Development and Validation of a Novel Risk Score for Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction

BackgroundPrimary percutaneous coronary intervention (PPCI) is the default treatment for patients with ST elevation myocardial infarction (STEMI) and carries a higher risk of adverse outcomes when compared with elective and urgent PCI. Conventional PCI risk scores tend to be complex and may underestimate the risk associated with PPCI due to under-representation of patients with STEMI in their datasets. This study aimed to develop a simple, practical and contemporary risk model to provide risk stratification in PPCI.MethodsDemographic, clinical and outcome data were collected for all patients who underwent PPCI between January 2009 and October 2013 at the Northern General Hospital, Sheffield. Multiple regression analysis was used to identify independent predictors of mortality and to construct a risk model. This model was then separately validated on an internal and external dataset.ResultsThe derivation cohort included 2870 patients with a 30-day mortality of 5.1% (145 patients). Only four variables were required to predict 30-day mortality: age [OR:1.047, 95% CI:1.031–1.063], call-to-balloon (CTB) time [OR:1.829, 95% CI:1.198–2.791], cardiogenic shock [OR:13.886, 95% CI:8.284–23.275] and congestive heart failure [OR:3.169, 95% CI:1.420–7.072]. Internal validation was performed in 693 patients and external validation in 660 patients undergoing PPCI. Our model showed excellent discrimination on ROC-curve analysis (C-Stat = 0.87 internal and 0.86, external), and excellent calibration on Hosmer-Lemeshow testing (p = 0.37 internal, 0.55 external).ConclusionsWe have developed a bedside risk model which can predict 30-day mortality after PPCI using only four variables: age, CTB time, congestive heart failure and shock.     

Predicting One-year Mortality After a “First” Hospitalization for Chronic Obstructive Pulmonary Disease: An Eight-Variable Assessment Score Tool

Several authors have studied predictors of outcomes following a hospitalization for chronic obstructive pulmonary disease (COPD); however, few have reported outcomes following a first hospitalization for COPD. The objective is to develop a predictive mortality risk model in patients surviving a first hospitalization for COPD. This is a retrospective cohort study using linked administrative and clinical data. The cohort included 1129 patients of 40–84 years, discharged alive from a hospitalization for COPD in a regional hospital (Sherbrooke, Canada) between 04/2006 and 03/2013 and to whom were prescribed at least two COPD drugs during their hospitalization. One-year mortality was analysed using logistic regression on a derivation sample and validated on a testing sample. In total, 141 (12.5%) patients died within one year from discharge of their first hospitalization for COPD. Predictors were: older age (OR (95% CI): 1.055 (1.026–1.085)), male sex (OR (95% CI): 1.474 (0.921–2.358)), having a severe COPD exacerbation (OR (95% CI): 2.548 (1.571–4.132)), higher hospital length of stay (OR (95% CI): 1.024 (0.996–1.053)), higher Charlson co-morbidity index (OR (95% CI): 1.262 (1.099–1.449)), being diagnosed of cancer (OR (95% CI): 2.928 (1.456–5.885)), the number of prior all-cause hospitalizations (OR (95% CI): 1.323 (1.097–1.595)), and a COPD duration exceeding 3 years (OR (95% CI): 1.710 (1.058–2.763)). A simple clinical prognosis tool is proposed and shows good discrimination in both the derivation and validation cohorts (c-statistic >0.78). One over eight patients discharged alive from a first COPD hospitalization will die the following year. It is thus important to identify higher-risk patients in order to plan and manage appropriate treatment.     

Development and Validation of a Prognostic Index for Risk Stratification of Patients with Early Repolarization

