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Campanile A, Prota C, Tedeschi M, Giano A, Pianese B, Cristiano M, Pompa A, Sorrentino R, Vigorito F, Ravera A. Adding the value of the Charlson Comorbidity Index to the GRACE score for mortality prediction in acute coronary syndromes. J Cardiovasc Med (Hagerstown) 2024; 25:114-122. [PMID: 38051655 DOI: 10.2459/jcm.0000000000001579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
BACKGROUND Scarce and conflicting data still exist about the role of the Charlson Comorbidity Index (CCI) when added to the traditional Global Registry of Acute Coronary Events (GRACE) risk score for outcome prediction in patients with acute coronary syndrome (ACS). METHODS All consecutive admissions due to ACS, from 1 January 2018 to 31 December 2020 were retrospectively reviewed from an internal database of a tertiary cardiac center in Salerno (Italy). Logistic and Cox proportional regression analyses were performed in order to assess the contribution of the CCI on 30-day and long-term mortality. The CCI adding value to the GRACE score was analyzed with several measures of improvement in discrimination: increase in the area under the receiver-operating characteristic curve (AUC), the integrated discrimination improvement (IDI), and the categorical and continuous net reclassification improvement (cNRI) more than 0. Robustness of the results was assessed through an internal validation procedure with bootstrapping. RESULTS One thousand three hundred and ten patients were identified. The median age was 68 (58-78) years. One hundred and twenty (9.2%) and 113 (9.5%) deaths occurred, respectively, during the first 30 days from admission and during long-term follow-up (median follow-up time: 13 months; interquartile range: 9-24). After multivariate regression analysis, the CCI was not associated with short-term mortality, while it was significantly and independently associated with long-term mortality along with the GRACE score (hazard ratio: 1.34, 95% confidence interval: 1.22-1.47; P < 0.001). An additive effect of CCI with the GRACE risk score was observed in predicting long-term mortality: AUC from 0.768 to 0.819 ( P = 0.003), category-based NRI: 0.215, cNRI>0: 0.669 ( P < 0.001), IDI: 0.066 ( P < 0.001). CONCLUSION The CCI is a predictor of long-term mortality and improves risk stratification of patients with ACS over the GRACE risk score.
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Affiliation(s)
- Alfonso Campanile
- Department of Cardiology, Intensive Cardiac Care Unit, Ruggi D' Aragona Hospital
| | - Costantina Prota
- Department of Cardiology, Intensive Cardiac Care Unit, Ruggi D' Aragona Hospital
| | - Michele Tedeschi
- Department of Medicine and Surgery, School of Cardiology, University of Salerno
| | - Angelo Giano
- Department of Medicine and Surgery, School of Cardiology, University of Salerno
| | | | - Mario Cristiano
- Department of Medicine and Surgery, School of Cardiology, University of Salerno
| | - Antonella Pompa
- Department of Medicine and Surgery, School of Cardiology, University of Salerno
| | - Rosanna Sorrentino
- Department of Cardiology, Intensive Cardiac Care Unit, Ruggi D' Aragona Hospital
| | | | - Amelia Ravera
- Department of Cardiology, Intensive Cardiac Care Unit, Ruggi D' Aragona Hospital
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2
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Savic L, Mrdovic I, Asanin M, Stankovic S, Lasica R, Matic D, Simic D, Krljanac G. Prognostic Impact of Non-Cardiac Comorbidities on Long-Term Prognosis in Patients with Reduced and Preserved Ejection Fraction following Acute Myocardial Infarction. J Pers Med 2023; 13:1110. [PMID: 37511723 PMCID: PMC10381839 DOI: 10.3390/jpm13071110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/01/2023] [Accepted: 07/05/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND We aimed to analyze the prevalence and long-term prognostic impact of non-cardiac comorbidities in patients with reduced and preserved left-ventricular ejection fraction (EF) following ST-elevation myocardial infarction (STEMI). METHOD A total of 3033 STEMI patients undergoing primary percutaneous coronary intervention (pPCI) were divided in two groups: reduced EF < 50% and preserved EF ≥ 50%. The follow-up period was 8 years. RESULTS Preserved EF was present in 1726 (55.4%) patients and reduced EF was present in 1389 (44.5%) patients. Non-cardiac comorbidities were more frequent in patients with reduced EF compared with patients with preserved EF (38.9% vs. 27.4%, respectively, p < 0.001). Lethal outcome was registered in 240 (17.2%) patients with reduced EF and in 40 (2.3%) patients with preserved EF, p < 0.001. Diabetes and chronic kidney disease (CKD) were independent predictors for 8-year mortality in patients with preserved EF. In patients with reduced EF, CKD was independently associated with 8-year mortality. CONCLUSION In patients who had reduced EF, the prevalence of non-cardiac comorbidities was higher than in patients who had preserved EF after STEMI. Only diabetes mellitus and CKD were independently associated with 8-year mortality in analyzed patients.
