Patient-reported outcomes as predictors of 10-year survival in women after acute myocardial infarction

Association between living alone and all-cause mortality of young and middle-aged patients with acute myocardial infarction: analysis of the China Acute Myocardial Infarction (CAMI) registry

BACKGROUND

Lack of social support is a known predictor of the prognosis after acute myocardial infarction (AMI). Although as a common factor associated with social support, there are limited data on long-term prognostic impact of living status in young and middle-aged patients with AMI.

METHODS

We analyzed data from the China Acute Myocardial Infarction (CAMI) Registry, consecutive AMI young and middle-aged patients admitted at 108 hospitals in China between January 2013 and September 2014 were included. Eligible patients were assigned to living alone and not living alone groups based on their living status. The primary endpoint was 2-year all-cause mortality. The secondary endpoints included in-hospital mortality and 2-year major adverse cardiac and cerebrovascular events (MACCEs; a composite of all-cause mortality, MI, or stroke). Multilevel logistic and multilevel Cox regression models were used to evaluate the effect of living status on short-term and long-term outcomes.

RESULTS

A total of 8307 consecutive AMI young and middle-aged patients were included, 192 (2.3%) patients were living alone. Of the analyzed patients, living alone was associated with 2-year all-cause mortality and MACCEs among all analyzed patients after multivariate adjustment (adjusted hazard ratio [HR] = 2.171 [1.210-3.895], P = 0.009; adjusted HR = 2.169 [1.395-3.370], P = 0.001), but not with poorer in-hospital mortality.

CONCLUSIONS

The analysis suggested that living alone was associated with both 2-year all-cause mortality and MACCEs in AMI young and middle-aged patients but did not show an extra effect on the in-hospital mortality after covariate adjustment.

TRIAL REGISTRATION

Trial registration number: NCT01874691; Registered 31 October 2012.

Living alone and cardiovascular outcomes: a meta-analysis of 11 cohort studies

To explore whether living alone could increase the risk of cardiovascular outcomes. We searched PubMed, EMBASE, and Web of Science from their inception to 5 October 2020. Cohort studies evaluating the relationship between living alone and cardiovascular outcomes were included. Subgroup analyses were conducted to explore which characteristics would affect the relationship. A total of 13 effect sizes obtained from 11 studies were included and spanned from 1993 to 2019, with 424,286 participants. This study found that living alone increased the risk of cardiovascular outcomes (HR = 1.22, 95% CI: 1.10-1.36, I² = 80.3%, P = 0.000). In subgroup analyses, living alone increased the risk of cardiovascular outcomes in patients from Europe (HR = 1.37, 95% CI: 1.17-1.61, I² = 76.2%, P = 0.000), but not increased in Asia (HR = 1.17, 95% CI: 0.83-1.66, I² = 76.2%, P = 0.000) and multiple regions (HR = 1.02, 95% CI: 0.96-1.08, I² = 0.0%, P = 0.738). For different cardiovascular outcomes, living alone has statistical significance in increasing the risk of cardiovascular mortality (HR = 1.23, 95% CI: 1.05-1.46, I² = 84.0%, P = 0.000) and myocardial infarction (HR = 1.11, 95% CI: 1.02-1.21, I² = 29.6%, P = 0.213). The risk of cardiovascular mortality in men was higher than women (HR = 1.52, 95% CI: 1.24-1.86 vs HR = 1.01, 95% CI: 0.85-1.20; P < 0.05 for interaction). Sensitivity analysis suggested that the results of the meta-analysis were robust. In conclusion, living alone could increase the risk of cardiovascular outcomes and men were more prone to cardiovascular mortality and myocardial infarction.

Prognostic implications for patients after myocardial infarction: an integrative literature review and in-depth interviews with patients and experts

Background

As patients with myocardial infarction (MI) survive for a long time after acute treatment, it is necessary to pay attention to the prevention of poor prognosis such as heart failure (HF). To identify the influencing factors of adverse clinical outcomes through a review of prospective cohort studies of post-MI patients, and to draw prognostic implications through in-depth interviews with post-MI patients who progressed to HF and clinical experts.

Methods

A mixed-method design was used that combined a scoping review of 21 prospective cohort studies, in-depth interviews with Korean post-MI patients with HF, and focus group interviews with cardiologists and nurses.

Results

A literature review showed that old age, diabetes, high Killip class, low left ventricular ejection fraction, recurrent MI, comorbidity of chronic disease and current smoking, and low socioeconomic status were identified as influencing factors of poor prognosis. Through interviews with post-MI patients, these influencing factors identified in the literature as well as a lack of disease awareness and lack of self-care were confirmed. Experts emphasized the importance of maintaining a healthy lifestyle after acute treatment with the recognition that it is a chronic disease that must go together for a lifetime.

Conclusion

This study confirmed the factors influencing poor prognosis after MI and the educational needs of post-MI patients with transition to HF. Healthcare providers should continue to monitor the risk group, which is expected to have a poor prognosis, along with education emphasizing the importance of self-care such as medication and lifestyle modification.

Are we any WISER yet? Progress and contemporary need for smart trials to include women in coronary artery disease trials

Despite calls to ensure proportionate representation of both sexes in biomedical research, women continue to be underrepresented in cardiovascular disease (CVD) clinical trials. A comprehensive analysis of seven large suspected ischemic heart disease/coronary artery disease (HD/CAD) clinical trials (PROMISE, ISCHEMIA, CIAO-ISCHEMIA, ORBITA, FAME, FAME 2 and COURAGE trial) provides understanding of contributions to barriers to enrollment of women and leads to strategies to address these barriers. Specifically, in the seven trials, enrollment of women did not exceed 27%, while numerous barriers are evident. Proposed strategies to improve women´s inclusion in clinical trials, include adding reproductive stage/estrogen status, attention to study design inclusion/exclusion criteria using female thresholds, consideration of diagnostic and intervention study design to be inclusive, increasing women and minorities in leadership positions, including sex as a biological variable (SABV) in study design and statistical analysis, and addressing social and race/ethnicity barriers. Dedicated action to actualizing these steps are needed at this time to developing diagnostic and therapeutic strategies resulting in better care and improved outcomes for CVD in women.