Background: Early repolarization (ER) is associated with increased mortality in the general population. We sought to develop and validate a prognostic index (PI) of mortality in patients with ER. Methods: We identified 852 consecutive patients (mean age 49 ± 12 years) with ER (J‐point elevation ≥0.1 mV in inferior or lateral leads), from the VA electronic electrocardiogram (ECG) database. A random sample of age‐matched patients with normal ECG was used as control (n = 257). The initial cohort was randomly split into a derivation and a validation cohort (2/3 and 1/3 of patients, respectively). A PI was derived from the weighed sum of the regression coefficients of each independent risk factor in the final model using Cox regression analysis. Results: During a median follow‐up of 6.4 years, 170 patients died. ER was associated with increased mortality compared to control (HR 1.49, 95% CI 1.05–2.12; P = 0.03). Older age, lower body mass index, non‐African American race, current use of angiotensin‐converting enzyme inhibitors/angiotensin receptor blockers or sulfonyureas, prolonged corrected QT (QTc), and higher ER amplitude independently predicted all‐cause mortality. Annualized mortality rates were 1.3%, 2.2%, and 3.7% in the low, intermediate, and high‐risk groups, respectively, in the derivation cohort (log rank P < 0.0001) and 0.8%, 1.9%, and 4.1% in the low, intermediate, and high‐risk groups, respectively, in the validation cohort (log rank P < 0.0001). Model discrimination was very good (c‐statistic = 0.85 and 0.80 for derivation and validation cohort, respectively). Conclusions: A PI derived from simple clinical and ECG characteristics predicts mortality in patients with ER and may be used clinically for risk stratification.     

Detection of patients presenting with adverse drug events in the emergency department

Background: Adverse drug events (ADE) have been studied widely in hospitalised and emergency department (ED) patients. Less is known about the ED visits of drug‐related injury in Taiwan. This study seeks to determine the incidence, risk and patient outcomes of ADE in an ED population. Methods: We conducted a prospective observational cohort study of patients 18 years and older presenting to the ED of an urban, tertiary medical centre. ED visits between 1 March 2009 and 28 February 2010 identified by investigators for suspected ADE were further assessed by using the Naranjo Adverse Drug Reaction probability scale. Outcomes (ED disposition, injury severity and preventability) and associated variables (triage, gender, drug category, number of drugs, Charlson comorbidity index score and ADE mechanism) were measured. Results: Of 58 569 ED visits, 452 patients (0.77%) had physician‐documented ADE. 24% of patients with ADE were hospitalised with life‐threatening conditions, with a mortality rate of 10.0%. The majority of ADE were considered preventable (73.4%), and the unintentional overdose was the most common cause. Cardiovascular agents accounted for the most ADE (25.8%) and consisted of 65.3% of ADE in patients aged 65 years and older. Risk factors for ADE‐related hospitalisation were elderly age (odds ratio (OR) 1.9, 95% confidence interval (CI) 1.1–3.4), severity of ADE (OR 6.9, 95% CI 3.3–14.5) and higher Charlson comorbidity index scores (OR 3.4, 95% CI 2.0–5.7). Conclusion: ADE‐related ED visits are not uncommon in Taiwan and many cases are preventable. ED‐based surveillance may provide useful information for monitoring outpatient ADE.     

External validation of the CACE-HF risk score for mortality in patients with heart failure

AimsTo validate externally the CACE-HF clinical prediction rule, which predicts 1-year mortality in patients with heart failure (HF).MethodsWe performed an external validation of the CACE-HF risk score in patients included in the RICA heart failure registry who had completed 1 year of follow-up, comparing the characteristics of the derivation and validation cohorts. The performance of the risk score was evaluated in terms of calibration, using calibration-in-the-large (a), calibration slope (b), and the Hosmer-Lemeshow test, and in terms of discrimination, using the area under the ROC curve.ResultsIn total, 3337 patients were included in the validation cohort. There were no significant differences between the derivation and validation cohorts in 1-year mortality (24.63% vs. 22.98%) or in the risk score and risk classes. The discrimination capacity in the validation cohort was slightly lower, 0.67 (95% CI: 0.65, 0.69), compared to that of the derivation cohort. Calibration results were a −0.05 (95% CI: −0.14, 0.03), indicating that the average predictions did not differ from the average outcome frequency, and b = 0.75 (95% CI: 0.64, 0.86), indicating a modest inconsistency in predictor effects. Observed mortality versus predicted mortality according to the deciles and risk classes were very similar in both cases, indicating good calibration.ConclusionsThe results of the external validation of the CACE-HF risk score show that although the capacity for discrimination was slightly lower than in the derivation cohort, the calibration was excellent. This tool, therefore, can assist in decision-making in the management of these patients.     