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Affiliation(s)
- Lidija Savic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
- University Clinical Center of Serbia, Emergency Hospital, Coronary Care Unit & Cardiology Clinic, 11000 Belgrade, Serbia
| | - Igor Mrdovic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
- University Clinical Center of Serbia, Emergency Hospital, Coronary Care Unit & Cardiology Clinic, 11000 Belgrade, Serbia
| | - Milika Asanin
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
- University Clinical Center of Serbia, Emergency Hospital, Coronary Care Unit & Cardiology Clinic, 11000 Belgrade, Serbia
| | - Sanja Stankovic
- Center for Medical Biochemistry, Emergency Hospital, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Ratko Lasica
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
- University Clinical Center of Serbia, Emergency Hospital, Coronary Care Unit & Cardiology Clinic, 11000 Belgrade, Serbia
| | - Dragan Matic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
- University Clinical Center of Serbia, Emergency Hospital, Coronary Care Unit & Cardiology Clinic, 11000 Belgrade, Serbia
| | - Damjan Simic
- University Clinical Center of Serbia, Emergency Hospital, Coronary Care Unit & Cardiology Clinic, 11000 Belgrade, Serbia
| | - Gordana Krljanac
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
- University Clinical Center of Serbia, Emergency Hospital, Coronary Care Unit & Cardiology Clinic, 11000 Belgrade, Serbia
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Wu S, Qiu Z, Lu Y, Wu X, Gao T, Xu J, Li S, Zhou X. Predictive value of ACEF II score for adverse prognosis in patients with coronary heart disease after percutaneous coronary intervention. Postgrad Med J 2023; 99:605-612. [PMID: 37319156 DOI: 10.1136/postgradmedj-2022-141609] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 02/28/2022] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To investigate the predictive value of age, creatinine and ejection fraction (ACEF) II score for the incidence of major adverse cardiovascular and cerebrovascular events (MACCEs) in patients with coronary heart disease (CHD) after percutaneous coronary intervention (PCI). METHODS A total of 445 patients with CHD who underwent PCI were consecutively enrolled. The receiver operating characteristic (ROC) curve was used to analyse the power of the ACEF II score in predicting MACCE. Kaplan-Meier survival curves and log-rank tests were chosen for survival analysis of adverse prognosis between groups. Finally, multivariate Cox proportional risk regression analysis was used to investigate independent risk factors for MACCEs in patients with CHD after PCI. RESULTS There was a significantly higher incidence of MACCEs in patients with high ACEF II scores. The area under the ROC curve of ACEF II score was 0.718, suggesting it had ideal predictive value for MACCE risks. The ACEF II score had a best cut-off value of 1.461 (sensitivity 79.4%, specificity 53.7%). Survival analysis indicated that patients in the high-score group had a significantly lower cumulative MACCE-free survival rate. Multivariate Cox regression analysis showed that ACEF II scores ≥1.461, Gensini scores ≥61.5, age, cardiac troponin I and previous PCI were independent risk factors of MACCE in patients with CHD after PCI, while the utilisation of statins was an independent protective factor. CONCLUSIONS The ACEF II score has an ideal capacity for risk stratification in patients with CHD undergoing PCI and offers good predictive value for MACCE in the long term.
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Affiliation(s)
- Siyi Wu
- Department of Cardiology, Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Zhiqing Qiu
- Department of Cardiology, Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Yaqiong Lu
- Department of Cardiology, Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Xiaoguang Wu
- Department of Cardiology, Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Ting Gao
- Department of Cardiology, Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Jie Xu
- Department of Cardiology, Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Shuangshuang Li
- Department of Cardiology, Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Xiang Zhou
- Department of Cardiology, Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
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Oberoi M, Ainani N, Abbott JD, Mamas MA, Velagapudi P. Age Considerations in the Invasive Management of Acute Coronary Syndromes. US CARDIOLOGY REVIEW 2022. [DOI: 10.15420/usc.2021.29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The elderly constitute a major proportion of patients admitted with acute coronary syndrome (ACS) in the US. Due to pre-existing comorbidities, frailty, and increased risk of complications from medical and invasive therapies, management of ACS in the elderly population poses challenges. In patients with ST-elevation MI, urgent revascularization with primary percutaneous coronary intervention remains the standard of care irrespective of age. However, an early invasive approach in elderly patients with non-ST-elevation MI is based on individual evaluation of risks versus benefits. In this review, the authors discuss the unique characteristics of elderly patients presenting with ACS, specific geriatric conditions that need to be considered while making treatment decisions in these situations, and available evidence, current guidelines, and future directions for invasive management of elderly patients with ACS.
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Affiliation(s)
- Mansi Oberoi
- Department of Internal Medicine, Sanford School of Medicine, University of South Dakota, Sioux Falls, SD
| | - Nitesh Ainani
- Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, NE
| | - J Dawn Abbott
- Department of Internal Medicine, Division of Cardiology, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Institute of Applied Clinical Sciences, University of Keele, Stoke-on-Trent, UK
| | - Poonam Velagapudi
- Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, NE
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5
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Percutaneous cholecystostomy: An update for the 2020s. North Clin Istanb 2021; 8:537-542. [PMID: 34909596 PMCID: PMC8630714 DOI: 10.14744/nci.2021.81594] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 03/02/2021] [Indexed: 12/24/2022] Open
Abstract
Cholecystectomy is the standard treatment of acute cholecystitis. Surgery, however, poses significant risks for patients with advanced age and/or comorbid conditions. For such patients, percutaneous cholecystostomy (PC) is the only option. This interventional procedure does not have any absolute contraindications because of the life-threatening nature of the disease, in which other treatment options cannot be offered due to their risks. Nonetheless, these risk factors necessitate performing PC under urgent, rapid, and in many cases suboptimal conditions. In this article, PC was revisited in the light of our extensive experience in addition to the most current literature. Pre-procedural evaluation including the risk assessment and procedural steps was presented in detail. If conducted properly, PC provides significant clinical improvement in the short term and is life-saving, especially in the elderly and in patients with comorbid diseases or high surgical risk. It may also be the definitive treatment method for acute cholecystitis.
