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Myers LC, Peltan ID, Thai KK, Kipnis P, Desai M, Devis Y, Clancy H, Lu YW, Brown SM, Go AS, Neugebauer RS, Liu VX, Walkey AJ. Predicting stroke risk after sepsis hospitalization with new-onset atrial fibrillation. J Hosp Med 2024; 19:565-571. [PMID: 38594918 DOI: 10.1002/jhm.13343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 11/20/2023] [Accepted: 03/17/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND New-onset atrial fibrillation (AF) during sepsis is common, but models designed to stratify stroke risk excluded patients with secondary AF. We assessed the predictive validity of CHA2DS2VASc scores among patients with new-onset AF during sepsis and developed a novel stroke prediction model incorporating presepsis and intrasepsis characteristics. METHODS We included patients ≥40 years old who survived hospitalizations with sepsis and new-onset AF across 21 Kaiser Permanente Northern California hospitals from January 1, 2011 to September 30, 2017. We calculated the area under the receiver operating curve (AUC) for CHA2DS2VASc scores to predict stroke or transient ischemic attack (TIA) within 1 year after a hospitalization with new-onset AF during sepsis using Fine-Gray models with death as competing risk. We similarly derived and validated a novel model using presepsis and intrasepsis characteristics associated with 1-year stroke/TIA risk. RESULTS Among 82,748 adults hospitalized with sepsis, 3992 with new-onset AF (median age: 80 years, median CHA2DS2VASc of 4) survived to discharge, among whom 70 (2.1%) experienced stroke or TIA outcome and 1393 (41.0%) died within 1 year of sepsis. The CHA2DS2VASc score was not predictive of stroke risk after sepsis (AUC: 0.50, 95% confidence interval [CI]: 0.48-0.52). A newly derived model among 2555 (64%) patients in the derivation set and 1437 (36%) in the validation set included 13 variables and produced an AUC of 0.61 (0.49-0.73) in derivation and 0.54 (0.43-0.65) in validation. CONCLUSION Current models do not accurately stratify risk of stroke following new-onset AF secondary to sepsis. New tools are required to guide anticoagulation decisions following new-onset AF in sepsis.
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Affiliation(s)
- Laura C Myers
- The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, California, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Ithan D Peltan
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, Utah, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Khanh K Thai
- The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, California, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Patricia Kipnis
- The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, California, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Manisha Desai
- Biomedical Informatics Department, Stanford University, Palo Alto, California, USA
| | - Ycar Devis
- Section of Pulmonary, Critical Care, Allergy, Sleep Medicine, Department of Medicine, The Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Heather Clancy
- The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, California, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Yun W Lu
- The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, California, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Samuel M Brown
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, Utah, USA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Alan S Go
- The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, California, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
- Department of Epidemiology and Biostatistics and Department of Medicine, University of California, San Francisco, San Francisco, California, USA
- Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Romain S Neugebauer
- The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, California, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Vincent X Liu
- The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, California, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Allan J Walkey
- Section of Pulmonary, Critical Care, Allergy, Sleep Medicine, Department of Medicine, The Pulmonary Center, Boston University School of Medicine, Boston, Massachusetts, USA
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Papini S, Iturralde E, Lu Y, Greene JD, Barreda F, Sterling SA, Liu VX. Development and validation of a machine learning model using electronic health records to predict trauma- and stressor-related psychiatric disorders after hospitalization with sepsis. Transl Psychiatry 2023; 13:400. [PMID: 38114475 PMCID: PMC10730505 DOI: 10.1038/s41398-023-02699-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 11/17/2023] [Accepted: 11/29/2023] [Indexed: 12/21/2023] Open
Abstract
A significant minority of individuals develop trauma- and stressor-related disorders (TSRD) after surviving sepsis, a life-threatening immune response to infections. Accurate prediction of risk for TSRD can facilitate targeted early intervention strategies, but many existing models rely on research measures that are impractical to incorporate to standard emergency department workflows. To increase the feasibility of implementation, we developed models that predict TSRD in the year after survival from sepsis using only electronic health records from the hospitalization (n = 217,122 hospitalizations from 2012-2015). The optimal model was evaluated in a temporally independent prospective test sample (n = 128,783 hospitalizations from 2016-2017), where patients in the highest-risk decile accounted for nearly one-third of TSRD cases. Our approach demonstrates that risk for TSRD after sepsis can be stratified without additional assessment burden on clinicians and patients, which increases the likelihood of model implementation in hospital settings.