Health-related quality of life is dynamic in alcoholic hepatitis and responds to improvement in liver disease and reduced alcohol consumption

BACKGROUND

The impact of alcoholic hepatitis (AH) on health-related quality of life (HRQOL) remains inadequately described. We aimed to characterize HRQOL in AH and heavy drinkers (HD), and its associations with clinical variables and outcomes.

METHODS

This is a post hoc analysis of participants in the Translational Research and Evolving Alcoholic Hepatitis Treatment 001 study (NCT02172898). HRQOL was measured using Short Form Health Survey (SF-36). Mean SF-36 scores were compared in AH and HD with two-sample t-tests. Associations among clinical characteristics, 30-day mortality, and SF-36 mental and physical component scores (MC, PC) were investigated with generalized linear and logistic multivariate regression models. Trends of MC and PC scores were analyzed using one-way ANOVA.

RESULTS

Participants with AH (n = 258) and HD (n = 181) were similar demographically. AH cases had a mean Model for End-stage Liver Disease (MELD) score of 23 (7). AH cases had lower PC scores [37 (10) vs. 48 (11), p < 0.001] but higher MC scores [37 (13) vs. 32 (13), p < 0.001]. MC scores were independently associated with age, male gender, and daily alcohol consumption; PC scores were independently associated with age, BMI, alanine aminotransferase concentration, alkaline phosphatase concentration, white blood cell counts, and the presence of ascites. With each 5-point decrease in the baseline PC score, the adjusted odds of dying within 30 days increased by 26.7% (95% CI 1% to 46%). Over time, HRQOL in AH improved (day 0 to day 180 delta PC score: 4.5 ± 1.7, p = 0.008; delta MC score: 9.8 ± 2.0, p < 0.001). Participants with a MELD score <15 by day 180 had greater increases in PC scores than those with MELD score ≥15 (delta PC score 7.1 ± 1.8 vs. -0.7 ± 2.3, p = 0.009), while those abstinent by day 180 had greater increases in MC scores than those who were not abstinent (delta MC score 9.1 ± 1.8 vs. 2.8 ± 2.4, p = 0.044).

CONCLUSIONS

HRQOL is poor in AH and HD in a domain-specific pattern. Independent of MELD score, lower baseline HRQOL is associated with higher 30-day mortality. Over time, HRQOL improves with greater gains seen in individuals with improved MELD scores and those who were abstinent.

The experience of women following first acute coronary syndrome: An integrative literature review

AIM

There is lack of evidence and research understanding among women's lived experiences following first acute coronary syndrome, thus their recovery process remains poorly understood. To date research has largely focused on men's experience of acute coronary syndrome while this area of health care and recovery has considerable impact on women's health and quality of life. Our aim was to review the literature exploring lived experience of women following first acute coronary syndrome.

DESIGN

Integrative review of the literature.

DATA SOURCE

We searched PubMed, MEDLINE, EMBASE, CINAHL and Scopus from 2008-2018 for articles published in English.

REVIEW METHOD

Of 1675 publications identified, 18 qualitative, quantitative, and mixed method studies met our inclusion criteria. Quality of included studies was assessed using Joanna Briggs Institute quality assessment tools. Findings were integrated using thematic synthesis.

RESULTS

Experiencing acute coronary syndrome was reported to have significant impacts on women's lives. The most common issues reported were physical limitations, fear, and uncertainties about the future, sexual dissatisfaction, and social isolation. Women also reported to have higher short- and long-term mortality rate, stroke, recurrent, and hospital readmissions compared with men.

CONCLUSION

This review identified current knowledge and gaps about lived experience of women following first acute coronary syndrome. It is anticipated that the information gained from this literature review will support new research aimed at improving the care women receive following acute coronary syndrome and therefore enhance their recovery and quality of life.

IMPACT

This review contributes to the current body of knowledge by addressing women's physical, psychosocial, and sexual state following acute coronary syndrome. Improvement in women's quality of life after acute coronary syndrome necessitates further research which ultimately results in better management and treatment of women and their recovery following first acute coronary syndrome.

Time to expand risk evaluation systems for cardiac surgery? Looking beyond physiological parameters

Risk assessment in cardiac surgery traditionally consists of medical and physiological parameters. However, non-physiological factors have also been found to be predictive of poor outcomes following cardiac surgery. Therefore, the isolated focus on physiological parameters is questionable. This paper describes the emotional, behavioural, social and functional factors that have been established to play a role in outcomes following cardiac surgery. This forms a basis for future research, testing the value of these factors above and beyond the physiological parameters. By including such non-physiological factors, the accuracy of the existing risk scoring systems could potentially be improved.