Non-genetic risk factors and predicting efficacy for docetaxel--drug-induced liver injury among metastatic breast cancer patients

Background and Aim: Docetaxel has been chosen as one of the most popular anticancer drugs in the treatment of breast cancer for more than a decade. There is increasingly awareness for the occurrence of docetaxel and/or docetaxel–drug‐induced liver injury (DILI), although the underlying mechanism of occurrence and its risk factors remain unclear. Methods: We conducted a retrospective cohort study to identify non‐genetic risk factors for docetaxel–DILI among 647 metastasis breast cancer patients treated with docetaxel‐containing regimens. Results: Sixty‐seven (10.36%) patients were diagnosed as docetaxel–DILI. By logistic regression analysis, premenopausal status (odds ratio [OR][95% confidence interval {CI}] = 2.24 [1.30–3.87]), past hepatitis B virus (HBV) infections (OR [95% CI] = 4.23 [1.57–11.42]), liver metastasis (OR [95% CI] = 3.70 [2.16–6.34]). The predominant occurrence of DILI was seen in groups with docetaxel combination regimens. (OR [95% CI] = 2.66 [1.59–4.55]). The potential increasing occurrence of docetaxel–DILI was associated with multiple risk factors in an exposure–response manner (P < 0.001), and patients with more than three risk factors would be exposed to a 36.61‐fold risk of DILI (95% CI = 10.18–131.62). Further analysis by the risk score and area under the receiver–operator characteristic curve (AUC) showed that those four factors contributed to an AUC of 0.7536 (95% CI = 0.70–0.81), with a predictive sensitivity of 74.63% and specificity of 65.17%. Conclusions: Docetaxel–DILI with a relatively higher incidence should be addressed among metastatic breast cancer patients. Four predominant risk factors, including premenopausal status, past HBV infection, liver metastasis, and docetaxel combination regimens, were potential predicators for DILI.     

Identification of older patients with heart failure who may be candidates for hospice care: development of a simple four-item risk score

OBJECTIVES: To identify predictors of 6‐month mortality in older patients with heart failure (HF) and to develop a risk score for identifying potential candidates for hospice care. DESIGN: Secondary data analysis of a previously conducted randomized, clinical trial. SETTING: Barnes‐Jewish Hospital, St. Louis, Missouri. PARTICIPANTS: Two hundred eighty‐two patients with HF aged 70 and older. INTERVENTION: Participants were randomized to conventional care or a multidisciplinary intervention designed to reduce rehospitalization. MEASUREMENTS: All‐cause 6‐month mortality. RESULTS: Patients were followed for up to 14 years; 43 (15.2%) died within 6 months of hospital discharge. Multivariate logistic regression analysis identified four independent predictors of 6‐month mortality: serum urea nitrogen of 30 mg/dL or greater (odds ratio (OR)=5.78, 95% confidence interval (CI)=2.65–12.66), systolic blood pressure less than 120 mmHg (OR=4.81, 95% CI=1.94–11.91), peripheral arterial disease (OR=3.09, 95% CI=1.26–7.58), and serum sodium less than 135 mEq/L (OR=2.27, 95% CI=0.98–5.27). Patients were stratified into four risk groups based on the presence or absence of these four risk factors. Six‐month mortality rates for patients with zero, one, two, or three or more risk factors were 3.7%, 16.3%, 41.0%, and 66.7%, respectively (P<.05). The presence of three or more risk factors was associated with a positive predictive value of 66.7% and a negative predictive value of 86.4%. CONCLUSION: Although additional studies are needed, these findings suggest that a simple four‐item risk score can identify older patients with HF at high risk of dying within 6 months. This may enable clinicians to better advise patients about prognosis, adjust management accordingly, and if appropriate, facilitate referral for hospice care. Conversely, patients with a more‐favorable prognosis may be suitable candidates for more‐aggressive interventions.     

Characteristics,risk factors and outcomes of adult cancer patients with extensively drug-resistant Pseudomonas aeruginosa infections

Objective

To evaluate the characteristics and outcomes of cancer patients with extensively drug-resistant (XDR) Pseudomonas aeruginosa infections.