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Zhang F, Wong C, Chiu Y, Ensor J, Mohamed MO, Peat G, Mamas MA. Prognostic impact of comorbidity measures on outcomes following acute coronary syndrome: A systematic review. Int J Clin Pract 2021; 75:e14345. [PMID: 33973320 DOI: 10.1111/ijcp.14345] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 05/07/2021] [Indexed: 11/27/2022] Open
Abstract
AIM To identify existing comorbidity measures and summarise their association with acute coronary syndrome (ACS) outcomes. METHODS We searched published studies from MEDLINE (OVIDSP) and EMBASE from inception to March 2021, studies of the pre-specified conference proceedings from Web of Science since May 2017, and studies included in any relevant systematic reviews. Studies that reported no comorbidity measures, no association of comorbid burden with ACS outcomes, or only used a comorbidity measure as a confounder without further information were excluded. After independent screening by three reviewers, data extraction and risk of bias assessment of each included study was undertaken. Results were narratively synthesised. RESULTS Of 4166 potentially eligible studies identified, 12 (combined n = 6 885 982 participants) were included. Most studies had a high risk of bias at quality assessment. Six different types of comorbidity measures were identified with the Charlson comorbidity index (CCI) the most widely used measure among studies. Overall, the greater the comorbid burden or the higher comorbidity scores recorded, the greater was the association with the risk of mortality. CONCLUSION The review summarised different comorbidity measures and reported that higher comorbidity scores were associated with worse ACS outcomes. The CCI is the most widely measure of comorbid burden and shows additive value to clinical risk scores in use.
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Affiliation(s)
- Fangyuan Zhang
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institutes of Applied Clinical Science and Primary Care and Health Sciences, Keele University, Keele, UK
| | - Chunwai Wong
- Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Yida Chiu
- Papworth Trials Unit Collaboration, Royal Papworth Hospital, Cambridge, UK
| | - Joie Ensor
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institutes of Applied Clinical Science and Primary Care and Health Sciences, Keele University, Keele, UK
- School of Medicine, Keele University, Keele, UK
| | - Mohamed O Mohamed
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institutes of Applied Clinical Science and Primary Care and Health Sciences, Keele University, Keele, UK
- Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - George Peat
- School of Medicine, Keele University, Keele, UK
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institutes of Applied Clinical Science and Primary Care and Health Sciences, Keele University, Keele, UK
- Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK
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7
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García-Blas S, Cordero A, Diez-Villanueva P, Martinez-Avial M, Ayesta A, Ariza-Solé A, Mateus-Porta G, Martínez-Sellés M, Escribano D, Gabaldon-Perez A, Bodi V, Bonanad C. Acute Coronary Syndrome in the Older Patient. J Clin Med 2021; 10:4132. [PMID: 34575243 PMCID: PMC8467899 DOI: 10.3390/jcm10184132] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 09/06/2021] [Accepted: 09/07/2021] [Indexed: 01/21/2023] Open
Abstract
Coronary artery disease is one of the leading causes of morbidity and mortality, and its prevalence increases with age. The growing number of older patients and their differential characteristics make its management a challenge in clinical practice. The aim of this review is to summarize the state-of-the-art in diagnosis and treatment of acute coronary syndromes in this subgroup of patients. This comprises peculiarities of ST-segment elevation myocardial infarction (STEMI) management, updated evidence of non-STEMI therapeutic strategies, individualization of antiplatelet treatment (weighting ischemic and hemorrhagic risks), as well as assessment of geriatric conditions and ethical issues in decision making.
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Affiliation(s)
- Sergio García-Blas
- Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA Biomedical Research Institute, University of Valencia, 46010 Valencia, Spain; (S.G.-B.); (A.G.-P.); (V.B.)
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain; (A.C.); (M.M.-S.); (D.E.)
| | - Alberto Cordero
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain; (A.C.); (M.M.-S.); (D.E.)
- Cardiology Department, Hospital Universitario de San Juan, 03550 Alicante, Spain
| | - Pablo Diez-Villanueva
- Cardiology Department, Hospital Universitario de La Princesa, 28006 Madrid, Spain; (P.D.-V.); (M.M.-A.)
| | - Maria Martinez-Avial
- Cardiology Department, Hospital Universitario de La Princesa, 28006 Madrid, Spain; (P.D.-V.); (M.M.-A.)
| | - Ana Ayesta
- Cardiology Department, Hospital Central de Asturias, 33011 Oviedo, Spain;
| | - Albert Ariza-Solé
- Cardiology Department, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (A.A.-S.); (G.M.-P.)
| | - Gemma Mateus-Porta
- Cardiology Department, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (A.A.-S.); (G.M.-P.)
| | - Manuel Martínez-Sellés
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain; (A.C.); (M.M.-S.); (D.E.)
- Cardiology Department, Hospital Universitario Gregorio Marañón, Universidad Europea, Universidad Complutense, 28007 Madrid, Spain
| | - David Escribano
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain; (A.C.); (M.M.-S.); (D.E.)
- Cardiology Department, Hospital Universitario de San Juan, 03550 Alicante, Spain
| | - Ana Gabaldon-Perez
- Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA Biomedical Research Institute, University of Valencia, 46010 Valencia, Spain; (S.G.-B.); (A.G.-P.); (V.B.)
| | - Vicente Bodi
- Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA Biomedical Research Institute, University of Valencia, 46010 Valencia, Spain; (S.G.-B.); (A.G.-P.); (V.B.)
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), 28029 Madrid, Spain; (A.C.); (M.M.-S.); (D.E.)
| | - Clara Bonanad
- Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA Biomedical Research Institute, University of Valencia, 46010 Valencia, Spain; (S.G.-B.); (A.G.-P.); (V.B.)
