Nursing Home Admission and Initiation of Domiciliary Care Following Infective Endocarditis

Need for home care or nursing home admission after myocardial infarction complicated by cardiogenic shock and/or out-of-hospital cardiac arrest

AIMS

Myocardial infarction (MI) with cardiogenic shock (CS) and/or out-of-hospital cardiac arrest (OHCA) are conditions with potential loss of autonomy. In patients with MI, the association between CS and OHCA and need for home care or nursing home admission was examined.

METHODS AND RESULTS

Danish nationwide registries identified patients with MI (2008-19), who prior to the event lived at home without home care and discharged alive. One-year cumulative incidences and hazard ratios (HRs) were reported for home care need or nursing home admission, a composite proxy for disability in activities of daily living (ADL), along with all-cause mortality. The study population consisted of 67 109 patients with MI (by groups: -OHCA/-CS: 63 644; -OHCA/+CS: 1776; +OHCA/-CS: 968; and +OHCA/+CS: 721). The 1-year cumulative incidences of home care/nursing home were 7.1% for patients who survived to discharge with -OHCA/-CS, 20.9% for -OHCA/+CS, 5.4% for +OHCA/-CS, and 8.2% for those with +OHCA/+CS. The composite outcome was driven by home care. With the -OHCA/-CS as reference, the adjusted HRs for home care/nursing home were 2.86 (95% CI: 2.57-3.19) for patients with -OHCA/+CS; 1.31 (95% CI: 1.00-1.73) for + OHCA/-CS; and 2.18 (95% CI: 1.68-2.82) for those with +OHCA/+CS. The 1-year cumulative mortality were 5.1% for patients with -OHCA/-CS, 9.8% for -OHCA/+CS, 3.0% for +OHCA/-CS, and 3.4% for those with +OHCA/+CS.

CONCLUSION

In patients discharged alive after a MI, CS, and to a lesser degree OHCA were associated with impaired ADL with a two-fold higher 1-year incidence of home care or nursing home admission compared with MI patients without CS or OHCA.

Long-term incidence of infective endocarditis among patients with congenital heart disease

BACKGROUND

Patients with congenital heart disease (CHD) are at lifelong high risk of infective endocarditis (IE). The risk of IE presumably differs among different CHD, but little knowledge exists on the area.

METHODS

In this observational cohort study, all CHD-patients born in 1977 to 2018 were identified using Danish nationwide registries and followed from the date of birth until first-time IE, emigration, death, or end of study (December 31, 2018). The comparative risk of IE among CHD-patients vs age- and sex-matched controls from the background population was assessed. The risk of IE was stratified according to the type of CHD and factors associated with IE including sex and relevant time-varying coefficients (ie, cyanosis, cardiac prostheses, diabetes mellitus, chronic kidney disease, and cardiac implantable electronic devices) were examined using Cox-regression analysis.

RESULTS

A total of 23,464 CHD-patients (50.0% men) were identified and matched with 93,856 controls. During a median follow-up of 17.7 years, 217(0.9%) CHD-patients and 4(0.0%) controls developed IE, corresponding to incidence rates of 5.2(95%CI 4.6-6.0) and 0.02(95%CI 0.01-0.1) per 10,000 person-years, respectively. The incidence of IE was greatest among patients with tetralogy of fallot, malformations of the heart chambers (including transposition of the great arteries, univentricular heart, and truncus arteriosus), atrioventricular septal defects, and heart valve defects. Factors associated with IE among CHD-patients included male sex, cyanosis, cardiac prostheses, chronic kidney disease, and cardiac implantable electronic devices.

CONCLUSIONS

CHD-patients have a substantially higher associated incidence of IE than the background population. With the increasing longevity of these patients, relevant guidelines concerning preventive measures are important.

Prescription practices of antibiotic prophylaxis among patients at high risk of infective endocarditis

Introduction

Antibiotic prophylaxis is recommended for patients considered in high risk of infective endocarditis (i.e., patients with prior infective endocarditis, heart valve prosthesis, and certain congenital heart diseases).

