum creatinine (≥ 25% or ≥ 0.5 mg/dl) from baseline occurring at any time during the first 3 post-procedural days.

Results

CIN occurred in 23 female and 26 male patients (25.0% vs 11.2%, p = 0.003), while cumulative mortality was 10.6%. Women presented unfavorable basal characteristics and underwent myocardial reperfusion less quickly. At multivariable analysis, reduced left ventricular ejection fraction (LVEF) (odds ratio [OR] 7.32 95% confidence interval [CI]: 2.60–21, p < 0.001) and female gender (OR 2.49 95%CI 1.22–5.07, p = 0.01) predicted CIN, whereas the occurrence of CIN (hazard ratio [HR] 3.65 95%CI 1.55–8.59, p = 0.003) and a Mehran risk score (MRS) ≥ 6 (HR 1.76 95%CI 1.13–2.74, p = 0.01) independently predicted long-term mortality.

Conclusions

After primary PCI, female gender and LVEF are associated with an increased risk of CIN, whereas MRS and development of CIN predict long-term mortality.     

Impact of body composition, fat distribution and sustained weight loss on cardiac function in obesity

Background

Older age is an independent predictor of all-cause mortality in patients with mild to moderate heart failure (HF). Whether older age is also an independent predictor of mortality in patients with more advanced HF is unknown.

Methods

Of the 2707 Beta-Blocker Evaluation of Survival Trial (BEST) participants with ambulatory chronic HF (New York Heart Association class III/IV and left ventricular ejection fraction < 35%), 1091 were elderly (≥ 65 years). Propensity scores for older age, estimated for each of the 2707 patients, were used to assemble a cohort of 603 pairs of younger and older patients, balanced on 66 baseline characteristics.

Results

All-cause mortality occurred in 33% and 36% of younger and older matched patients respectively during 4 years of follow-up (hazard ratio {HR} associated with age ≥65 years, 1.05; 95% confidence interval {CI}, 0.87-1.27; P = 0.614). HF hospitalization occurred in 38% and 40% of younger and older matched patients respectively (HR, 1.01; 95% CI, 0.84-1.21; P = 0.951). Among 603 pairs of unmatched and unbalanced patients, all-cause mortality occurred in 28% and 36% of younger and older patients respectively (HR, 1.34; 95% CI, 1.10-1.64; P = 0.004) and HF hospitalization occurred in 34% and 40% of younger and older unmatched patients respectively (HR, 1.24; 95% CI, 1.03-1.50; P = 0.024).

Conclusion

Significant bivariate associations suggest that older age is a useful marker of poor outcomes in patients with advanced chronic systolic HF. However, lack of significant independent associations suggests that older age per se has no intrinsic effect on outcomes in these patients.     

Trends in mortality after first hospitalization with Atrial Fibrillation diagnosis in Sweden 1987 to 2006

Background

To examine trends in 3-year mortality after a first hospitalization with diagnosed atrial fibrillation in a large cohort with and without important comorbidities.

Methods

The Swedish Hospital Discharge and Cause of Death Registries were linked to investigate trends in mortality for all patients 35 to 84 years hospitalized for the first time with a discharge diagnosis (principal or contributory) of atrial fibrillation in Sweden during 1987 to 2006. We performed an analysis of temporal trends in mortality stratified for presence or absence of co-morbidities affecting survival.

Results

Exactly 376,000 patients (56% male, mean age 72 years) with a first diagnosis of atrial fibrillation during 1987–2006 were identified and followed for 3 years. Patients with one or more of the prespecified comorbidities had the highest mortality and the largest absolute decline in mortality, but patients without these comorbidities had a slightly larger relative decline (absolute risk reduction in 3-year mortality (AAR) from 42.5 to 34.7%, Hazard Ratio (HR) 0.76; 95% confidence interval (95% CI) 0.74 to 0.77 versus ARR 16.2% to 11.7%, HR 0.71; 0.68 to 0.74. In patients aged below 65 years, with no comorbidities, there was minimal change in mortality, and they still had a 2 times increased mortality compared to the general population (SMR 1.95; 1.84 - 2.06).

Conclusions

Survival after a first hospitalization with a diagnosis of atrial fibrillation improved regardless comorbidities. Patients aged < 65 years old without diagnosed comorbidities still had a poor prognosis compared to the general population.     

