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Concomitant Surgical Ablation in Paroxysmal vs Persistent Atrial Fibrillation During Mitral Surgery.The Annals of Thoracic Surgery Jul 2024Despite prospective randomized evidence supporting concomitant treatment of Atrial Fibrillation (AF) during mitral valve (MV) surgery, variation in surgical management...
BACKGROUND
Despite prospective randomized evidence supporting concomitant treatment of Atrial Fibrillation (AF) during mitral valve (MV) surgery, variation in surgical management of AF remains. We sought to assess longitudinal outcomes following surgical treatment of persistent or paroxysmal AF during MV surgery in Medicare Beneficiaries.
METHODS
All Medicare beneficiaries with a diagnosis of AF undergoing MV surgery (2018-2020) were evaluated. Patients were stratified by no AF treatment versus Left Atrial Appendage Obliteration (LAAO) alone versus LAAO and Surgical Ablation (SA+LAAO). Doubly robust risk-adjustment and subgroup analysis by persistent or paroxysmal AF were performed.
RESULTS
A total of 7,517 patients with preoperative AF underwent MV surgery (32.1% no AF treatment, 23.1% LAAO alone, 44.7% SA+LAAO). After doubly robust risk-adjustment, AF treatment with SA+LAAO or LAAO alone was associated with lower 3-year readmission for stroke or bleeding. However, SA+LAAO was associated with reduced 3-year mortality, and readmission for AF or heart failure, compared to no AF treatment or LAAO alone. Compared to no AF treatment or LAAO alone, SA+LAAO was associated with lower composite endpoint of stroke or death at 3 years (HR 0.75 and HR 0.83, respectively). Subgroup analysis identified similar longitudinal benefits of SA+LAAO in patients with persistent or paroxysmal AF.
CONCLUSIONS
In Medicare beneficiaries with AF undergoing MV surgery, SA+LAAO was associated with improved longitudinal outcomes compared to LAAO alone or no AF treatment in patients with paroxysmal or persistent AF. These contemporary real-world data further clarify the benefit of SA+LAAO during mitral valve surgery across all types of AF.
PubMed: 38964701
DOI: 10.1016/j.athoracsur.2024.06.020 -
Chest Jul 2024Reintubation is associated with higher risk of mortality. There is no clear evidence on the best spontaneous breathing trial (SBT) method to reduce the risk of...
Association between spontaneous breathing trial methods and reintubation in adult critically ill patients: A systematic review and network meta-analysis of randomized controlled trials.
BACKGROUND
Reintubation is associated with higher risk of mortality. There is no clear evidence on the best spontaneous breathing trial (SBT) method to reduce the risk of reintubation.
RESEARCH QUESTION
Are different methods of conducting SBT in critically ill patients associated with different risk of reintubation compared to T-tube?
STUDY DESIGN AND METHODS
We conducted a systematic review and Bayesian network meta-analysis of randomized controlled trials (RCTs) investigating the effects of different SBT methods on reintubation. We surveyed PubMed, MEDLINE, CINAHL and CENTRAL databases from inception to 26th January 2024. The Surface Under the Cumulative Ranking curve (SUCRA) was used to determine the likelihood that an intervention was ranked as the best. Pairwise comparisons were also investigated by frequentist meta-analysis. Certainty of the evidence was assessed according to the GRADE approach.
RESULTS
A total of 22 RCTs were included, for a total of 6196 patients. The network included nine nodes, with 13 direct pairwise comparisons. About 71% of the patients were allocated to T-tube and PSV-ZEEP, with 2135 and 2101 patients, respectively. The only intervention with a significantly lower risk of reintubation compared to T-tube was high flow oxygen (HFO) (RR 0.23, CrI 0.09 to 0.51, moderate quality evidence). HFO was associated with the highest probability of being the best intervention for reducing the risk of reintubation (81.86%, SUCRA 96.42), followed by continuous positive airway pressure (11.8%, SUCRA 76.75).
INTERPRETATION
HFO SBT was associated with a lower risk of reintubation in comparison to other SBT methods. The results of our analysis should be considered with caution due to the low number of studies that investigated HFO SBT, and potential clinical heterogeneity related to co-interventions. Further trials should be performed to confirm the results on larger cohorts of patients and assess specific subgroups.
PubMed: 38964674
DOI: 10.1016/j.chest.2024.06.3773 -
Chest Jul 2024When comparing outcomes after sepsis, it is essential to account for patient case mix to make fair comparisons. We developed a model to assess risk-adjusted 30-day...
BACKGROUND
When comparing outcomes after sepsis, it is essential to account for patient case mix to make fair comparisons. We developed a model to assess risk-adjusted 30-day mortality in the Michigan Hospital Medicine Safety's sepsis initiative (HMS-Sepsis).