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8
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Sanchis J, García Acuña JM, Raposeiras S, Barrabés JA, Cordero A, Martínez-Sellés M, Bardají A, Díez-Villanueva P, Marín F, Ruiz-Nodar JM, Vicente-Ibarra N, Alonso Salinas GL, Rigueiro P, Abu-Assi E, Formiga F, Núñez J, Núñez E, Ariza-Solé A. Carga de comorbilidad y beneficio de la revascularización en ancianos con síndrome coronario agudo. Rev Esp Cardiol 2021. [DOI: 10.1016/j.recesp.2020.06.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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9
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Kayama K, Yamada T, Tamaki S, Watanabe T, Morita T, Furukawa Y, Kawasaki M, Kikuchi A, Kawai T, Seo M, Nakamura J, Kawahira M, Fukunami M. Incremental prognostic value of cardiac metaiodobenzylguanidine imaging over the co-morbid burden in acute decompensated heart failure. ESC Heart Fail 2021; 8:1167-1177. [PMID: 33438366 PMCID: PMC8006734 DOI: 10.1002/ehf2.13173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 11/03/2020] [Accepted: 11/27/2020] [Indexed: 12/14/2022] Open
Abstract
Aims Co‐morbidities are associated with poor clinical outcomes in patients with chronic heart failure, while cardiac iodine‐123 (I‐123) metaiodobenzylguanidine (MIBG) imaging provides prognostic information in such patients. We sought to prospectively investigate the incremental prognostic value of cardiac MIBG imaging over the co‐morbid burden, in patients admitted for acute decompensated heart failure (ADHF). Methods and results In 433 consecutive ADHF patients with survival to discharge, we measured the co‐morbidity using age‐adjusted Charlson co‐morbidity index (ACCI), commonly employed to evaluate a weighted and scored co‐morbid condition, adding additional points for age. In cardiac MIBG imaging, the cardiac MIBG heart‐to‐mediastinum ratio (late HMR) was measured on the delayed image. Over a follow‐up period of 2.9 ± 1.5 years, 160 patients had a cardiac event (a composite of cardiac death and unplanned hospitalization for worsening heart failure). Patients with high ACCI (≥6: median value) had a significantly greater risk of a cardiac event. In multivariate Cox analysis, the ACCI and late HMR were significantly and independently associated with a cardiac event. In both high and low ACCI subgroups (ACCI ≥ 6 and <6, respectively), patients with low late HMR had a significantly greater risk of a cardiac event (high ACCI: 51% vs. 34% P = 0.0026, adjusted HR 1.74 [1.21–2.51]; low ACCI: 34% vs. 17%, P = 0.0228, adjusted HR 2.19 [1.10–4.37]). Conclusions Cardiac MIBG imaging could provide additional prognostic information over ACCI, which was also promoted to be a useful risk model, in patients admitted for ADHF.
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Affiliation(s)
- Kiyomi Kayama
- Division of Cardiology, Osaka General Medical Center, Osaka, Japan
| | - Takahisa Yamada
- Division of Cardiology, Osaka General Medical Center, Osaka, Japan
| | - Shunsuke Tamaki
- Division of Cardiology, Osaka General Medical Center, Osaka, Japan
| | - Tetsuya Watanabe
- Division of Cardiology, Osaka General Medical Center, Osaka, Japan
| | - Takashi Morita
- Division of Cardiology, Osaka General Medical Center, Osaka, Japan
| | - Yoshio Furukawa
- Division of Cardiology, Osaka General Medical Center, Osaka, Japan
| | - Masato Kawasaki
- Division of Cardiology, Osaka General Medical Center, Osaka, Japan
| | - Atsushi Kikuchi
- Division of Cardiology, Osaka General Medical Center, Osaka, Japan
| | - Tsutomu Kawai
- Division of Cardiology, Osaka General Medical Center, Osaka, Japan
| | - Masahiro Seo
- Division of Cardiology, Osaka General Medical Center, Osaka, Japan
| | - Jun Nakamura
- Division of Cardiology, Osaka General Medical Center, Osaka, Japan
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10
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Ran P, Yang JQ, Li J, Li G, Wang Y, Qiu J, Zhong Q, Wang Y, Wei XB, Huang JL, Siu CW, Zhou YL, Zhao D, Yu DQ, Chen JY. A risk score to predict in-hospital mortality in patients with acute coronary syndrome at early medical contact: results from the Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome (CCC-ACS) Project. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:167. [PMID: 33569469 PMCID: PMC7867931 DOI: 10.21037/atm-21-31] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background A number of models have been built to evaluate risk in patients with acute coronary syndrome (ACS). However, accurate prediction of mortality at early medical contact is difficult. This study sought to develop and validate a risk score to predict in-hospital mortality among patients with ACS using variables available at early medical contact. Methods A total of 62,546 unselected ACS patients from 150 tertiary hospitals who were admitted between 2014 and 2017 and enrolled in the Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome (CCC-ACS) project, were randomly assigned (at a ratio of 7:3) to a training dataset (n=43,774) and a validation dataset (n=18,772). Based on the identified predictors which were available prior to any blood test, a new point-based risk score for in-hospital death, CCC-ACS score, was derived and validated. The CCC-ACS score was then compared with Global Registry of Acute Coronary Events (GRACE) risk score. Results The in-hospital mortality rate was 1.9% in both the training and validation datasets. The CCC-ACS score, a new point-based risk score, was developed to predict in-hospital mortality using 7 variables that were available before any blood test including age, systolic blood pressure, cardiac arrest, insulin-treated diabetes mellitus, history of heart failure, severe clinical conditions (acute heart failure or cardiogenic shock), and electrocardiographic ST-segment deviation. This new risk score had an area under the curve (AUC) of 0.84 (P=0.10 for Hosmer-Lemeshow goodness-of-fit test) in the training dataset and 0.85 (P=0.13 for Hosmer-Lemeshow goodness-of-fit test) in the validation dataset. The CCC-ACS score was comparable to the Global Registry of Acute Coronary Events (GRACE) score in the prediction of in-hospital death in the validation dataset. Conclusions The newly developed CCC-ACS score, which utilizes factors that are acquirable at early medical contact, may be able to stratify the risk of in-hospital death in patients with ACS. Clinical trial registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT02306616.