Patient-Reported Outcomes in Patients with Chronic Kidney Disease and Kidney Transplant-Part 1

Chronic kidney disease (CKD) is a complex medical condition that is associated with several comorbidities and requires comprehensive medical management. Given the chronic nature of the condition, its frequent association with psychosocial distress, and its very significant symptom burden, the subjective patient experience is key toward understanding the true impact of CKD on the patients’ life. Patient-reported outcome measures are important tools that can be used to support patient-centered care and patient engagement during the complex management of patients with CKD. The routine collection and use of patient-reported outcomes (PROs) in clinical practice may improve quality of care and outcomes, and may provide useful data to understand the disease from both an individual and a population perspective. Many tools used to measure PROs focus on assessing health-related quality of life, which is significantly impaired among patients with CKD. Health-related quality of life, in addition to being an important outcome itself, is associated with clinical outcomes such as health care use and mortality. In Part 1 of this review, we provide an overview of PROs and implications of their use in the context of CKD. In Part 2, we will review the selection of appropriate measures and the relevant domains of interest for patients with CKD.

Health related quality of life among myocardial infarction survivors in the United States: a propensity score matched analysis

Background

Little is known regarding the health-related quality of life among myocardial infarction (MI) survivors in the United States. The purpose of this population-based study was to identify differences in health-related quality of life domains between MI survivors and propensity score matched controls.

Methods

This retrospective, cross-sectional matched case-control study examined differences in health-related quality of life (HRQoL) among MI survivors of myocardial infarction compared to propensity score matched controls using data from the 2015 Behavioral Risk Factor Surveillance System (BRFSS) survey. Propensity scores were generated via logistic regression for MI survivors and controls based on gender, race/ethnicity, age, body mass index (BMI), smoking status, and comorbidities. Chi-square tests were used to compare differences between MI survivors to controls for demographic variables. A multivariate analysis of HRQoL domains estimated odds ratios. Life satisfaction, sleep quality, and activity limitations were estimated using binary logistic regression. Social support, perceived general health, perceived physical health, and perceived mental health were estimated using multinomial logistic regression. Significance was set at p < 0.05.

Results

The final sample consisted of 16,729 MI survivors matched to 50,187 controls (n = 66,916). Survivors were approximately 2.7 times more likely to report fair/poor general health compared to control (AOR = 2.72, 95% CI: 2.43–3.05) and 1.5 times more likely to report limitations to daily activities (AOR = 1.46, 95% CI: 1.34–1.59). Survivors were more likely to report poor physical health >15 days in the month (AOR = 1.63, 95% CI: 1.46–1.83) and poor mental health >15 days in the month (AOR = 1.25, 95% CI: 1.07–1.46) compared to matched controls. There was no difference in survivors compared to controls in level of emotional support (rarely/never: AOR = 0.75, 95% CI: 0.48–1.18; sometimes: AOR = 0.73, 95% CI: 0.41–1.28), hours of recommended sleep (AOR = 1.14, 95% CI: 0.94–1.38), or life satisfaction (AOR = 1.62, 95% CI: 0.99–2.63).

Conclusion

MI survivors experienced lower HRQoL on domains of general health, physical health, daily activity, and mental health compared to the general population.

Sex Differences in Trajectories of Risk After Rehospitalization for Heart Failure, Acute Myocardial Infarction, or Pneumonia

BACKGROUND

Women have an increased risk of rehospitalization in the immediate postdischarge period; however, few studies have determined how readmission risk dynamically changes on a day-to-day basis over the full year after hospitalization by sex and how these differences compare with the risk for mortality.

METHODS AND RESULTS

We identified >3 000 000 hospitalizations of patients with a principal discharge diagnosis of heart failure, acute myocardial infarction, or pneumonia and estimated sex differences in the daily risk of rehospitalization/death 1 year after discharge from a population of Medicare fee-for-service beneficiaries aged 65 years and older. We calculated the (1) time required for adjusted rehospitalization/mortality risks to decline 50% from maximum values after discharge, (2) time required for the adjusted readmission risk to approach plateau periods of minimal day-to-day change, and (3) extent to which adjusted risks are greater among recently hospitalized patients versus Medicare patients. We identified 1 392 289, 530 771, and 1 125 231 hospitalizations for heart failure, acute myocardial infarction, and pneumonia, respectively. The adjusted daily risk of rehospitalization varied by admitting condition (hazard rate ratio for women versus men, 1.10 for acute myocardial infarction; hazard rate ratio, 1.04 for heart failure; and hazard rate ratio, 0.98 for pneumonia). However, for all conditions, the adjusted daily risk of death was higher among men versus women (hazard rate ratio women versus with men, <1). For both sexes, there was a similar timing of peak daily risk, half daily risk, and reaching plateau.

CONCLUSIONS

Although the association of sex with daily risk of rehospitalization varies across conditions, women are at highest risk after discharge for acute myocardial infarction. Future studies should focus on understanding the determinants of sex differences in rehospitalization risk among conditions.

Sustained quality of life improvement after intracoronary injection of autologous bone marrow cells in the setting of acute myocardial infarction: results from the BONAMI trial

PURPOSE

Cardiac cell therapy is a promising treatment for acute myocardial infarction (AMI), leading to cardiac function improvement. However, whether it translates into quality of life (QoL) improvement is unclear. We hypothesized that administration of bone marrow cells (BMC) to patients with AMI improves QoL.

METHODS

In the multicenter BONAMI trial (NCT00200707), patients with reperfused AMI and decreased myocardial viability were randomized to intracoronary autologous BMC infusion (n = 52) or state-of-the-art therapy (n = 49). QoL data, derived from the Minnesota Living with Heart Failure questionnaire (MLHFQ), were obtained 1, 3, and 12 months after AMI and analyzed using a Rasch-family model.

RESULTS

Using this model, QoL improved over time in the BMC group (p = 0.025) but not in the control group. Furthermore, the BMC-group patients displayed a better QoL than the control-group patients at 3 and 12 months post-AMI (p = 0.034 and p = 0.003, respectively). These findings were not detected when analyzing MLHFQ data using a standard method. Cardiac function, myocardial viability, mortality, and number of major adverse cardiac events did not differ between treatment groups.