QUESTION
Can HMS-Sepsis registry data adequately predict risk of 30-day mortality? Do performance assessments using adjusted vs unadjusted data differ?
STUDY DESIGN AND METHODS
Retrospective cohort of community-onset sepsis hospitalizations in HMS-Sepsis registry (4/2022-9/2023), with split derivation (70%) and validation (30%) cohorts. We fit a risk-adjustment model (HMS-Sepsis mortality model) incorporating acute physiology, demographic, and baseline health data and assessed model performance using c-statistics, Brier's scores, and comparisons of predicted vs observed mortality by deciles of risk. We compared hospital performance (1st quintile, middle quintiles, 5th quintile) using observed versus adjusted mortality to understand the extent to which risk-adjustment impacted hospital performance assessment.
RESULTS
Among 17,514 hospitalizations from 66 hospitals during the study period, 12,260 (70%) were used for model derivation and 5,254 (30%) for model validation. 30-day mortality for the total cohort was 19.4%. The final model included 13 physiologic variables, two physiologic interactions, and 16 demographic and chronic health variables. The most significant variables were age, metastatic solid tumor, temperature, altered mental status, and platelet count. The model c-statistic was 0.82 for the derivation cohort, 0.81 for the validation cohort, and ≥0.78 for all subgroups assessed. Overall calibration error was 0.0% and mean calibration error across deciles of risk was 1.5%. Standardized mortality ratios yielded different assessments than observed mortality for 33.9% of hospitals.
CONCLUSIONS
The HMS-Sepsis mortality model had strong discrimination, adequate calibration, and reclassified one-third of hospitals to a different performance category from unadjusted mortality. Based on its strong performance, the HMS-Sepsis mortality model can aid in fair hospital benchmarking, assessment of temporal changes, and observational causal inference analysis.
PubMed: 38964673
DOI: 10.1016/j.chest.2024.06.3769 -
Journal of the American Society of... Jul 2024
PubMed: 38964666
DOI: 10.1016/j.echo.2024.06.016 -
Hellenic Journal of Cardiology : HJC =... Jul 2024Observational studies have shown that the management of patients with cardiogenic shock (CS) by dedicated multidisciplinary teams improve clinical outcomes....
BACKGROUND
Observational studies have shown that the management of patients with cardiogenic shock (CS) by dedicated multidisciplinary teams improve clinical outcomes. Nevertheless, these studies reflect a specific organisational setting with most patients being transfers from referring hospitals, hospitalised in cardiac intensive care units (ICU), or treated with mechanical circulatory support (MCS) devices. The purpose of this study was to document the organisation and outcomes of a CS team offering acute care in all-comer population.
METHODS
A CS team was developed in a large academic tertiary institution. The team consisted of emergency care physicians, critical care cardiologists, interventional cardiologists, cardiac surgeons, ICU physicians and heart failure specialists and was supported by predefined operating protocol, dedicated communication platform and regular team meetings.
RESULTS
Over 12 months, 70 CS patients (69±13 years old, 67% males) were included. Acute myocardial infarction (AMI-CS) was the most common cause (64%); 31% of the patients presented post-resuscitated cardiac arrest and 56% needed invasive mechanical ventilation (IMV). Coronary angiography was performed in 70% and 53% had percutaneous coronary intervention. MCS was used in 10% and 6% were referred for urgent cardiac surgery. The in-hospital mortality in our centre was 40% with 39% of the patients dying within 24-hours from presentation. 76% of the alive patients were discharged home.
CONCLUSIONS
Across an all-comer population, AMI was the most common cause of CS. A significant number of patients presented post cardiac arrest, and the majority required IMV. Mortality was high with a significant number dying within hours of presentation.
PubMed: 38964654
DOI: 10.1016/j.hjc.2024.06.011 -
Free Radical Biology & Medicine Jul 2024Hyperglycaemia-induced oxidative stress plays significant roles in the development of type 2 diabetes and its complications. This study investigates effects of...