Methods

This was a retrospective cohort of P. aeruginosa infections in cancer patients in Crete, Greece. Patients were followed until discharge. Mortality, predictors of mortality and risk factors for XDR P. aeruginosa infection were studied.

Results

Ninety seven episodes (89 patients) of P. aeruginosa infections (52 with bacteremia) were included in the study. In 22 cases, the infection was due to XDR isolates. All XDR isolates were susceptible to colistin and variably resistant to almost all other antibiotics. The multivariate analysis showed that the independent risk factors for XDR P. aeruginosa infection were hematologic malignancy (OR 40.7, 95 % CI 4.5–367.6) and prior fluoroquinolone use (OR 11.0, 95 % CI 2.0–60.5); lymphopenia was inversely associated with XDR infections (OR 0.16, 95 % CI 0.03–0.92). Mortality was 43 %; infection-related mortality was 24 %. Bacteremia (OR 8.47, 95 % CI 2.38–30.15), infection due to XDR isolates (OR 5.11, 95 % CI 1.15–22.62) and age (OR 1.05, 95 % CI 1.00–1.09) were independently associated with mortality.

Conclusion

Mortality in cancer patients with P. aeruginosa infections was high. Infection due to XDR isolates was independently associated with mortality.     

Acute kidney injury in critically ill A(H1N1)-infected patients: a study of the prognoses

Purpose: to identify factors correlated with poor outcome and factors correlated with acute kidney injury (AKI) onset in critically A(H1N1) infected patients. Methods: All patients admitted for respiratory distress due to a confirmed infection by A(H1N1) virus were included retrospectively. Results: Thirty‐four patients were included. Mean age was 37.3 ± 20.8 years. Independent factors correlated to mortality in multivariate analysis were shock [OR = 32.52, CI95% (1.29–816.3); p = 0.034], AKI [OR = 31.12, CI95% (1.3–746.5); p = 0.034] and hyperglycaemia over than 5.7 mmol/l on admission [OR = 74, CI95% (1.01–5495); p = 0.049]. Only age over 30 years was identified as an independent factor correlated with the onset of AKI [OR = 18, CI95% (1.04‐312.41); p = 0.047] in multivariate analysis. Conclusion: AKI, as well as hypotension, is an independent factor correlated with mortality. Its onset is usually linked to multi‐organ failure. Advanced age is an important risk factor for renal dysfunction in this group of patients.     

Risk Prediction for Peripartum Cardiomyopathy in Delivering Mothers: A Validated Risk Model: PPCM Risk Prediction Model

BackgroundPeripartum cardiomyopathy (PPCM) causes significant morbidity and mortality in childbearing women. Delays in diagnosis lead to worse outcomes; however, no validated risk prediction model exists. We sought to validate a previously described model and identify novel risk factors for PPCM presenting at the time of delivery.Methods and ResultsAdministrative hospital records from 5,277,932 patients from 8 states were screened for PPCM, identified by International Classification of Disease-9 Clinical Modification codes (674.5x) at the time of delivery. Demographics, comorbidities, procedures, and outcomes were quantified. Performance of a previously published regression model alone and with the addition of novel PPCM-associated characteristics was assessed using receiver operating characteristic area under the curve (AUC) analysis. Novel risk factors were identified using multivariate logistic regression and the likelihood ratio test. In total, 1186 women with PPCM were studied, including 535 of 4,003,912 delivering mothers (0.013%) in the derivation set compared with 651 of 5,277,932 (0.012%) in the validation set. The previously published risk prediction model performed well in both the derivation (area under the curve 0.822) and validation datasets (area under the curve 0.802). Novel PPCM-associated characteristics in the combined cohort included diabetes mellitus (odds ratio [OR] of PPCM 1.93, 95% confidence interval [CI] 1.23–3.02, P = .004), mood disorders (OR 1.74, 95% CI 1.22–2.47, P = .002), obesity (OR 1.92, 95% CI 1.45–2.55, P < .001), and Medicaid insurance (OR 1.54, 95% CI 1.22-1.96, P < .001).ConclusionsThis is the first validated risk prediction model to identify women at increased risk for PPCM at the time of delivery. Diabetes mellitus, obesity, mood disorders, and lower socioeconomic status are risk factors associated with PPCM. This model may be useful for identifying women at risk and preventing delays in diagnosis.     