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Affiliation(s)
- Peng Ran
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jun-Qing Yang
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jie Li
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Guang Li
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yan Wang
- School of Public Health, Fudan University, Key Laboratory of Public Health Safety, Ministry of Education, Shanghai, China
| | - Jia Qiu
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Qi Zhong
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yu Wang
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xue-Biao Wei
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jie-Leng Huang
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Chung-Wah Siu
- Cardiology Division, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Ying-Ling Zhou
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Dong Zhao
- Department of Epidemiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Dan-Qing Yu
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Ji-Yan Chen
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
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11
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Wellejus Albertsen L, Heide-Jørgensen U, Schmidt SAJ, Grey C, Jackson R, Sørensen HT, Schmidt M. The DANish Comorbidity Index for Acute Myocardial Infarction (DANCAMI): Development, Validation and Comparison with Existing Comorbidity Indices. Clin Epidemiol 2020; 12:1299-1311. [PMID: 33244274 PMCID: PMC7685362 DOI: 10.2147/clep.s277325] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 10/08/2020] [Indexed: 12/22/2022] Open
Abstract
Objective To develop and validate the DANish Comorbidity index for Acute Myocardial Infarction (DANCAMI) for adjustment of comorbidity burden in studies of myocardial infarction prognosis. Methods Using medical registries, we identified patients with first-time myocardial infarction in Denmark during 2000–2013 (n=36,685). We developed comorbidity indices predicting 1-year all-cause mortality from all comorbidities (DANCAMI) and restricted to non-cardiovascular comorbidities (rDANCAMI). For variable selection, we eliminated comorbidities stepwise using hazard ratios from multivariable Cox models. We compared DANCAMI/rDANCAMI with Charlson and Elixhauser comorbidity indices using standard performance measures (Nagelkerke’s R2, Harrell’s C-statistic, the Integrated Discrimination Improvement, and the continuous Net Reclassification Index). We assessed the significance of the novel DANCAMI variables not included in the Charlson Comorbidity Index. External validation was performed in patients with myocardial infarction in New Zealand during 2007–2016 (n=75,069). Results The DANCAMI included 24 comorbidities. The rDANCAMI included 17 non-cardiovascular comorbidities. In the Danish cohort, the DANCAMI indices outperformed both the Charlson and the Elixhauser comorbidity indices on all performance measures. The DANCAMI indices included multiple variables that were significant predictors of 1-year mortality even after controlling for all variables in the Charlson Comorbidity Index. These novel variables included valvular heart disease (hazard ratio for 1-year mortality=1.25, 95% CI: 1.14–1.35), coagulopathy (1.13, 95% CI: 1.05–1.22), alcohol and drug abuse (1.35, 95% CI: 1.15–1.58), schizophrenia (1.60, 95% CI: 1.46–1.76), affective disorder (1.29, 95% CI: 1.22–1.36), epilepsy (1.26, 95% CI: 1.05–1.50), neurodegenerative disorder (1.30, 95% CI: 1.10–1.54) and chronic pancreatitis (1.71, 95% CI: 1.14–2.56). The results were supported by the external validation in New Zealand. Conclusion DANCAMI assessed comorbidity burden of patients with first-time myocardial infarction, outperformed existing comorbidity indices, and was generalizable to patients outside Denmark. DANCAMI is recommended as a standard approach for comorbidity adjustment in studies of myocardial infarction prognosis.
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Affiliation(s)
| | - Uffe Heide-Jørgensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Corina Grey
- Section of Epidemiology and Biostatistics, School of Population Health, University of Auckland, Auckland, New Zealand
| | - Rod Jackson
- Section of Epidemiology and Biostatistics, School of Population Health, University of Auckland, Auckland, New Zealand
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Morten Schmidt
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Cardiology, Regional Hospital West Jutland, Herning, Denmark.,Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
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12
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Steiner-Temnykh L, Dakhoul L, Slaven J, Nephew L, Patidar KR, Orman E, Desai AP, Vilar-Gomez E, Kubal C, Ekser B, Chalasani N, Ghabril M. Comorbidity Burden May Be Associated with Increased Mortality in Patients with Severe Acute Liver Injury Referred for Liver Transplantation. Ann Transplant 2020; 25:e926453. [PMID: 33139688 PMCID: PMC7648405 DOI: 10.12659/aot.926453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Severe acute liver injury (S-ALI) can lead to acute liver and multisystem failure, with high mortality and need for liver transplantation (LT); however, the burden and impact of liver disease and comorbid conditions are unknown. MATERIAL AND METHODS We assessed liver disease and Charlson Comorbidity Index (CCI) in adults without cirrhosis evaluated for LT at our center for S-ALI between 2004 and 2017. The study endpoints were 30-day death or LT and 90-day mortality (with LT as a competing risk). RESULTS A total of 136 patients with S-ALI were included; 13% had underlying liver disease and a higher Model for End-stage Liver Disease score than those without liver disease. Sixty patients (41%) died or underwent LT within 30 days. They were older and more frequently female and had disease of autoimmune, viral, or indeterminate etiology. Transplant-free survival was associated with acetaminophen injury. The mean CCI was higher in patients with 30-day mortality or LT (1.5±2.4) vs. LT-free survivors (0.8±1.2), (P=0.03). Beyond severity of illness, CCI was associated with increased 90-day mortality (subhazard ratio 1.17, 95% confidence interval, 1.01-1.35) but not 30-day mortality or LT in the risk-adjusted analyses. CONCLUSIONS Comorbidity burden may be an important modifier of transplant-free survival in patients with S-ALI, but further studies are needed to validate these findings.