CONCLUSION

Our results suggest that BMC therapy can improve QoL, stressing the need for confirmation trials and for systematic QoL assessment in cardiac cell therapy trials .

Sustained quality of life improvement after intracoronary injection of autologous bone marrow cells in the setting of acute myocardial infarction: results from the BONAMI trial

PURPOSE

Cardiac cell therapy is a promising treatment for acute myocardial infarction (AMI), leading to cardiac function improvement. However, whether it translates into quality of life (QoL) improvement is unclear. We hypothesized that administration of bone marrow cells (BMC) to patients with AMI improves QoL.

METHODS

In the multicenter BONAMI trial (NCT00200707), patients with reperfused AMI and decreased myocardial viability were randomized to intracoronary autologous BMC infusion (n = 52) or state-of-the-art therapy (n = 49). QoL data, derived from the Minnesota Living with Heart Failure questionnaire (MLHFQ), were obtained 1, 3, and 12 months after AMI and analyzed using a Rasch-family model.

RESULTS

Using this model, QoL improved over time in the BMC group (p = 0.025) but not in the control group. Furthermore, the BMC-group patients displayed a better QoL than the control-group patients at 3 and 12 months post-AMI (p = 0.034 and p = 0.003, respectively). These findings were not detected when analyzing MLHFQ data using a standard method. Cardiac function, myocardial viability, mortality, and number of major adverse cardiac events did not differ between treatment groups.

CONCLUSION

Our results suggest that BMC therapy can improve QoL, stressing the need for confirmation trials and for systematic QoL assessment in cardiac cell therapy trials .

Patients' goals, resources, and barriers to future change: A qualitative study of patient reflections at hospital discharge after myocardial infarction

BACKGROUND

Myocardial infarction (MI) patients may find it challenging to adhere to lifestyle advice and medications. Understanding motivational factors and barriers to change is crucial. However, empirical evidence on patients' ability to effect lifestyle changes at the time of discharge is limited.

AIM

The aim of this study was to identify at the time of hospital discharge the goals, resources, and barriers to future change in MI patients.

METHODS

We conducted a qualitative interview study with a purposive sample of 20 MI patients (eight women) in a cardiac department at a university hospital in Norway. All interviews were conducted before hospital discharge, transcribed verbatim, and analysed using qualitative content analysis.

FINDINGS

Three themes suggested that, at the time of discharge, patients' views of their MI were complex and diverse. Patients were motivated to change their lifestyle and contemplated taking their life in new directions, adopting a change of life perspective. Frequently, patients struggled to understand the context of living with an MI, manage symptoms, and understand the precipitating causes of MI. There were also patients who wanted to maintain their present lifestyle and live as normal as possible. They just wanted to keep going.

CONCLUSIONS AND IMPLICATIONS

There is a need for a different approach to communicating with MI patients at the time of discharge. Person-centred care that allows personal narratives to emerge may enable health-care professionals to offer more individualised guidance to MI patients that will help them cope with the everyday challenges they experience after discharge.

Activity performance problems of patients with cardiac diseases and their impact on quality of life

[Purpose] To describe the functional consequences of patients with cardiac diseases and analyze associations between activity limitations and quality of life. [Subjects and Methods] Seventy subjects (mean age: 60.1±12.0 years) were being treated by Physical Medicine and Rehabilitation and Cardiology Departments were included in the study. Activity limitations and participation restrictions as perceived by the individual were measured by the Canadian Occupational Performance Measure (COPM). The Nottingham Extended Activities of Daily Living (NEADL) Scale was used to describe limitations in daily living activities. To detect the impact of activity limitations on quality of life the Nottingham Health Profile (NHP) was used. [Results] The subjects described 46 different types of problematic activities. The five most identified problems were walking (45.7%), climbing up the stairs (41.4%), bathing (30%), dressing (28.6%) and outings (27.1%). The associations between COPM performance score with all subgroups of NEADL and NHP; total, energy, physical abilities subgroups, were statistically significant. [Conclusion] Our results showed that patients with cardiac diseases reported problems with a wide range of activities, and that also quality of life may be affected by activities of daily living. COPM can be provided as a patient-focused outcome measure, and it may be a useful tool for identifying those problems.

Quality of life and comorbidity among older home care clients: role of positive attitudes toward aging

PURPOSE

Comorbidity has a negative impact on quality of life (QoL). This study aimed to investigate whether the impact of comorbidity on QoL is lower in older home care clients with positive attitudes toward aging.

METHODS

Totally, 361 older adults aged 50-91 years who were clients of 14 home care agencies in two regions in the Czech Republic gave an in-person interview to research nurses and completed the WHOQOL-BREF, the WHOQOL-OLD, and the Attitudes to Aging Questionnaire. The Charlson comorbidity index was calculated using ICD-10 codes. To address possible interaction between comorbidity and attitudes toward aging for QoL, the presence of additive interaction between comorbidity and attitudes toward aging on QoL was examined by synergy index. All analyses were adjusted by age, gender, education, and living arrangement.

RESULTS

A higher comorbidity index was significantly associated with lower scores of both QoL measures; one index increase was associated with 3.7 [95 % confidence interval (CI) 1.5: 5.9] decreases in generic QoL and 3.6 (95 % CI 1.3: 5.9) decreases in older-specific QoL. In stratified analyses by attitudes toward aging, comorbidity showed no association with QoL among those with positive attitudes, while it was significantly associated with low QoL in those without positive attitudes. The presence of additive interactions between comorbidity and less than positive attitudes on falling in low QoL was clearly suggested.

CONCLUSIONS

The negative impact of comorbidity on QoL might be mitigated by promoting a positive self-perception of aging in older people.