Clinical characteristics and outcomes of diffuse alveolar hemorrhage in patients with systemic lupus erythematosus

ObjectiveTo identify the clinical characteristics of diffuse alveolar hemorrhage (DAH) compared to other types of acute diffuse lung infiltration in SLE patients, and the factors associated with mortality in these patients.MethodsWe studied a retrospective cohort including SLE patients with acute diffuse lung infiltration on thoracic CT between January 2004 and August 2014. We divided them into 2 groups, a DAH and a non-DAH group, and compared the clinical characteristics and outcomes in the 2 groups. We also evaluated the risk factors for mortality in SLE patients with diffuse lung infiltration.ResultsOf 47 patients with diffuse lung infiltration, 24 patients (51.1%) satisfied the criteria for DAH and the remaining 23 patients (48.9%) were assigned to the non-DAH group. There were no significant differences between the demographic features of the 2 groups. However, decreased hemoglobin (OR = 3.46; 95% CI: 1.38–8.67; p < 0.01) and C4 (OR = 1.21; 95% CI: 1.03–1.42; p = 0.02) levels, and presence of hypoxia (OR = 23.09; 95% CI: 1.47–365.34; p = 0.03) at the time of diagnosis were associated with SLE-DAH. In addition, severe conditions requiring mechanical ventilation (OR = 64.61; 95% CI: 1.98–2112.02; p = 0.02) were associated with increased mortality, whereas DAH did not increase mortality compared with non-DAH in SLE patients with diffuse lung infiltration.ConclusionsIn SLE patients with acute diffuse lung infiltration, it is important to promptly evaluate the DAH when patients have low levels of hemoglobin or C4, and symptoms of hypoxia. Mortality is associated with severe conditions requiring mechanical ventilation rather than with DAH in patients with diffuse lung infiltration.     

Aging and comorbidities influence the risk of hospitalization and mortality in diabetic patients experiencing severe hypoglycemia

Background and aimsTo assess the risk of hospitalization and mortality within 1 year of severe hypoglycaemia and theirs clinical predictors.Methods and resultsWe retrospectively examined 399 admissions for severe hypoglycemia in adults with DM at the Emergency Department (ED) of the University Hospital of Novara (Italy) between 2012–2017, and we compared the clinical differences between older (aged ≥65 years) and younger individuals (aged 18–64 years). A logistic regression model was used to explore predictors of hospitalization following ED access and 1-year later, according to cardiovascular (CV) or not (no-CV) reasons; 1-year all-cause mortality was also detected.The study cohort comprised 302 patients (median [IQR] age 75 [17] years, 50.3% females, 93.4% white, HbA_1c level 7.6% [1.0%]). Hospitalization following ED access occurred in 16.2% of patients and kidney failure (OR 0.50 [95% CI 1.29–5.03]) was the only predictor of no-CV specific hospitalization; 1-year hospitalization occurred in 24.5% of patients and obesity (OR 3.17 [95% CI 1.20–8.12]) and pre-existing heart disease (OR 3.20 [95% 1.20–9.39]) were associated with CV specific hospitalization; 1-year all-cause mortality occurred in 14.9% of patients and was associated with older age (OR 1.12 [95% CI 1.07–1.18]) and pre-existing heart disease (OR 2.63 [95% CI 1.19–6.14])ConclusionsSevere hypoglycemia is associated with risk of hospitalization and mortality mainly in elderly patients and it may be predictive of future cardiovascular events in diabetic patients with pre-existing heart disease and obesity.     