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Affiliation(s)
| | - Lara Dakhoul
- Departmental of Gastroenterology and Hepatology, Indiana University, Indianapolis, IN, USA
| | - James Slaven
- Departmental of Biostatistics, Indiana University, Indianapolis, IN, USA
| | - Lauren Nephew
- Departmental of Gastroenterology and Hepatology, Indiana University, Indianapolis, IN, USA
| | - Kavish R Patidar
- Departmental of Gastroenterology and Hepatology, Indiana University, Indianapolis, IN, USA
| | - Eric Orman
- Departmental of Gastroenterology and Hepatology, Indiana University, Indianapolis, IN, USA
| | - Archita P Desai
- Departmental of Gastroenterology and Hepatology, Indiana University, Indianapolis, IN, USA
| | - Eduardo Vilar-Gomez
- Departmental of Gastroenterology and Hepatology, Indiana University, Indianapolis, IN, USA
| | | | - Burcin Ekser
- Departmental of Transplant Surgery, Indiana University, Indianapolis, IN, USA
| | - Naga Chalasani
- Departmental of Gastroenterology and Hepatology, Indiana University, Indianapolis, IN, USA
| | - Marwan Ghabril
- Departmental of Gastroenterology and Hepatology, Indiana University, Indianapolis, IN, USA
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13
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Coppel S, Mathur K, Ekser B, Patidar KR, Orman E, Desai AP, Vilar-Gomez E, Kubal C, Chalasani N, Nephew L, Ghabril M. Extra-hepatic comorbidity burden significantly increases 90-day mortality in patients with cirrhosis and high model for endstage liver disease. BMC Gastroenterol 2020; 20:302. [PMID: 32938387 PMCID: PMC7493147 DOI: 10.1186/s12876-020-01448-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 09/11/2020] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND We examined how extra-hepatic comorbidity burden impacts mortality in patients with cirrhosis referred for liver transplantation (LT). METHODS Adults with cirrhosis evaluated for their first LT in 2012 were followed through their clinical course with last follow up in 2019. Extra-hepatic comorbidity burden was measured using the Charlson Comorbidity Index (CCI). The endpoints were 90-day transplant free survival (Cox-Proportional Hazard regression), and overall mortality (competing risk analysis). RESULTS The study included 340 patients, mean age 56 ± 11, 63% male and MELD-Na 17.2 ± 6.6. The CCI was 0 (no comorbidities) in 44%, 1-2 in 44% and > 2 (highest decile) in 12%, with no differences based on gender but higher CCI in patients with fatty and cryptogenic liver disease. Thirty-three (10%) of 332 patients not receiving LT within 90 days died. Beyond MELD-Na, the CCI was independently associated with 90-day mortality (hazard ratio (HR), 1.32 (95% confidence interval (CI) 1.02-1.72). Ninety-day mortality was specifically increased with higher CCI category and MELD ≥18 (12% (CCI = 0), 22% (CCI = 1-2) and 33% (CCI > 2), (p = 0.002)) but not MELD-Na ≤17. At last follow-up, 69 patients were alive, 100 underwent LT and 171 died without LT. CCI was associated with increased overall mortality in the competing risk analysis (Sub-HR 1.24, 95%CI 1.1-1.4). CONCLUSIONS Extra-hepatic comorbidity burden significantly impacts short-term mortality in patients with cirrhosis and high MELD-Na. This has implications in determining urgency of LT and mortality models in cirrhosis and LT waitlisting, especially with an ageing population with increasing prevalence of fatty liver disease.
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Affiliation(s)
- Scott Coppel
- Medicine, Indiana University, Indianapolis, IN, USA
| | - Karan Mathur
- Gastroenterology and Hepatology, Indiana University, 702 Rotary Circle, suite 225, Indianapolis, IN, 46202, USA
| | - Burcin Ekser
- Transplant Surgery, Indiana University, Indianapolis, IN, USA
| | - Kavish R Patidar
- Gastroenterology and Hepatology, Indiana University, 702 Rotary Circle, suite 225, Indianapolis, IN, 46202, USA
| | - Eric Orman
- Gastroenterology and Hepatology, Indiana University, 702 Rotary Circle, suite 225, Indianapolis, IN, 46202, USA
| | - Archita P Desai
- Gastroenterology and Hepatology, Indiana University, 702 Rotary Circle, suite 225, Indianapolis, IN, 46202, USA
| | - Eduardo Vilar-Gomez
- Gastroenterology and Hepatology, Indiana University, 702 Rotary Circle, suite 225, Indianapolis, IN, 46202, USA
| | | | - Naga Chalasani
- Gastroenterology and Hepatology, Indiana University, 702 Rotary Circle, suite 225, Indianapolis, IN, 46202, USA
| | - Lauren Nephew
- Gastroenterology and Hepatology, Indiana University, 702 Rotary Circle, suite 225, Indianapolis, IN, 46202, USA
| | - Marwan Ghabril
- Gastroenterology and Hepatology, Indiana University, 702 Rotary Circle, suite 225, Indianapolis, IN, 46202, USA.