Methods

This study investigated prescription patterns and prescription filling patterns of antibiotic prophylaxis in patients at high risk of infective endocarditis. Prescription and prescription filling were evaluated by examination of patients records and an unselected patient cohort using Danish nationwide registries, respectively.

Results

Approximately 50 % of the patients were prescribed relevant antibiotic prophylaxis but not all filled their prescription.

Conclusion

Compliance with guidelines by Danish clinicians is only approximately 50 % and not all the patients fill their prescription. Clearly, there is room for improvement - an improvement which has the potential to reduce the incidence of infective endocarditis.

Nursing Home Admission Following Transcatheter Aortic Valve Replacement: A Danish Nationwide Cohort Study

BACKGROUND

Loss of autonomy associated with nursing home admission (NHA) is a concern for patients. Yet the incidence of NHA after transcatheter aortic valve replacement (TAVR) is unknown.

OBJECTIVES

The aim of this study was to investigate the incidence and factors associated with NHA following TAVR compared with the general population.

METHODS

Through Danish registries, patients alive at discharge after TAVR were identified from January 2014 to October 2021. Patients were matched 1:5 on sex, age, and calendar year to the general population. The 3-year cumulative incidence and 95% CI of NHA were estimated using the Aalen-Johansen estimator, accounting for the competing risk for death. Through multivariate cause-specific Cox regression models, factors associated with NHA were examined.

RESULTS

In total, 5,312 TAVR patients were matched to 26,560 control subjects with a median age of 81 years and 56.1% males. Comorbidity burden was higher for TAVR patients. The 3-year cumulative incidence of NHA was 6.3% (95% CI: 5.5%-7.1%) for TAVR patients compared with 5.8% (95% CI: 5.4%-6.1%) for the general population. For TAVR patients >85 years of age, the cumulative incidence of NHA was 11.6% (95% CI: 9.5%-13.8%), and the risk for death was 23.3% (95% CI: 20.4%-26.2%). Factors associated with NHA were increasing age, frailty, living alone, and atrial fibrillation.

CONCLUSIONS

TAVR was not associated with an increased incidence of NHA compared with the general population. Despite the increased incidence of NHA for TAVR patients >85 years of age, approximately 2 in 3 patients were still alive and not admitted to nursing homes 3 years after TAVR.

Incidence of Infective Endocarditis Among Patients With Tetralogy of Fallot

Background

Patients with tetralogy of Fallot (ToF) are considered at high risk of infective endocarditis (IE) as a result of altered hemodynamics and multiple invasive procedures, including pulmonary valve replacement (PVR). Data on the long‐term risk of IE are sparse.

Methods and Results

In this observational cohort study, all patients with ToF born from 1977 to 2018 were identified using Danish nationwide registries and followed from date of birth until occurrence of first‐time IE, emigration, death, or end of study (December 31, 2018). The comparative risk of IE among patients with ToF versus age‐ and sex‐matched controls from the background population was assessed. Because of rules on anonymity, exact numbers cannot be reported if the number of patients is <4. A total of 1164 patients with ToF were identified and matched with 4656 controls. Among patients with ToF, 851 (73.1%) underwent early surgical intracardiac repair and 276 (23.7%) underwent PVR during follow‐up. During a median follow‐up of 20.3 years, 41 (3.5%) patients with ToF (comprising 24 [8.7%] with PVR and 17 [1.9%] without PVR) and <4 (<0.8%) controls were admitted with IE. The incidence rates of IE per 10 000 person‐years were 22.4 (95% CI, 16.5–30.4) and 0.1 (95% CI, 0.01–0.7) among patients and controls, respectively. Moreover, PVR was associated with a further increased incidence of IE among patients with ToF (incidence rates per 10 000 person‐years with and without PVR were 46.7 [95% CI, 25.1–86.6] and 2.8 [95% CI 2.0–4.0], respectively).