Outcome and determinants of prognosis in patients undergoing isolated tricuspid valve surgery: Retrospective single center analysis

Aims

Although tricuspid valve (TV) surgery has become more popular, isolated TV surgery is infrequently performed. The aims of this study were (1) to evaluate the postoperative and long-term mortality of patients undergoing isolated TV surgery, (2) to compare the outcomes of patients undergoing their first TV surgery or TV reoperation, and (3) to assess the additive value of echocardiographic and invasive hemodynamic evaluations for predicting postoperative outcome.

Methods

We followed a contemporary cohort of patients undergoing isolated TV surgery from January 1, 1995, through December 31, 2011. Preoperative demographic, echocardiographic, hemodynamic, and operative data were included. Outcome was all-cause mortality.

Results

Ninety-two patients (38% male; mean age: 56 ± 14 years) were included. Kaplan-Meier survival analyses showed that 30-day, 3-month, 5-year, and 10-year mortality were 7.9%, 15.2%, 25.7%, and 53.7%, respectively. No difference in outcome was found between patients undergoing first TV surgery (n = 61) and TV reoperation (n = 31) (p = 0.669). Univariable Cox analysis identified age (p < 0.0001), extracardiac vascular disease (p = 0.001), glomerular filtration rate (p = 0.022), NYHA classification (p = 0.010), and mean pulmonary artery pressure (p = 0.005) as predictors of mortality. Multivariable analysis identified significant associations with outcome, only for age (p = 0.010) and NYHA functional class (p = 0.044). In younger patients (< 59 years), mean pulmonary artery pressure was associated with the worse outcome (p = 0.024).

Conclusions

Isolated TV surgery is still associated with important postoperative and long-term mortality, both for first TV surgery and TV reoperation. Pre-operative NYHA functional class and, in younger patients, pulmonary hypertension appear to determine prognosis.     

Prolonged impact of home versus clinic-based management of chronic heart failure: Extended follow-up of a pragmatic,multicentre randomized trial cohort

Objectives

We compared the longer-term impact of the two most commonly applied forms of post-discharge management designed to minimize recurrent hospitalization and prolong survival in typically older patients with chronic heart failure (CHF).

Methods

We followed a multi-center randomized controlled trial cohort of Australian patients hospitalized with CHF and initially allocated to home-based or specialized CHF clinic-based intervention for 1368 ± 216 days. Blinded endpoints included event-free survival from all-cause emergency hospitalization or death, all-cause mortality and rate of all-cause hospitalization and stay.

Results

280 patients (73% male, aged 71 ± 14 years and 73% left ventricular systolic dysfunction) were initially randomized to home-based (n = 143) or clinic-based (n = 137) intervention. During extended follow-up (complete for 274 patients), 1139 all-cause hospitalizations (7477 days of hospital stay) and 121 (43.2%) deaths occurred. There was no difference in the primary endpoint; 20 (14.0%) home-based versus 13 (7.4%) clinic-based patients remained event-free (adjusted HR 0.89, 95% CI 0.70 to 1.15; p = 0.378). Significantly fewer home-based (51/143, 35.7%) than clinic-based intervention (71/137, 51.8%) patients died (adjusted HR 0.62, 95% CI 0.42 to 0.90: p = 0.012). Home-based versus clinic-based intervention patients accumulated 592 and 547 all-cause hospitalizations (p = 0.087) associated with 3067 (median 4.0, IQR 2.0 to 6.8) versus 4410 (6.0, IQR 3.0 to 12.0) days of hospital stay (p < 0.01 for rate and duration of hospital stay).

Conclusions

Relative to clinic-based intervention, home-based intervention was not associated with prolonged event-free survival. Home-based intervention was, however, associated with significantly fewer all-cause deaths and significantly fewer days of hospital stay in the longer-term.

Trial registration

Australian New Zealand Clinical Trials Registry number 12607000069459 (http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=81803)     

Calidad de vida relacionada con la salud en una cohorte nacional de pacientes con hipertensión arterial pulmonar o hipertensión pulmonar tromboembólica crónica

Background

Patients with pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) experience impaired health-related quality of life (HRQL). The objective of this study was to evaluate HRQL in a nation-wide sample.

Patients and methods

This is a prospective, multicenter, non-interventional study of HRQL including 139 (89%) PAH and 17 (11%) CTEPH patients (women 70.5%; mean age, 52.2) recruited from 21 Spanish hospitals. 55% had idiopathic PAH, 34% other PAH and 11% CTEPH. HRQL was measured using the Short Form 36 Health Survey (SF-36) and EuroQoL-5D (baseline and after 6 months).