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14
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Zhang F, Bharadwaj A, Mohamed MO, Ensor J, Peat G, Mamas MA. Impact of Charlson Co-Morbidity Index Score on Management and Outcomes After Acute Coronary Syndrome. Am J Cardiol 2020; 130:15-23. [PMID: 32693918 DOI: 10.1016/j.amjcard.2020.06.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 06/02/2020] [Accepted: 06/05/2020] [Indexed: 11/28/2022]
Abstract
Patients presenting with acute coronary syndrome (ACS) are frequently co-morbid. However, there is limited data on how co-morbidity burden impacts their receipt of invasive management and subsequent outcomes. We analyzed all patients with a discharge diagnosis of ACS from the National Inpatient Sample (2004 to 2014), stratified by Charlson Co-morbidity Index (CCI) into 4 classes (CCI 0, 1, 2, and ≥3). Regression analyses were performed to examine associations between co-morbidity burden and receipt of invasive intervention and in-hospital clinical outcomes. Of all 6,613,623 ACS patients analyzed, the prevalence of patients with severe co-morbidity (CCI ≥3) increased from 10.8% (2004) to 18.1% (2014). CCI class negatively correlated with receipt of invasive management, with CCI ≥3 group being the least likely to receive coronary angiography and percutaneous coronary intervention (odds ratio (OR) 0.42 95% confidence interval [CI] 0.41 to 0.43 and OR 0.47, 95% CI 0.46 to 0.48, respectively). CCI class was independently associated with an increased risk of mortality and complications, especially CCI ≥3 that was associated with significantly increased odds of Major Acute Cardiovascular & Cerebrovascular Events (OR 1.70, 95% CI 1.66 to 1.75), mortality (OR 1.74, 95% CI 1.68 to 1.79), acute ischemic stroke (OR 2.35, 95% CI 2.23 to 2.46), and major bleeding (OR 1.64, 95% CI 1.59 to 1.69). Co-morbidity burden has significantly increased amongst those presenting with ACS over an 11-year period and correlates with reduced likelihood of receipt of invasive management and increased odds of mortality and adverse outcomes. In conclusion, objective assessment of co-morbidities using CCI score identifies high-risk ACS patients in whom targeted risk reduction strategies may reduce their inherent risk of mortality and complications.
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Affiliation(s)
- Fangyuan Zhang
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, United Kingdom
| | - Aditya Bharadwaj
- Division of Cardiology, Department of Medicine, Loma Linda University, Loma Linda, California
| | - Mohamed O Mohamed
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, United Kingdom; Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom
| | - Joie Ensor
- School of Primary, Community, and Social Care, Keele University, United Kingdom
| | - George Peat
- School of Primary, Community, and Social Care, Keele University, United Kingdom
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, United Kingdom; Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom; School of Primary, Community, and Social Care, Keele University, United Kingdom.
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15
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Sanchis J, García Acuña JM, Raposeiras S, Barrabés JA, Cordero A, Martínez-Sellés M, Bardají A, Díez-Villanueva P, Marín F, Ruiz-Nodar JM, Vicente-Ibarra N, Alonso Salinas GL, Rigueiro P, Abu-Assi E, Formiga F, Núñez J, Núñez E, Ariza-Solé A. Comorbidity burden and revascularization benefit in elderly patients with acute coronary syndrome. ACTA ACUST UNITED AC 2020; 74:765-772. [PMID: 32778402 DOI: 10.1016/j.rec.2020.06.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 06/11/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION AND OBJECTIVES To evaluate the interaction between comorbidity burden and the benefits of in-hospital revascularization in elderly patients with non-ST-segment elevation acute coronary syndrome (NSTEACS). METHODS This retrospective study included 7211 patients aged ≥ 70 years from 11 Spanish NSTEACS registries. Six comorbidities were evaluated: diabetes, peripheral artery disease, cerebrovascular disease, chronic pulmonary disease, renal failure, and anemia. A propensity score was estimated to enable an adjusted comparison of in-hospital revascularization and conservative management. The end point was 1-year all-cause mortality. RESULTS In total, 1090 patients (15%) died. The in-hospital revascularization rate was 60%. Revascularization was associated with lower 1-year mortality; the strength of the association was unchanged by the addition of comorbidities to the model (HR, 0.61; 95%CI, 0.53-0.69; P=.0001). However, the effects of revascularization were attenuated in patients with renal failure, peripheral artery disease, and chronic pulmonary disease (P for interaction=.004, .007, and .03, respectively) but were not modified by diabetes, anemia, and previous stroke (P=.74, .51, and .28, respectively). Revascularization benefits gradually decreased as the number of comorbidities increased (from a HR of 0.48 [95%CI, 0.39-0.61] with 0 comorbidities to 0.83 [95%CI, 0.62-1.12] with ≥ 5 comorbidities; omnibus P=.016). The results were similar for the propensity score model. The same findings were obtained when invasive management was considered the exposure variable. CONCLUSIONS In-hospital revascularization improves 1-year mortality regardless of comorbidities in elderly patients with NSTEACS. However, the revascularization benefit is progressively reduced with an increased comorbidity burden. Renal failure, peripheral artery disease, and chronic lung disease were the comorbidities with the most detrimental effects on revascularization benefits.