Self-rated health is associated with the length of stay at the intensive care unit and hospital following cardiac surgery

Background

Recently, a considerable amount of evidence suggested that anxiety, depression and other psychosocial variables might influence the outcomes of cardiac surgery. This study investigated the relationship between length of stay at the intensive care unit (ICU) and hospital after surgery and different psychosocial variables (e.g. depression, anxiety, self rated health, happiness, satisfaction).

Methods

We enrolled prospective patients who were waiting for elective cardiac surgery (N = 267) and consented to take part in the study. We collected data of sociodemographic, medical and perioperative factors as well as psychosocial questionnaires completed 1.56 days (standard deviation [SD] = 0.7) before surgery. The primary clinical endpoint was an ICU stay of at least 3 days and the secondary was hospital stay of at least 10 days.

Results

Two hundred sixty-seven patients participated in this study. Four patients (1.5%) died in the hospital and 38 patients (14.5%) spent more than 3 days in the ICU and 62 patients (23.2%) spent more than 10 days in the hospital. After controlling for medical and sociodemographic factors, lower self rated health (Adjusted Odds Ratio [AOR]: 0.51, 95% confidence interval [CI]: 0.28-0.95; p = 0.03), lower rate of happiness (AOR: 0.76, 95% CI: 0.59-0.97, p = 0.03), postoperative cardiac failure (AOR: 7.09, 95% CI:1.21-41.54; p = 0.03) and postoperative complications (AOR: 9.52, 95% CI: 3.76-24.11; p < 0.001) were associated with longer ICU stay. More than 10 days of hospital stay was associated with higher occurrence of COPD (AOR 4.56, CI: 1.95-10.67, p < 0.001), NYHA stage (AOR 6.76, CI: 2.57-17.79, p < 0.001), operation time (AOR 1.45, CI: 1.19-1.76, p < 0.001), female gender (AOR 2.16, CI: 1.06-4.40, p = 0.034) and lower self-rated health (AOR 0.63, CI: 0.41-0.99, p = 0.044).

Conclusions

Lower happiness and self-rated health may influence the outcome of cardiac surgery. Therefore, these variables should be assessed in patients.

Comparison of long-term mortality after acute myocardial infarction treated by percutaneous coronary intervention in patients living alone versus not living alone at the time of hospitalization

Living alone was reported to be associated with increased risk of cardiovascular disease. There are, however, limited data on the relation between living alone and all-cause mortality in patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI). The Coronary REvascularization Demonstrating Outcome Study in Kyoto (CREDO-Kyoto) AMI registry was a cohort study of patients with AMI enrolled in 26 hospitals in Japan from 2005 through 2007. For the current analysis, we included those patients who underwent PCI within 24 hours of symptom onset, and we assessed their living status to determine if living alone would be an independent prognostic risk factor. Among 4,109 patients eligible for the current analysis of 5,429 patients enrolled in the CREDO-Kyoto AMI registry, 515 patients (12.5%) were living alone at the time of hospital admission. The cumulative 5-year incidence of all-cause death was 18.3% in the living alone group and 20.1% in the not living alone group (log-rank p = 0.77). After adjusting for potential confounders, risk of the living alone group relative to the not living alone group for all-cause death was not significantly different (adjusted hazard ratio 0.82, 95% confidence interval 0.65 to 1.02, p = 0.08). In a subgroup analysis stratified by age, the adjusted risk for all-cause death was also not different between the living alone group and the not living alone group both in the older population (aged ≥75 years) and the younger population (aged <75 years). In conclusion, living alone was not associated with higher long-term mortality in patients with AMI who underwent PCI.

Self-reported health-related quality of life predicts 5-year mortality and hospital readmissions in patients with ischaemic heart disease

BACKGROUND

Patient health-related quality of life (HRQL) is an important health outcome with lower HRQL associated with adverse events in patients with ischaemic heart disease (IHD).

DESIGN

Baseline health-related quality of life was investigated as a predictor of 5-year all-cause mortality and cardiac readmissions in Danish patients with IHD.

METHODS

The international HeartQoL Project survey was designed to develop a core HRQL questionnaire for patients with IHD. Baseline scores on each of the 14 items ultimately included in the HeartQoL questionnaire were linked to Danish national health registries and hazard ratios for mortality and readmissions were estimated using Cox regression models.

RESULTS

Among 938 eligible Danish patients with IHD, 662 (70.6%) participated in the international HeartQoL Project. During the 5-year follow-up, 83 patients died and 196 patients were readmitted. Adjusted analyses showed a significant linear association between all-cause mortality and both lower global HRQL (HR = 1.67, 95% CI: 1.26-2.23; p<0.001) and physical scores (HR=1.71, 1.33-2.21; p<0.001) and between readmission and both lower global (HR=1.73, 1.41-2.12; p < 0.001) and physical scores (HR = 1.63, 1.35-1.96; p < 0.001). A significant, but non-linear, effect was found for emotional HRQL score on outcomes.

CONCLUSION

This study shows a significant and linear relationship between lower global and physical HRQL scores in patients with IHD and 5-year all-cause mortality and cardiac readmission.

Marital status and ischemic heart disease incidence and mortality in women: a large prospective study

BACKGROUND

Being married has been associated with a lower mortality from ischemic heart disease (IHD) in men, but there is less evidence of an association for women, and it is unclear whether the associations with being married are similar for incident and for fatal IHD. We examined the relation between marital status and IHD incidence and mortality in the Million Women Study.

METHODS

A total of 734,626 women (mean age 60 years) without previous heart disease, stroke or cancer, were followed prospectively for hospital admissions and deaths. Adjusted relative risks (RRs) for IHD were calculated using Cox regression in women who were married or living with a partner versus women who were not. The role of 14 socio-economic, lifestyle and other potential confounding factors was investigated.