Use of pulse oximetry to predict in-hospital complications in normotensive patients with pulmonary embolism

PURPOSE: A simple method is needed to risk stratify normotensive patients with pulmonary embolism. We studied whether bedside clinical data can predict in-hospital complications from pulmonary embolism. METHODS: We performed a multicenter derivation phase, followed by validation in a single center. All patients were normotensive; the diagnosis of pulmonary embolism was established by objective imaging. Classification and regression analysis was performed to derive a decision tree from 27 parameters recorded from 207 patients. The validation study was conducted on a separate group of 96 patients to determine the derived criterion's diagnostic accuracy for in-hospital complications (cardiogenic shock, respiratory failure, or death). RESULTS: Mortality in the derivation phase was 4% (n = 8) at 24 hours and 10% (n = 21) at 30 days. A room-air pulse oximetry reading <95% was the most important predictor of death; mortality was 2% (95% confidence interval [CI]: 0% to 6%) in patients with pulse oximetry >or=95% versus 20% (95% CI: 12% to 29%) with pulse oximetry <95%. In the validation phase, the room-air pulse oximetry was <95% at the time of diagnosis in 9 of 10 patients who developed an in-hospital complication (sensitivity, 90%) and >or=95% in 55 of 86 patients without complications (specificity, 64%). CONCLUSION: Mortality from pulmonary embolism in normotensive patients is high. A room-air pulse oximetry reading >or=95% at diagnosis is associated with a significantly lower probability of in-hospital complications from pulmonary embolism.     

Pseudomonas aeruginosa bacteremia over a 10-year period: multidrug resistance and outcomes in transplant recipients

Abstract: Aim. Transplant recipients are at risk for hospital‐acquired infections (HAIs), including those caused by Pseudomonas aeruginosa. Of all HAIs, bloodstream infection (BSI) remains one of the most life‐threatening. Methods. Over a 10‐year period, we studied 503 patients, including 149 transplant recipients, with pseudomonal BSI from the University of Pittsburgh Medical Center. Trends in antimicrobial susceptibility, risk factors for multidrug resistance (MDR), and outcomes were compared between transplant and non‐transplant patients. Results. Resistance to all antibiotic classes was significantly greater in pseudomonal blood culture isolates from transplant compared with non‐transplant patients (P<0.001). Of isolates from transplant recipients (n=207), 43% were MDR, compared with 18% of isolates from non‐transplant patients (n=391) (odds ratio [OR] 3.47; 95% confidence interval [CI] 2.34–5.14, P<0.001). Among all patients, independent risk factors for MDR P. aeruginosa BSI included previous transplantation (OR 2.38; 95% CI 1.51–3.76, P<0.001), hospital‐acquired BSI (OR 2.41; 95% CI 1.39–4.18, P=0.002), and prior intensive care unit (ICU) admission (OR 2.04; 95% CI 1.15–3.63, P=0.015). Mortality among transplant recipients was 42%, compared with 32% in non‐transplant patients (OR 1.55; 95% CI 0.87–2.76, P=0.108). For transplant recipients, onset of BSI in the ICU was the only independent predictor of mortality (OR 8.00; 95% CI 1.71–37.42, P=0.008). Conclusions. Transplant recipients are at greater risk of MDR P. aeruginosa BSI, with an appreciable mortality. Future management must concentrate on the implementation of effective preventative strategies.     

Contemporary clinical outcomes of primary percutaneous coronary intervention in elderly versus younger patients presenting with acute ST-segment elevation myocardial infarction

Background: Primary percutaneous coronary intervention (PPCI) is the choice reperfusion strategy for acute ST‐segment elevation myocardial infarction (STEMI). However, data on PPCI in elderly patients are sparse. This study determined clinical outcome post‐PPCI in elderly versus younger patients with STEMI. Methods and Results: A cohort of 790 consecutive STEMI patients was studied for survival and major adverse cardiovascular events (MACE) after PPCI using a precise cardiac catheterization protocol. Patients were divided into two groups: those ≥75 years (elderly) and those <75 years. Median door‐to‐balloon time (DBT) was 82 minutes in the elderly versus 66 minutes in the younger group (P = 0.002). In‐hospital all‐cause mortality was higher in the elderly group (15.5% vs. 2.7%, P < 0.001). In elderly patients, MACE were found to be higher (32.3% vs. 16.1%, P < 0.001). Using a multivariate logistic regression analysis, age (odds ratio [OR]= 1.04, 95% confidence interval [CI]= 1.02–1.05, P < 0.001), diabetes (OR = 2.17, 95% CI = 1.33–3.53, P = 0.002), renal failure (OR = 3.75, 95% CI = 1.30–10.79, P = 0.014) and coronary artery disease (OR = 1.61, 95% CI = 1.00–2.59, P = 0.050) were associated with higher in‐hospital MACE, while age (OR = 1.05, 95% CI = 1.02–1.08, P = 0.001), diabetes (OR = 2.18, 95% CI = 1.06–4.47, P = 0.034) and renal failure (OR = 6.65, 95% CI = 2.01–22.09, P = 0.002) were associated with higher in‐hospital mortality. Kaplan–Meier 1‐year survival rate was lower in the elderly. Conclusions: In a contemporary population of STEMI patients treated with PPCI, overall in‐hospital MACE and mortality remain higher in elderly compared to younger patients. Although partly due to higher burden of preexisting comorbidities, a higher DBT may also be responsible. (J Interven Cardiol 2011;24:357–365)     