Hyperglycaemia-induced oxidative stress plays significant roles in the development of type 2 diabetes and its complications. This study investigates effects of magainin-AM2 on high-sucrose diet induced redox imbalance and cognitive impairment in Drosophila melanogaster. Effects of various concentrations of sucrose, magainin-AM2 or a combination of both agents on mortality, eclosion rate, generation of reactive oxygen and nitrogen species, activities of antioxidant enzymes, thiol system, and markers of cognitive functions in control and treated flies were examined. Results showed that the exposure of flies to high sucrose (30% - 60% w/w) diet increased mortality rate (38 - 67%, P<0.001) and levels of glucose (1.8 - 1.9-fold, P<0.001), hydrogen peroxide (1.4 - 1.5-fold, P<0.01) and nitrite/nitrate (1.2-fold, P<0.01). Decreased levels of total thiol (53 - 59%, P<0.01), non-protein thiols (59 - 63%, P<0.01), catalase activities (39 - 47%, P<0.01 -0.05) and glutathione-s-transferase activities (31 - 43%, P<0.01 - 0.05) were also observed. Magainin-AM2 (0 - 10 μM/kg diet) did not affect fly mortality rate, levels of hydrogen peroxide and nitrite/nitrate, and activities of catalase and glutathione-s-transferase. However, the peptide produced a dose-dependent increase in total thiol 1.2 - 1.6-fold, P<0.001-0.01)and increases non-protein thiol levels at 10μM/kg diet (2.0-fold, P<0.01). Magainin-AM2 inhibited sucrose-induced elevation of glucose (55 - 70%, P<0.001), hydrogen peroxide (11 - 12%, P<0.01) and nitrite/nitrate (20 - 34%, P<0.01 - 0.05). The peptide prevented sucrose-induced reduction in total and non-protein thiols (1.9 - 2.0-fold, P<0.05) levels and activities of catalase (2.3 - 3.1-fold, P<0.001) and glutathione-s-transferase (1.8 - 2.8-fold, P<0.001- 0.05). Magainin-AM2 inhibited sucrose-induced reduction in acetylcholinesterase activities (3.6 - 4.0-fold, P<0.001), eclosion rate (18%, P<0.001) and negative geotaxis (1.3 - 14-fold, P<0.001). These results indicate that beneficial actions of magainin-AM2 may also involve the prevention of hyperglycaemia-induced oxidative damage and encourage its further development as an anti-diabetic agent.
PubMed: 38964592
DOI: 10.1016/j.freeradbiomed.2024.06.028 -
Environmental Research Jul 2024Long-term exposure to ambient air pollution has been linked with all-cause mortality and cardiovascular and respiratory diseases. Suggestive associations between ambient...
BACKGROUND
Long-term exposure to ambient air pollution has been linked with all-cause mortality and cardiovascular and respiratory diseases. Suggestive associations between ambient air pollutants and neurodegeneration have also been reported, but due to the small effect and relatively rare outcomes evidence is yet inconclusive. Our aim was to investigate the associations between long-term air pollution exposure and mortality from neurodegenerative diseases.
METHODS
A Dutch national cohort of 10.8 million adults aged ≥30 years was followed from 2013 until 2019. Annual average concentrations of air pollutants (ultra-fine particles (UFP), nitrogen dioxide (NO), fine particles (PM and PM) and elemental carbon (EC)) were estimated at the home address at baseline, using land-use regression models. The outcome variables were mortality due to amyotrophic lateral sclerosis (ALS), Parkinson's disease, non-vascular dementia, Alzheimer's disease, and multiple sclerosis (MS). Hazard ratios (HR) were estimated using Cox models, adjusting for individual and area-level socio-economic status covariates.
RESULTS
We had a follow-up of 71 million person-years. The adjusted HRs for non-vascular dementia were significantly increased for NO (1.03; 95% confidence interval (CI) 1.02-1.05) and PM (1.02; 95%CI 1.01-1.03) per interquartile range (IQR; 6.52 and 1.47 μg/m, respectively). The association with PM was also positive for ALS (1.02; 95%CI 0.97-1.07). These associations remained positive in sensitivity analyses and two-pollutant models. UFP was not associated with any outcome. No association with air pollution was found for Parkinson's disease and MS. Inverse associations were found for Alzheimer's disease.
CONCLUSION
Our findings, using a cohort of more than 10 million people, provide further support for associations between long-term exposure to air pollutants (PM and particularly NO) and mortality of non-vascular dementia. No associations were found for Parkinson and MS and an inverse association was observed for Alzheimer's disease.
PubMed: 38964584
DOI: 10.1016/j.envres.2024.119552 -
International Journal of Cardiology Jul 2024Current risk score models for predicting mortality in infective endocarditis (IE) include data often unavailable in registries, limiting their use for confounding...
INTRODUCTION
Current risk score models for predicting mortality in infective endocarditis (IE) include data often unavailable in registries, limiting their use for confounding adjustment in population-based research.
METHODS
This study assessed the Danish Comorbidity Index for Acute Myocardial Infarction (DANCAMI) for its ability to predict 30-day, 1-year, and 5-year mortality in IE patients, compared to the Charlson Comorbidity Index (CCI) and Elixhauser Comorbidity Index (ECI). The study included all adult Danish patients with first-time IE from 1995 to 2021. The area under the receiver operating characteristic curve (AUC) was estimated using logistic regression to measure discriminatory performance for all-cause and cardiovascular mortality at the specified time intervals. A baseline model included age and sex, while extended models incorporated continuous comorbidity scores.