RESULTS

81% of women reported being married or living with a partner and they were less likely to live in deprived areas, to smoke or be physically inactive, but had a higher alcohol intake than women who were not married or living with a partner. During 8.8 years of follow-up, 30,747 women had a first IHD event (hospital admission or death) and 2,148 died from IHD. Women who were married or living with a partner had a similar risk of a first IHD event as women who were not (RR = 0.99, 95% confidence interval (CI) 0.96 to 1.02), but a significantly lower risk of IHD mortality (RR = 0.72, 95% CI 0.66 to 0.80, P <0.0001). This lower risk of IHD death was evident both in women with and without a prior IHD hospital admission (respectively: RR = 0.72, 95% CI 0.60 to 0.85, P <0.0001, n = 683; and 0.70, 95% CI 0.62 to 0.78, P <0.0001, n = 1,465). These findings did not vary appreciably between women of different socio-economic groups or by lifestyle and other factors.

CONCLUSIONS

After adjustment for socioeconomic, lifestyle and other factors, women who were married or living with a partner had a similar risk of developing IHD but a substantially lower IHD mortality compared to women who were not married or living with a partner.

Mental health status and risk of new cardiovascular events or death in patients with myocardial infarction: a population-based cohort study

OBJECTIVE

To examine the association between mental health status after first-time myocardial infarction (MI) and new cardiovascular events or death, taking into account depression and anxiety as well as clinical, sociodemographic and behavioural risk factors.

DESIGN

Population-based cohort study based on questionnaires and nationwide registries. Mental health status was assessed 3 months after MI using the Mental Component Summary score from the Short-Form 12 V.2.

SETTING

Central Denmark Region.

PARTICIPANTS

All patients hospitalised with first-time MI from 1 January 2009 through 31 December 2009 (n=880). The participants were categorised in quartiles according to the level of mental health status (first quartile=lowest mental health status).

MAIN OUTCOME MEASURES

Composite endpoint of new cardiovascular events (MI, heart failure, stroke/transient ischaemic attack) and all-cause mortality.

RESULTS

During 1940 person-years of follow-up, 277 persons experienced a new cardiovascular event or died. The cumulative incidence following 3 years after MI increased consistently with decreasing mental health status and was 15% (95% CI 10.8% to 20.5%) for persons in the fourth quartile, 29.1% (23.5% to 35.6%) in the third quartile, 37.0% (30.9% to 43.9%) in the second quartile, and 47.5% (40.9% to 54.5%) in the first quartile. The HRs were high, even after adjustments for age, sociodemographic characteristics, cardiac disease severity, comorbidity, secondary prophylactic medication, smoking status, physical activity, depression and anxiety (HR3rd quartile 1.90 (95% CI 1.23 to 2.93), HR2nd quartile 2.14 (1.37 to 3.33), HR1st quartile 2.23 (1.35 to 3.68) when using the fourth quartile as reference).

CONCLUSIONS

Low mental health status following first-time MI was independently associated with an increased risk of new cardiovascular events or death. Further research is needed to disentangle the pathways that link mental health status following MI to prognosis and to identify interventions that can improve mental health status and prognosis.

Self-rated health predicts outcome in patients with type 2 diabetes and myocardial infarction: a DIGAMI 2 quality of life sub-study

The Diabetes mellitus Insulin-Glucose Infusion in Acute Myocardial Infarction (DIGAMI) 2 Quality of Life (QoL) sub-study included 465 patients with type 2 diabetes and acute myocardial infarction (AMI) followed for 2 years. Self-rated health was reported by the rating scale (RS), graded 0 = death to 100 = perfect health. Prospective associations between RS and all-cause mortality, cardiovascular (CV) death and cardiovascular events (CVEs = CV death, non-fatal AMI, stroke) were assessed. Median age was 68 years (range 59-74), 68% male. Patients experiencing CVE (n = 132) or death (n = 71) had lower RS compared with patients free from events: 60 (50-79) versus 70 (55-81) (p < 0.001) and 60 (50-75) versus 70 (51-80) (p = 0.008). The RS score predicted CVE [hazard ratio (HR); 95% confidence interval (CI): 0.87; 0.80-0.95] and all-cause mortality (0.86; 0.76-0.97), and corresponding HRs after adjustment were 0.90; 0.83-0.99 and 0.90; 0.79-1.02, respectively. A low self-rated health is of prognostic importance in patients with type 2 diabetes and AMI and may serve as an easily obtainable indicator of high risk for CVEs supplementing traditional risk factors.

Living alone and risk of cardiovascular events following discharge after acute myocardial infarction in Japan

BACKGROUND

Little is known about the long-term risk of cardiovascular events after discharge among acute myocardial infarction (AMI) survivors living alone in Japan.

METHODS AND RESULTS

A large-scale prospective, observational study in the Osaka region involved consecutive patients with AMI from January 2002 through December 2010. We evaluated the association between living alone and longitudinal risk of cardiovascular events following discharge after AMI. A Cox proportional-hazards model was used to assess the association between living alone and the primary composite endpoint consisting of major adverse cardiovascular events and total deaths. During the study period, 5845 patients (4415 male patients, 1430 female patients) were registered. Living alone was found to be independently associated with a higher risk of composite endpoint consisting of major adverse cardiovascular events and total deaths [adjusted hazard ratio (HR) 1.32; 95% confidence interval (CI): 1.11-1.58]. Multivariate-adjusted HRs of composite endpoint were 1.34 (95% CI: 1.08-1.68) among male patients and 1.31 (95% CI: 0.95-1.81) in the female patients. AMI survivors living alone tend to have a higher adjusted HR of composite endpoint than those not living alone irrespective of age and gender groups.