Outcomes Following Percutaneous Coronary Intervention in Saphenous Vein Grafts With and Without Embolic Protection Devices

ObjectivesThe aim of this study was to describe the early (inpatient and 30-day) and late (1-year) outcomes of percutaneous coronary intervention (PCI) in saphenous vein grafts (SVGs), with and without the use of embolic protection devices (EPD), in a large, contemporary, unselected national cohort from the database of the British Cardiovascular Intervention Society.BackgroundThere are limited, and discrepant, data on the clinical benefits of the adjunctive use of EPDs during PCI to SVGs in the contemporary era.MethodsA longitudinal cohort of patients (2007 to 2014, n = 20,642) who underwent PCI to SVGs in the British Cardiovascular Intervention Society database was formed. Clinical, demographic, procedural, and outcome data were analyzed by dividing into 2 groups: no EPD (PCI to SVGs without EPDs, n = 17,730) and EPD (PCI to SVGs with EPDs, n = 2,912).ResultsPatients in the EPD group were older, had more comorbidities, and had a higher prevalence of moderate to severe left ventricular systolic dysfunction. Mortality was lower in the EPD group during hospital admission (0.70% vs. 1.29%; p = 0.008) and at 30 days (1.44% vs. 2.01%; p = 0.04) but similar at 1 year (6.22% vs. 6.01%; p = 0.67). Following multivariate analyses, no significant difference in mortality was observed during index admission (odds ratio [OR]: 0.71; 95% confidence interval [CI]: 0.42 to 1.19; p = 0.19), at 30 days (OR: 0.87; 95% CI: 0.60 to 1.25; p = 0.45), and at 1 year (OR: 0.92; 95% CI: 0.77 to 1.11; p = 0.41), along with similar rates of in-hospital major adverse cardiovascular events (OR: 1.16; 95% CI: 0.83 to 1.62; p = 0.39) and stroke (OR: 0.68; 95% CI: 0.20 to 2.35; p = 0.54). In propensity score–matched analyses, lower inpatient mortality was observed in the EPD group (OR: 0.46; 95% CI: 0.13 to 0.80; p = 0.002), although the adjusted risk for the periprocedural no-reflow or slow-flow phenomenon was higher in patients in whom EPDs were used (OR: 2.16; 95% CI: 1.71 to 2.73; p < 0.001).ConclusionsIn this contemporary cohort, EPDs were used more commonly in higher risk patients but were associated with similar clinical outcomes in multivariate analyses. Lower inpatient mortality was observed in the EPD group in univariate and propensity score–matched analyses.     

Morbidity and mortality following coronary artery bypass graft surgery in patients with cirrhosis: a population‐based study