Conclusions

Patients with ToF are associated with a substantially higher incidence of IE than the background population. In particular, PVR was associated with an increased incidence of IE. With an increasing life expectancy of these patients, intensified awareness, preventive measures, and surveillance of this patient group are decisive.

Comprehensive cardiac rehabilitation for patients following infective endocarditis: results of the randomized CopenHeartIE trial

AIMS

Infective endocarditis is a complex and highly mortal disease requiring lengthy treatment. Physical and mental deconditioning is common. Nonetheless, rehabilitation is virtually unexplored in this population. The aim of this trial was therefore to investigate the effects of cardiac rehabilitation in patients following endocarditis.

METHODS AND RESULTS

In a randomized trial, adults with left-sided or cardiac device endocarditis were randomized 1:1 to 12 weeks of physical exercise training and five psycho-educational consultations (cardiac rehabilitation) vs. usual care without rehabilitation (control). Primary outcome was mental health measured by SF-36 Mental Component Summary (MCS) at 6 months. Secondary outcome was physical capacity measured by peak oxygen uptake (VO2) at 4 months. Exploratory outcomes were investigated. Low inclusion rate resulted in trial termination before reaching the target sample size. A total of 117 participants (mean age: 60 years, 81% male) were randomized to cardiac rehabilitation (n = 58) or to control (n = 59). Mental health and physical capacity at baseline were generally poor (MCS: 38.9-42.2 points, VO2 peak: 16.1-16.6 mL/kg/min). Cardiac rehabilitation compared with control showed no effect on mental health (MCS: 44.6 points vs. 48.8 points, P = 0.41) or physical capacity (VO2 peak: 19.9 mL/kg/min vs. 18.0 mL/kg/min, P = 0.09). Effects favouring the intervention were identified in exploratory outcomes including general fatigue (P = 0.005), and physical capacity as maximal power (W) (P = 0.005). Adherence to the intervention was 28%.

CONCLUSIONS

Results indicate no effect of cardiac rehabilitation in patients following endocarditis; however, lack of statistical power and poor adherence render findings inconclusive. Valuable insight into patients' capabilities and safety was gained, and further investigations into rehabilitation needs and modes of delivery in this high-need population should be a future priority.

Incidence of infective endocarditis during the coronavirus disease 2019 pandemic: A nationwide study

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The incidence of IE during lockdown was 11.1 IE cases per 100,000 PY.

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No reduction in the incidence of IE during the lockdown compared to preceding years.

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No difference in the incidence of IE pre- versus post-lockdown in 2020.

Background

The incidence of infective endocarditis (IE) has increased in recent decades. Societal lockdown including reorganization of the healthcare system during the COVID-19 pandemic may influence the incidence of IE. This study sets out to investigate the incidence of IE during the Danish national lockdown.

Methods

In this nationwide cohort study, patients admitted with IE in either one of two periods A) A combined period of 1 January to 7 May for 2018 and 2019, or B) 1 January to 6 May 2020, were identified using Danish nationwide registries. Weekly incidence rates of IE admissions for the 2018/2019-period and 2020-period were computed and incidence rate ratios (IRR) for 2020-incidence vs 2018/2019-incidence were calculated using Poisson regression analysis.

Results

In total, 208 (67.3% men, median age 74.1 years) and 429 (64.1% men, median age 72.7 years) patients were admitted with IE in 2020 and 2018/2019, respectively. No significant difference in incidence rates were found comparing the 2020-period and 2018/2019-period (IRR: 0.96 (95% CI: 0.82–1.14). The overall incidence rate pre-lockdown (week 1–10: 1 January to 11 March 2020) was 14.2 IE cases per 100,000 person years (95% CI: 12.0–16.9) as compared with 11.4 IE cases per 100,000 person years (95% CI: 9.1–14.1) during lockdown (week 11–18: 12 March to 6 May 2020) corresponding to an IRR of 0.80 (95% CI: 0.60–1.06) and thus no significant difference pre- versus post-lockdown.

Conclusion

In this nationwide cohort study, no significant difference in the incidence of IE admissions during the national lockdown due to the COVID-19 pandemic was found.