CONCLUSIONS

From this large AMI registry in Osaka, AMI survivors living alone after discharge had a higher risk of cardiovascular events and total deaths than those not living alone.

Relation of patients living without a partner or spouse to being physically active after acute coronary syndromes (from the PULSE accelerometry substudy)

Living alone is associated with adverse outcomes after acute coronary syndromes (ACS). One potential mediator of the relation between partner status and outcomes after ACS is physical activity. To evaluate the association of partner status with physical activity after ACS, data from 107 participants enrolled in the Prescription Use, Lifestyle, and Stress Evaluation (PULSE) study, a prospective observational study of post-ACS patients, were analyzed. Accelerometers were used to measure physical activity after hospital discharge. The primary outcome measure was a maximum 10 hours of daytime activity 1 month after discharge. One month after discharge from ACS hospitalizations, participants without a partner or spouse exhibited 24.4% lower daytime activity than those with a partner or spouse (p = 0.003). After controlling for age, gender, body mass index, Charlson co-morbidity index, and traditional psychosocial and clinical cardiovascular correlates of post-ACS physical activity, partner status remained an independent predictor of post-ACS physical activity (20.5% lower daytime activity among those without a partner or spouse, p = 0.008). In conclusion, in this study of accelerometer-measured physical activity after an ACS hospitalization, those without a partner or spouse exhibit significantly less physical activity than those with a partner or spouse 1 month after discharge from the hospital. Low physical activity may be an important mediator of the prognosis associated with partner status after ACS.

Gender differences in predictors of self-rated health in Armenia: a population-based study of an economy in transition

INTRODUCTION

Self-rated health is a widely used health outcome measure that strongly correlates with physical and mental health status and predicts mortality. This study identified the set of predictors of fair/poor self-rated health in adult female and male populations of Armenia during a period of long-lasting socio-economic transition to a market economy.

METHODS

Differences in self-rated health were analyzed along three dimensions: socioeconomic, behavioral/attitudinal, and psychosocial. The study utilized data from a 2006 nationwide household health survey that used a multi-stage probability proportional to size cluster sampling with a combination of interviewer-administered and self-administered surveys. Both female and male representatives of a household aged 18 and over completed the self-administered survey. Multivariate odds ratios (OR) for fair/poor self-rated health were calculated for different sets of variables and logistic regression models fitted separately for women and men to identify the determinants of fair/poor self-rated health.

RESULTS

Overall, 2310 women and 462 men participated in the survey. The rate of fair/poor self-rated health was 61.8% among women and 59.7% among men. For women, the set of independent predictors of fair/poor self-rated health included age, unemployment, poverty, low affordability of healthcare, depression, and weak social support. For men, the set included age, lower education, depression, weak social support, and drinking alcohol less than once a week. For both genders, depression and weak social support demonstrated the strongest independent association with fair/poor self-rated health.

CONCLUSIONS

The prevalence of fair/poor self-rated health was similar among men and women in this study, but the sets of independent predictors of perceived health differed somewhat, possibly, reflecting lifestyle differences between men and women in Armenia. Nevertheless, psychosocial variables were the strongest predictors of fair/poor self-rated health for both genders, indicating the importance of improving the country's psychosocial environment through social reforms and poverty reduction.

Meta-analysis of marital dissolution and mortality: reevaluating the intersection of gender and age

The study of marital dissolution (i.e. divorce and separation) and mortality has long been a major topic of interest for social scientists. We conducted meta-analyses and meta-regressions on 625 mortality risk estimates from 104 studies, published between 1955 and 2011, covering 24 countries, and providing data on more than 600 million persons. The mean hazard ratio (HR) for mortality in our meta-analysis was 1.30 (95% confidence interval [CI], 1.23-1.37) among HRs adjusted for age and additional covariates. The mean HR was higher for men (HR, 1.37; 95% CI, 1.27-1.49) than for women (HR, 1.22; 95% CI: 1.13-1.32), but the difference between men and women decreases as the mean age increases. Other significant moderators of HR magnitude included sample size; being from Western Europe, Israel, the United Kingdom and former Commonwealth nations; and statistical adjustment for general health status.

Capturing patients' perspectives of treatment in clinical trials/drug development

The patient's perspective of treatment outcomes is increasingly important to consumers and providers of healthcare. Recent studies have shown that traditional clinical endpoints may not accurately reflect the patient experience with treatment. Often patients' experience of their disease and associated treatment differs from the perspective of their physicians. When implemented with a clear and effective assessment strategy, patient-reported outcome (PRO) measures can be used to collect data directly from patients in the clinical setting. These data can be applied to a range of outcomes, such as treatment efficacy, safety, and patient satisfaction. Such information is valuable at various stages of drug development and can be used to understand the patient's perspective of the treatment for evaluating the treatment benefit of new products and to engage patients to make decisions about treatment options and ultimately to support commercialization of pharmaceutical products. Recognizing the value of these data, various regulatory agencies have recently released guidelines on how to best implement these measures in clinical trials to support label claims. The purpose of this paper is to discuss the benefits of collecting PRO data for evaluating the outcomes of treatments in clinical trials, through the product life cycle.