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Affiliation(s)
- Santiago Papini
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA.
- Department of Psychology, University of Hawai'i at Mānoa, Honolulu, HI, USA.
| | - Esti Iturralde
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Yun Lu
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - John D Greene
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Fernando Barreda
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Stacy A Sterling
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Vincent X Liu
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
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Kosyakovsky LB, Angriman F. Cardiovascular Disease After COVID-19: A Call to Action. JACC. ADVANCES 2023; 2:100448. [PMID: 38939442 PMCID: PMC11198687 DOI: 10.1016/j.jacadv.2023.100448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Affiliation(s)
- Leah B. Kosyakovsky
- Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Federico Angriman
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
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Angriman F, Lawler PR, Shah BR, Martin CM, Scales DC. Prevalent diabetes and long-term cardiovascular outcomes in adult sepsis survivors: a population-based cohort study. Crit Care 2023; 27:302. [PMID: 37525272 PMCID: PMC10391991 DOI: 10.1186/s13054-023-04586-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 07/19/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND Sepsis survivors are at elevated risk for cardiovascular disease during long-term follow-up. Whether diabetes influences cardiovascular risk after sepsis survival remains unknown. We sought to describe the association of diabetes with long-term cardiovascular outcomes in adult sepsis survivors. METHODS Population-based cohort study in the province of Ontario, Canada (2008-2017). Adult survivors of a first sepsis-associated hospitalization, without pre-existing cardiovascular disease, were included. Main exposure was pre-existing diabetes (any type). The primary outcome was the composite of myocardial infarction, stroke, and cardiovascular death. Patients were followed up to 5 years from discharge date until outcome occurrence or end of study period (March 2018). We used propensity score matching (i.e., 1:1 to patients with sepsis but no pre-existing diabetes) to adjust for measured confounding at baseline. Cause-specific Cox proportional hazards models with robust standard errors were used to estimate hazard ratios (HR) alongside 95% confidence intervals (CI). A main secondary analysis evaluated the modification of the association between sepsis and cardiovascular disease by pre-existing diabetes. RESULTS 78,638 patients with pre-existing diabetes who had a sepsis-associated hospitalization were matched to patients hospitalized for sepsis but without diabetes. Mean age of patients was 71 years, and 55% were female. Median duration from diabetes diagnosis was 9.8 years; mean HbA1c was 7.1%. Adult sepsis survivors with pre-existing diabetes experienced a higher hazard of major cardiovascular disease (HR 1.25; 95% CI 1.22-1.29)-including myocardial infarction (HR 1.40; 95% CI 1.34-1.47) and stroke (HR 1.24; 95% CI 1.18-1.29)-during long-term follow-up compared to sepsis survivors without diabetes. Pre-existing diabetes modified the association between sepsis and cardiovascular disease (risk difference: 2.3%; 95% CI 2.0-2.6 and risk difference: 1.8%; 95% CI 1.6-2.0 for the effect of sepsis-compared to no sepsis-among patients with and without diabetes, respectively). CONCLUSIONS Sepsis survivors with pre-existing diabetes experience a higher long-term hazard of major cardiovascular events when compared to sepsis survivors without diabetes. Compared to patients without sepsis, the absolute risk increase of cardiovascular events after sepsis is higher in patients with diabetes (i.e., diabetes intensified the higher cardiovascular risk induced by sepsis).
