Impact of weight on long-term survival among patients without known coronary artery disease and a normal stress SPECT MPI

Background

While obesity has been shown to be associated with a worse mortality, an “obesity paradox”—lower mortality in obese patients—has been noted among many patients with coronary artery disease (CAD). The extent to which an obesity paradox operates among patients with only suspected CAD, is not well determined.

Methods and Results

A total of 3,673 patients (60 ± 13 years, 36% males) with no history of heart disease and a normal stress SPECT were included in this study. Normal weight was defined as BMI of 18.5-24.9 kg · m²; overweight 25-29.9 kg · m², obese >30 kg · m². The baseline clinical risk factors were recorded for each patient. The end point of the study was all-cause mortality. Of patients 942 (26%) were normal weight, 1,261 (34%) were overweight, and 1,470 (40%) were obese. Mean patient follow-up was 7.5 ± 3 years. When compared to normal weight patients (event rate 3.2%/year), there was a lower incidence of death in the overweight (event rate 1.5%/year, P < .0001) and the obese (event rate 1.2%/year, P < .0001) groups. After controlling for baseline risk factors, using a reference HR = 1 for normal weight patients, there was a lower risk of death in the overweight (HR = .54, 95% CI .43-.7) and the obese groups (HR = .49, 95% CI .38-.63).

Conclusion

In patients without known cardiac disease and a normal stress SPECT, overweight and obese patients had a lower rate of all-cause mortality compared to normal weight patients over long-term follow-up. This study substantially extends the spectrum of patients in whom the obesity paradox is present.     

Hurricane Katrina: impact on cardiac surgery case volume and outcomes

Hurricane Katrina produced a surge of patient referrals to our facility for cardiac surgery. We sought to determine the impact of this abrupt volume change on operative outcomes. Using our cardiac surgery database, which is part of the Department of Veterans Affairs' Continuous Improvement in Cardiac Surgery Program, we compared procedural outcomes for all cardiac operations that were performed in the year before the hurricane (Year A, 29 August 2004-28 August 2005) and the year after (Year B, 30 August 2005-29 August 2006). Mortality was examined as unadjusted rates and as risk-adjusted observed-to-expected ratios. We identified 433 cardiac surgery cases: 143 (33%) from Year A and 290 (67%) from Year B. The operative mortality rate was 2.8% during Year A (observed-to-expected ratio, 0.4) and 2.8% during Year B (observed-to-expected ratio, 0.6) (P = 0.9). We identified several factors that enabled our institution to accommodate the increase in surgical volume during the study period. We conclude that, although Hurricane Katrina caused a sudden, dramatic increase in the number of cardiac operations that were performed at our facility, good surgical outcomes were maintained.     

Prognostic impact of intra-aortic balloon pump insertion before versus after cardiac surgical intervention in a veteran population

Background

The relative prognostic impact of intra-aortic balloon pump (IABP) placement before versus after cardiac surgery is not well defined.

Methods

We reviewed data from all cardiac surgical patients who received perioperative IABP support at a veterans' hospital between April 1992 and April 2008. We compared outcomes between patients who received an IABP before surgery (BS, n = 36) and after surgery (AS, n = 28).

Results

The AS group had higher operative morbidity (71% vs 42%) and mortality (43% vs 14%) rates than the BS group (P < .02 for both). Furthermore, survival rates were lower in the AS group than in the BS group at 1 year (50% vs 83%) and 3 years (46% vs 80%) (log-rank test, P < .004).

Conclusions

Patients who require IABP after cardiac surgery may have worse outcomes than patients who receive IABP support before surgery. In both groups, after an early peak in mortality, the midterm outcomes were characterized by a reassuring plateau in the survival rates.     

Open-heart operations in patients with a spinal cord injury

BACKGROUND: The objective of our study was to evaluate the outcomes of open-heart surgery in patients with a spinal cord injury. METHODS: A retrospective analysis of all patients (n = 8) with a spinal cord injury who underwent open-heart operations in a single institution from April 1994 to November 2006 was conducted. RESULTS: All patients had a permanent spinal cord injury with levels ranging from T3 to L2 with a mean age of 62 years (range, 47-72). Seven coronary artery bypass operations and 2 aortic valve replacements were performed. The mean cardiac ejection fraction was 44% (range, 20-60). Seventy-five percent of the patients were extubated within 24 hours of the operation. A decubitus ulcer occurred in only 1 patient. The acute hospital stay averaged 14 days (range, 6-36). One patient died from multiorgan failure on postoperative day 13 giving an in-hospital 30-day mortality of 12.5%. The 5-year survival was 75% with a mean follow-up of 67 months (range, .5-129). CONCLUSIONS: Open-heart operations in patients with a spinal cord injury can be performed safely with acceptable early and late outcomes.