Effect of living alone on patient outcomes after hospitalization for acute myocardial infarction

Considerable attention has been devoted to the effect of social support on patient outcomes after acute myocardial infarction (AMI). However, little is known about the relation between patient living arrangements and outcomes. Thus, we used data from PREMIER, a registry of patients hospitalized with AMI at 19 United States centers from 2003 through 2004, to assess the association of living alone with outcomes after AMI. Outcome measurements included 4-year mortality, 1-year readmission, and 1-year health status using the Seattle Angina Questionnaire (SAQ) and the Short Form-12 Physical Health Component scales. Patients who lived alone had higher crude 4-year mortality (21.8% vs 14.5%, p <0.001) but comparable rates of 1-year readmission (41.6% vs 38.3%, p = 0.79). Living alone was associated with lower unadjusted quality of life (mean SAQ -2.40, 95% confidence interval [CI] -4.44 to -0.35, p = 0.02) but had no impact on Short Form-12 Physical Health Component (-0.45, 95% CI -1.65 to 0.76, p = 0.47) compared to patients who did not live alone. After multivariable adjustment, patients who lived alone had a comparable risk of mortality (hazard ratio 1.35, 95% CI 0.94 to 1.93) and readmission (hazard ratio 0.99, 95% CI 0.76 to 1.28) as patients who lived with others. Mean quality-of-life scores remained lower in patients who lived alone (SAQ -2.91, 95% CI -5.56 to -0.26, p = 0.03). In conclusion, living alone may be associated with poorer angina-related quality of life 1 year after MI but is not associated with mortality, readmission, or other health status measurements after adjusting for other patient and treatment characteristics.

Type D personality and health status in cardiovascular disease populations: a meta-analysis of prospective studies

BACKGROUND

Knowledge of the factors associated with individual differences in patient-reported outcomes is essential to identify high-risk patients and improve secondary prevention.

DESIGN

In this meta-analysis, we examined the association between Type D personality and the individual differences in patient-reported physical and mental health status among cardiovascular patients.

METHODS

A computerized search of the literature through PUBMED and PsychINFO (from 1995 to May 2011) was performed and prospective studies were selected that analysed the association between Type D personality and health status in cardiovascular patients. Two separate meta-analyses were performed for the association of Type D personality with physical and mental health status, respectively.

RESULTS

Of all identified studies, ten studies met the selection criteria. The meta-analyses showed that Type D was associated with a two-fold increased odds for impaired physical health status (3035 patients, OR 1.94, 95% CI 1.49-2.52) and a 2.5-fold increased odds for impaired mental health status (2213 patients, OR 2.55, 95% CI 1.57-4.16). There was no significant heterogeneity between the studies on physical health status (Q = 12.78; p = 0.17; I(2 )= 29.59), but there was between those on mental health status (Q = 21.91; p = 0.003; I(2 )= 68.04). Subgroup analyses showed that the association between Type D and mental health status decreased yet remained significant when adjusting for baseline health status.

CONCLUSION

Type D personality was shown to be an independent correlate of impaired patient-reported physical and mental health status in various cardiovascular patient groups. Clinicians should be aware of the association between chronic psychological distress and poor patient-reported outcomes.

Relation of body mass index to urinary creatinine excretion rate in patients with coronary heart disease

In patients with prevalent coronary heart disease (CHD), studies have found a paradoxical relation in that patients with higher body mass indexes (BMIs) have lower mortality. One possibility is that patients with higher BMIs have greater muscle mass, and higher BMI may be a marker of better overall health status. The aim of this study was to evaluate whether the paradoxical association of BMI with mortality in patients with CHD is attenuated when accounting for urinary creatinine excretion, a marker of muscle mass. The Heart and Soul Study is an observational study of outpatients with stable CHD. Outpatient 24-hour timed urine collections were obtained. Participants were followed up for death for 5.9 ± 1.9 years. Cox proportional-hazards models were used to evaluate the association between gender-specific BMI quintiles and mortality. There were 886 participants in the study population. Participants in higher quintiles of BMI were younger, were more likely to have diabetes mellitus and hypertension, and had higher urinary creatinine excretion rate. Compared to the lowest BMI quintile, subjects in higher BMI quintiles were less likely to die during follow-up. Adjustment for major demographic variables, traditional cardiovascular risk factors, and kidney function did not attenuate the relation. Additional adjustment for urinary creatinine excretion rate did not materially change the association between BMI and all-cause mortality. In conclusion, low muscle mass and low BMI are each associated with greater all-cause mortality, but low muscle mass does not appear to explain why CHD patients with low BMIs have worse prognosis.

[Predictors of self-rated health of citizens on the territory of endangered political security]

INTRODUCTION

Self-rated health is generally accepted by researchers as a valid measure of health status. The aims of the study were to investigate how the adult inhabitants of northern Kosovska Mitrovica described their health and which variables were the predictors of self-rated health status among that population.

METHOD

The research was done as a cross-sectional study on the representative sample of 318 adult inhabitants of northern Kosovska Mitrovica in 2006. The instrument of research was a questionnaire containing questions about self-rated health and demographic and socio-economic characteristics, mental health, social interaction, possibilities of performing everyday activities, health behaviour and habits, diseases and injuries, utilization of health care service. The independent variables were defined through the factor analysis taken from these groups of questions. The multivariate stepwise linear regression was done to determine the correlation between self-rated health and independent variables.

RESULTS

More than half of the respondents (54.7%) assessed their health as good or very good. The predictors of self-rated health were gender, mood problems, myocardial infarction, chronic bronchitis, psychic and neurotic disorders, rheumatic arthritis, high blood sugar, utilization of private gynaecologist service and paying for diagnostic service.

CONCLUSION

Most of the respondents from northern Kosovska Mitrovica assessed their own health as good or very good. Bad and very bad health was significantly associated with females, problems with mood, myocardial infarction, chronic bronchitis, psychic or neurotic disorders, rheumatoid arthritis and high blood sugar. Good and very good health was significantly associated with utilization of private gynaecologist service and paying for diagnostic service.