Results

HRQL in the patients with PAH or CTEPH was impaired. The physical component of SF-36 and the EuroQol-5D correlated with the functional class (FC). Mean EuroQol-5D visual analogical scale (EQ-5D VAS) scores were 73.5 ± 18.4, 62.9 ± 20.7 and 51.3 ± 16.0 (P < .0001) in patients with FC I, II and III, respectively. Every increase of one FC represented a loss of 4.0 on the PCS SF-36 and a loss of 9.5 on the EQ-5D VAS. Eight patients who died or received a transplant during the study period presented poorer initial HRQL compared with the rest of the population. No significant changes in HRQL were observed in survivors after 6 months of follow-up.

Conclusions

HRQL is impaired in this population, especially in PAH/CTEPH patients near death. HRQL measurements could help predict the prognosis in PAH and CTPH and provide additional information in these patients.     

Age adjusted Charlson Co-morbidity Index is an independent predictor of mortality over long-term follow-up in infective endocarditis

Background

Infective endocarditis (IE) is associated with high morbidity and mortality. The epidemiology of IE is changing, affecting more elderly patients with increased medical comorbidities. We aimed to assess the ability of the age adjusted Charlson Co-morbidity Index (ACCI) to predict early and late outcomes.

Methods

Between 1998 and 2010, adult patients with definite IE according to the modified Duke criteria were identified. The primary outcome was in-hospital and all-cause mortality. The secondary outcome was predictors of the primary outcome incorporating ACCI.

Results

148 patients with IE were followed up for a mean of 3.8 ± 3 years. The mean age was 57 ± 17 years and 66% were male. In-hospital mortality and all-cause mortality were 24 and 47% respectively. Comorbid conditions included diabetes mellitus (DM) (21%); ischaemic heart disease (16%); heart failure (HF) (14%); renal failure (eGFR < 60 ml/min/1.73 m²) (19%); and anaemia (64%). The most common causative organism was Staphylococcus aureus (53%). ACCI was > 3 in 59% of patients. Cardiac surgery was performed in 45% of patients. On Cox regression analysis, ACCI > 3 (HR = 3.0 [1.5–6.0], p < 0.002), new onset HF (HR = 2.2 [1.3–3.6], p < 0.003), anaemia (HR = 1.8 [1.1–3.2], p = 0.04) and age-per decade (HR = 1.4 [1.1–1.7]. p = 0.004) were independently associated with all-cause mortality. ACCI > 3 was the strongest predictor of in-hospital mortality (OR = 8.4 [2.8–24], p < 0.001). Of the individual ACCI components, prior HF, DM with complications and metastatic disease were independent predictors of all-cause mortality.

Conclusion

In-hospital and all-cause mortality of IE remain high. An ACCI > 3 was a strong predictor of mortality, in addition to age, new HF and anaemia.     

Validación de 2 escalas clínicas pronósticas en pacientes con tromboembolia pulmonar aguda sintomática

Objective

The aim of this study was to compare the predictive value of two clinical prognostic models, the Spanish score and the simplified Pulmonary Embolism Severity Index (sPESI), in an independent cohort of patients diagnosed of acute symptomatic pulmonary embolism (PE).

Methods

We performed a retrospective analysis of a cohort composed of 1447 patients with acute symptomatic PE. The Spanish score and the sPESI were calculated for each patient according to different clinical variables. We assessed the predictive accuracy of these scores for 30-day mortality, and a composite of non fatal recurrent venous thromboembolism and non fatal major bleeding, using C statistic, which was obtained by means of logistic regression and ROC curves.

Results

Overall, 138 patients died (9.5%) during the first month of follow-up. Both scores showed an excellent predictive value for 30-day all-cause mortality (C statistic, 0.72 and 0.74), but the performance was poor for the secondary endpoint (C statistic, 0.60 and 0.59). The sPESI classified fewer patients as low risk (32% versus 62%; P < .001). Low-risk patients based on the sPESI had a lower 30-day mortality than those based on the Spanish score (1.1% versus 4.2%), while the 30-day rate of non fatal recurrent VTE or major bleeding was similar (2.2% versus 2.3%).

Conclusions

Both scores provide excellent information to stratify the risk of mortality in patients treated of PE. The usefulness of these models for nonfatal adverse events is questionable. The sPESI identified low-risk patients with PE better than the Spanish score.