Background: The risk of cardiac surgery in patients with cirrhosis is poorly defined. Our objective was to describe outcomes of coronary artery bypass graft (CABG) surgery in cirrhotic patients from a population‐based perspective. Methods: We analysed the 1998–2004 Nationwide In‐patient Sample to identify patients hospitalized for CABG surgery. The effect of cirrhosis on mortality, complications, length of stay (LOS) and charges was evaluated using logistic regression models. Results: Between 1998 and 2004, there were 403 094 CABG admissions; 711 patients (0.2%) had cirrhosis. The average annual number of surgeries increased 4.2% [95% confidence interval (CI) 0.7–7.8] in cirrhotic patients, but decreased 5.5% (3.4–7.5) in non‐cirrhotic patients. Patients with cirrhosis had an increased risk of mortality [17 vs. 3%; adjusted odds ratio (OR) 6.67; 95% CI 5.31–8.31], complications [43 vs. 28%; OR 1.99 (95% CI 1.72–2.30)] and greater LOS and charges (P<0.0001). Predictors of mortality included age over 60 (OR 2.21; 95% CI 1.31–3.73), female gender (OR 1.92; 95% CI 1.08–3.41), ascites (OR 3.80; 95% CI 1.95–7.39) and congestive heart failure (OR 1.75; 95% CI 1.08–2.84). Hospital volume and off‐pump CABG did not affect mortality. Conclusions: Patients with cirrhosis have an increased risk of morbidity and mortality following CABG surgery. Additional studies are necessary to refine risk stratification in this high‐risk patient population.     

Preprocedural hemoglobin predicts mortality following peripheral vascular interventions

Background : Serum hemoglobin (H) level is a well‐known predictor of all‐cause mortality in patients undergoing percutaneous coronary interventions but has not been studied in patients undergoing peripheral vascular interventions (PVI). We sought to determine the prognostic significance of serum H in patients undergoing PVI. Methods : We identified 346 consecutive patients undergoing PVI who had a documented a baseline and a postprocedural serum H level over a 33‐month period. A multivariate analysis of predictors of 9‐month mortality was performed. Results : Of 346 patients identified, there were 28 deaths (8.1%) over a 9‐month follow‐up period. Periprocedural H change was not associated with death [OR: 1.12 (95% CI: 0.71–1.79), P = NS]. In a multivariate model independent predictors of all‐cause mortality were clinical bleeding [OR: 10.7 (95% CI: 0.012–0.769), P = 0.026], emergency intervention [OR: 4.5 (95% CI: 0.07–0.71), P = 0.011], ejection fraction [OR: 1.02 (95% CI: 1.01–1.05), P = 0.020], and preprocedural H [OR: 1.56 (95% CI: 1.19–2.04) P = 0.001]. Conclusion : In patients undergoing PVI, preprocedural H was a significant predictor of 9‐month all‐cause mortality. The highest mortality rate was seen in patients with a preprocedural H level ≤ 10 g/dl. Preprocedural H level can be used in clinical practice to risk stratify patients being considered for PVI. Further investigation is needed to assess if optimization of H level preprocedure improves midterm mortality. © 2011 Wiley‐Liss, Inc.     

Development and validation of a prognostic index for 2‐year mortality in Chinese older residents living in nursing homes

Aim: There is no mortality prediction index for Chinese nursing home older residents. The objective of this study was to derive and validate a 2‐year mortality prognostic index for them. Methods: We carried out a prospective cohort study on 1120 older residents from 12 nursing homes of Hong Kong. We obtained potential predictors of mortality and carried out updated functional assessment. Each risk factor associated independently with 2‐year mortality in a derivation cohort was assigned a score based on the odds ratio, and risk scores were calculated for each participant by adding the points of risk factors present. Similar analysis was carried out on the validation cohort. Results: Independent predictors of mortality included: aged 86–90 years (3 points); aged ≥91 years (4 points); Charlson comorbidity index ≥4 (6 points); Barthel Index 5–60 (5 points); Barthel Index 0 (10 points); number of hospitalizations in the preceding year (Adbefore) 1 (4 points); Adbefore 2 (5 points) and Adbefore ≥3 (6 points). In the derivation cohort, 2‐year mortality was 10.8% in the low‐risk group (≤4 points) and 59.9% in the high‐risk group (≥14 points). In the validation cohort, 2‐year mortality was 11.8% in the low‐risk group and 60.4% in the high‐risk group. The receiver–operator characteristic curve area was 0.761 for the derivation cohort and 0.742 for the validation cohort. Conclusions: Our prognostic index had satisfactory discrimination and calibration in an independent sample of Chinese nursing home older residents. It can be used to identify older residents with a high risk for poor outcomes, who need a different level of care. Geriatr Gerontol Int 2012; 12: 555–562.