RESULTS
We identified 8966 patients with IE. Mortality rates were 12% at 30 days, 26% at 1 year, and 36% at 5 years. For all-cause mortality, AUCs for the baseline versus DANCAMI models were 0.64 vs. 0.69 at 30 days, 0.66 vs. 0.73 at 1 year, and 0.72 vs. 0.79 at 5 years. For cardiovascular mortality, AUCs for baseline versus DANCAMI models were 0.67 vs. 0.69 at 30 days, 0.67 vs. 0.69 at 1 year, and 0.70 vs. 0.71 at 5 years. CCI and ECI demonstrated comparable AUCs to the DANCAMI model.
CONCLUSION
DANCAMI improved discrimination of short- and long-term mortality in IE patients and may be used for confounder adjustment similarly to CCI and ECI.
PubMed: 38964553
DOI: 10.1016/j.ijcard.2024.132328 -
International Journal of Cardiology Jul 2024Surprisingly, despite the high prevalence of metformin use in type 2 diabetes (T2D) patients with heart disease, limited safety data is available regarding metformin use...
Preadmission metformin use increased the incidence of hyperlactatemia at admission and 30-day in-hospital mortality among T2D patients with heart disease at high risk of hypoxia.
BACKGROUND
Surprisingly, despite the high prevalence of metformin use in type 2 diabetes (T2D) patients with heart disease, limited safety data is available regarding metformin use in patients with acute and critical heart disease.
METHODS
In this single-center retrospective study, patients admitted to the cardiology department for heart failure (HF) or acute coronary syndrome (ACS) between December 2013 and December 2021 and who underwent arterial blood gas analysis at admission with an estimated glomerular clearance rate of ≥45 ml/min/1.73 m were identified. The incidences of hyperlactatemia, acidosis, and 30-day in-hospital mortality were compared between preadmission metformin users and nonusers.
RESULTS
Of 526 admissions, 193/193 metformin users/nonusers were selected in a propensity score-matched model. Metformin users had greater lactate levels (2.55 ± 2.07 mmol/L vs. 2.00 ± 1.80 mmol/L P < 0.01), a greater incidence of hyperlactatemia [odds ratio (OR) = 2.55; 95% confidence interval (CI), 1.63-3.98; P < 0.01] and acidosis (OR = 1.78; 95% CI, 1.00-3.16; P < 0.05) at admission and a greater incidence of in-hospital mortality (OR = 3.83; 95% CI, 1.05-13.94; P < 0.05), especially those with HF/acute myocardial infarction, elderly age, or without preadmission insulin use.
CONCLUSIONS
Our results suggest that, compared to metformin nonusers, preadmission use of metformin may be associated with a greater incidence of hyperlactatemia and acidosis at admission and greater 30-day in-hospital mortality among T2D patients with HF or ACS at high risk of hypoxia, particularly those without preadmission insulin use. The safety of metformin in this population needs to be confirmed in prospective controlled trials.
PubMed: 38964551
DOI: 10.1016/j.ijcard.2024.132338 -
International Journal of Cardiology Jul 2024Heart disease remains the leading cause of death in the United States, while chronic lower respiratory diseases (CLRD) are the sixth leading cause of death. Patients...
BACKGROUND
Heart disease remains the leading cause of death in the United States, while chronic lower respiratory diseases (CLRD) are the sixth leading cause of death. Patients with CLRD have been shown to have an elevated risk of heart disease death. However, less is known regarding how this risk varies across demographic groups.
METHODS
We used the Multiple Cause of Death database from the Centers for Disease Control Wide-ranging ONline Data for Epidemiologic Research to obtain 1999-2020 information on deaths with heart disease as a primary cause of death and CLRD as a contributing cause. We calculated age-adjusted mortality rates (AAMR) over time and for demographic subgroups.
RESULTS
During 1999-2020, there were 1,178,048 heart disease deaths related to CLRD among people aged 45+. The AAMR for CLRD-associated heart disease deaths was 45.713 per 100,000 people. AAMR was highest among those aged 65+ (108.56 per 100,000). Elevated rates were seen among males (AAMR ratio = 1.744, 95% CI: 1.741-1.748), people living in the Midwest (AAMR ratio = 1.196, 95% CI: 1.190-1.202), and among people in rural areas (AAMR ratio = 1.309, 95% CI: 1.304-1.313) compared to their corresponding counterparts. Between 1999 and 2004 and 2016-2020 rates decreased among all demographic subgroups, except for among people aged 45-64, among whom deaths increased (AAMR ratio = 1.016, 95% CI: 1.003-1.030).
CONCLUSION
Rates of CLRD-associated heart disease deaths have declined over time, but significant disparities remain. Enhanced interventions particularly among older people (65+), people living in rural areas, people living in the Midwest, and men may reduce CLRD-associated heart disease deaths in the United States.
PubMed: 38964550
DOI: 10.1016/j.ijcard.2024.132323