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Affiliation(s)
- Federico Angriman
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
| | - Patrick R Lawler
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- McGill University Health Centre, Montreal, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, Canada
| | - Baiju R Shah
- ICES, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Claudio M Martin
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Canada
- Lawson Health Research Institute, London, Canada
| | - Damon C Scales
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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Angriman F, Rosella LC, Lawler PR, Ko DT, Martin CM, Wunsch H, Scales DC. Risk Factors for Major Cardiovascular Events in Adult Sepsis Survivors: A Population-Based Cohort Study. Crit Care Med 2023; 51:471-483. [PMID: 36790198 DOI: 10.1097/ccm.0000000000005793] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
OBJECTIVES To describe risk factors for major cardiovascular events in adults following hospital discharge after sepsis. DESIGN Population-based cohort study. SETTING Ontario, Canada (2008-2017). PATIENTS Adult patients (age 18 yr or older) who survived a first sepsis hospitalization without preexisting cardiovascular disease. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary composite outcome was myocardial infarction, stroke, or cardiovascular death up to 5 years following hospital discharge. We used cause-specific Cox proportional hazards models that accounted for the competing risk of noncardiovascular death to describe factors associated with major cardiovascular events. We identified 268,259 adult patients without cardiovascular disease (median age, 72 yr), of whom 10.4% experienced a major cardiovascular event during a median follow-up of 3 years. After multivariable adjustment, age (hazard ratio [HR], 1.53 for every 10 yr; 95% CI, 1.51-1.54), male sex (HR, 1.23; 95% CI, 1.20-1.26), diabetes mellitus (HR, 1.24; 95% CI, 1.21-1.27), hypertension (HR, 1.34; 95% CI, 1.30-1.38), prevalent atrial fibrillation (HR, 1.46; 95% CI, 1.40-1.52), and chronic kidney disease (HR, 1.11; 95% CI, 1.06-1.16) were associated with major cardiovascular events during long-term follow-up. Sepsis characteristics such as site of infection (pneumonia vs other: HR, 1.09; 95% CI, 1.05-1.12), septic shock (HR, 1.08; 95% CI, 1.05-1.11), and renal replacement therapy (HR, 1.51; 95% CI, 1.38-1.64) were also associated with subsequent cardiovascular events. In an analysis restricting to patients with troponin values measured during the hospitalization (26,400 patients), an elevated troponin was also associated with subsequent cardiovascular events (HR, 1.23; 95% CI, 1.13-1.33). CONCLUSIONS Classic cardiovascular risk factors, comorbid conditions, and characteristics of the sepsis episode were associated with a higher hazard of major cardiovascular events in adult sepsis survivors. These findings may inform enrichment strategies for future studies.
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Affiliation(s)
- Federico Angriman
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
- Laboratory Medicine and Pathobiology, Temerty Faculty of Medicine, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Lawson Health Research Institute, London, ON, Canada
| | - Laura C Rosella
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
- Laboratory Medicine and Pathobiology, Temerty Faculty of Medicine, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Lawson Health Research Institute, London, ON, Canada
| | - Patrick R Lawler
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Dennis T Ko
- ICES, Toronto, ON, Canada
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Claudio M Martin
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Lawson Health Research Institute, London, ON, Canada
| | - Hannah Wunsch
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Damon C Scales
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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Myers LC, Knox D, Thai KK, Kipnis P, Jacobs J, Lee C, Desai M, Devis Y, Clancy H, Lu YW, Go AS, Liu VX, Walkey AJ. Predicting Cardiovascular Events after Sepsis with Death as a Competing Risk. Ann Am Thorac Soc 2023; 20:145-148. [PMID: 36122170 PMCID: PMC9819256 DOI: 10.1513/annalsats.202206-536rl] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- Laura C. Myers
- Kaiser Permanente Northern CaliforniaOakland, California
| | | | - Khanh K. Thai
- Kaiser Permanente Northern CaliforniaOakland, California
| | | | | | - Catherine Lee
- Kaiser Permanente Northern CaliforniaOakland, California
| | - Manisha Desai
- Stanford University School of MedicineStanford, California
| | | | - Heather Clancy
- Kaiser Permanente Northern CaliforniaOakland, California
| | - Yun W. Lu
- Kaiser Permanente Northern CaliforniaOakland, California
| | - Alan S. Go
- Kaiser Permanente Northern CaliforniaOakland, California
- University of California San FranciscoSan Francisco, California
| | - Vincent X. Liu
- Kaiser Permanente Northern CaliforniaOakland, California
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