The unbearable underreporting of comorbidities in heart failure clinical trials

Cardiovascular Disease in Total Knee Arthroplasty: An Analysis of Hospital Outcomes, Complications, and Mortality

Background

Cardiovascular comorbidities have been identified as a significant risk factor for adverse outcomes following surgery. The purpose of this study was to investigate its prevalence and impact on postoperative outcomes, hospital metrics, and mortality in patients undergoing total knee arthroplasty (TKA). Our hypothesis was that patients with cardiovascular comorbidities would have worse outcomes, greater postoperative complication rates, and increased mortality compared to patients without cardiovascular disease.

Methods

In this retrospective study, data from the National Inpatient Sample database from 2011 to 2020 were queried for patients who underwent TKA with preexisting cardiac comorbidities, including congestive heart failure (CHF), coronary artery disease (CAD), valvular dysfunction, and arrhythmia. Multivariate logistic regression analyses compared hospital metrics (length of stay, costs, and adverse discharge disposition), postoperative complications, and mortality rates while adjusting for demographic and clinical variables. All statistical analyses were performed using R studio 4.2.2 and Stata MP 17 and 18 with Python package.

Results

A total of 385,585 patients were identified. Those with preexisting CHF, CAD, valvular dysfunction, or arrhythmias were found to be older and at higher risk of adverse outcomes, including prolonged length of stay, increased hospital charges, and increased mortality (p < 0.001). Additionally, all preexisting cardiac diagnoses led to an increased risk of postoperative myocardial infarction, acute kidney injury (AKI), and need for transfusion (p < 0.001). The presence of valvular dysfunction, arrhythmia, or CHF was associated with an increased risk of thromboembolic events (p < 0.001). The presence of CAD and valvular dysfunction was associated with an increased risk of urologic infection (p < 0.001).

Conclusions

This study demonstrated that CHF, CAD, valvular dysfunction, and arrhythmia are prevalent among TKA patients and associated with worse hospital metrics, higher risk of perioperative complications, and increased mortality. As our use of TKA rises, a lower threshold for preoperative cardiology referral in older individuals and early preoperative counseling/intervention in those with known cardiac disease may be necessary to reduce adverse outcomes.

Pathophysiological Rationale and Clinical Evidence for Neurohormonal Modulation in Heart Failure with Preserved Ejection Fraction

Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous syndrome resulting from the interaction between cardiac diseases, comorbidities and ageing. HFpEF is characterised by the activation of neurohormonal axes, namely of the renin-angiotensin-aldosterone system and the sympathetic nervous system, although to a lesser extent compared with heart failure with reduced ejection fraction. This provides a rationale for neurohormonal modulation as a therapeutic approach for HFpEF. Nonetheless, randomised clinical trials have failed to demonstrate a prognostic benefit from neurohormonal modulation therapies in HFpEF, with the sole exception of patients with left ventricular ejection fraction in the lower range of normality, for whom the American guidelines suggest that such therapies may be considered. In this review, the pathophysiological rationale for neurohormonal modulation in HFpEF is summarised and the clinical evidence on pharmacological and nonpharmacological approaches backing current recommendations discussed.

Choosing between Homologous or Heterologous COVID-19 Vaccination Regimens: A Cross-Sectional Study among the General Population in Italy

A shortage of COVID-19 vaccines and reports of side-effects led several countries to recommend a heterologous regimen for second vaccine doses. This study aimed to describe the reasons behind individuals’ choices of a homologous or a heterologous second vaccination. This cross-sectional study enrolled individuals under 60 who had received a first dose of Vaxzevria and could choose between a homologous or heterologous regimen for their second dose. Quantitative (socio-demographic, clinical characteristics) and qualitative data were collected and analysed through a generalized linear model and thematic analysis, respectively. Of the 1437 individuals included in the analysis, the majority (76.1%) chose a heterologous second dose of the COVID-19 vaccination. More females chose a heterologous vaccination regimen (p = 0.003). Younger individuals also tended to choose heterologous vaccination (p < 0.001). The main motivation in favour of heterologous vaccination was to follow the Italian Ministry of Health recommendations (n = 118; 53.9%). This study showed that most individuals, mainly younger people and females, chose a heterologous dose of COVID-19 vaccination after their first viral vector vaccine. Heterologous vaccinations could be an effective public health measure to control the pandemic as they are a safe and efficient alternative to homologous regimens.