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Affiliation(s)
- Juan Sanchis
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, INCLIVA, Universidad de Valencia, Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain.
| | - Jose María García Acuña
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Clínico Universitario de Santiago, Santiago de Compostela, A Coruña, Spain
| | - Sergio Raposeiras
- Servicio de Cardiología. Hospital Álvaro Cunqueiro de Vigo, Vigo, Pontevedra, Spain
| | - Jose A Barrabés
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Alberto Cordero
- Servicio de Cardiología, Hospital Clínico Universitario de San Juan, Alicante, Spain
| | - Manuel Martínez-Sellés
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario Gregorio Marañón, Universidad Complutense, Universidad Europea, Madrid, Spain
| | - Alfredo Bardají
- Servicio de Cardiología, Hospital Universitario de Tarragona Joan XXIII, IISPV, Universitat Rovira i Virgili, Tarragona, Spain
| | | | - Francisco Marín
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, IMIB-Arrixaca, El Palmar, Murcia, Spain
| | - Juan M Ruiz-Nodar
- Servicio de Cardiología, Hospital General Universitario de Alicante, Alicante, Spain
| | | | - Gonzalo L Alonso Salinas
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario Ramón y Cajal de Madrid, Madrid, Spain
| | - Pedro Rigueiro
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Clínico Universitario de Santiago, Santiago de Compostela, A Coruña, Spain
| | - Emad Abu-Assi
- Servicio de Cardiología. Hospital Álvaro Cunqueiro de Vigo, Vigo, Pontevedra, Spain
| | - Frances Formiga
- Servicio de Medicina Interna, Hospital Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Julio Núñez
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, INCLIVA, Universidad de Valencia, Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Eduardo Núñez
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, INCLIVA, Universidad de Valencia, Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Albert Ariza-Solé
- Servicio de Cardiología, Hospital Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
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16
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Forné C, Subirana I, Blanch J, Ferrieres J, Azevedo A, Meisinger C, Farmakis D, Tavazzi L, Davoli M, Ramos R, Brosa M, Marrugat J, Dégano IR. A cost-utility analysis of increasing percutaneous coronary intervention use in elderly patients with acute coronary syndromes in six European countries. Eur J Prev Cardiol 2020; 28:408-417. [PMID: 33966078 DOI: 10.1177/2047487320942644] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 06/25/2020] [Indexed: 01/08/2023]
Abstract
AIMS Percutaneous coronary intervention reduces mortality in acute coronary syndrome patients but the cost-utility of increasing its use in elderly acute coronary syndrome patients is unknown. METHODS We assessed the efficiency of increased percutaneous coronary intervention use compared to current practice in patients aged ≥75 years admitted for acute coronary syndrome in France, Germany, Greece, Italy, Portugal and Spain with a semi-Markov state transition model. In-hospital mortality reduction estimates by percutaneous coronary intervention use and costs were derived from the EUROpean Treatment & Reduction of Acute Coronary Syndromes cost analysis EU project (n = 28,600). Risk of recurrence and out-of-hospital all-cause mortality were obtained from the Information System for the Development of Research in Primary Care (SIDIAP) database from North-Eastern Spain (n = 55,564). In-hospital mortality was modelled using stratified propensity score analysis. The 8-year acute coronary syndrome recurrence risk and out-of-hospital mortality were estimated with a multistate survival model. The scenarios analysed were to increase percutaneous coronary intervention use among patients with the highest, moderate and lowest probability of receiving percutaneous coronary intervention based on the propensity score analysis. RESULTS France, Greece and Portugal showed similar total costs/1000 individuals (7.29-11.05 m €); while in Germany, Italy and Spain, costs were higher (13.53-22.57 m €). Incremental cost-utility ratios of providing percutaneous coronary intervention to all patients ranged from 2262.8 €/quality adjusted life year gained for German males to 6324.3 €/quality adjusted life year gained for Italian females. Increasing percutaneous coronary intervention use was cost-effective at a willingness-to-pay threshold of 10,000 €/quality adjusted life year gained for all scenarios in the six countries, in males and females. CONCLUSION Compared to current clinical practice, broadening percutaneous coronary intervention use in elderly acute coronary syndrome patients would be cost-effective across different healthcare systems in Europe, regardless of the selected strategy.
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Affiliation(s)
- C Forné
- Department of Basic Medical Sciences, University of Lleida, Spain
| | - I Subirana
- REGICOR Study Group, IMIM (Hospital del Mar Medical Research Institute), Spain.,CIBER Epidemiology and Public Health, Instituto de Salud Carlos III (ISCIII), Spain
| | - J Blanch
- Vascular Health Research Group (ISV-Girona), Jordi Gol Institute for Primary Care Research (IDIAPJGol), Spain
| | - J Ferrieres
- Department of Cardiology, Toulouse University School of Medicine, France
| | - A Azevedo
- Department of Clinical Epidemiology, Predictive Medicine and Public Health, University of Porto Medical School, Portugal
| | - C Meisinger
- MONICA/KORA Myocardial Infarction Registry, University Hospital of Augsburg, Germany.,Helmholtz Zentrum München, German Research Center for Environmental Health, Germany
| | - D Farmakis
- University of Cyprus Medical School, Cyprus.,Second Department of Cardiology, University of Athens Medical School, Greece
| | - L Tavazzi
- Maria Cecilia Hospital, GVM Care and Research, Italy
| | - M Davoli
- Department of Epidemiology, Lazio Regional Health Service, Italy
| | - R Ramos
- Vascular Health Research Group (ISV-Girona), Jordi Gol Institute for Primary Care Research (IDIAPJGol), Spain.,Catalan Institute of Health, Spain.,Department of Medical Sciences, University of Girona, Spain.,Girona Biomedical Research Institute (IdIBGi), Spain
| | - M Brosa
- Oblikue Consulting SL, Spain
| | - J Marrugat
- REGICOR Study Group, IMIM (Hospital del Mar Medical Research Institute), Spain.,Centro de Investigación Biomédica en Red (CIBER) of Cardiovascular Diseases, ISCIII, Spain
| | - I R Dégano
- REGICOR Study Group, IMIM (Hospital del Mar Medical Research Institute), Spain.,Centro de Investigación Biomédica en Red (CIBER) of Cardiovascular Diseases, ISCIII, Spain.,Faculty of Medicine, University of Vic-Central University of Catalonia (UVic-UCC), Spain
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17
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Martsevich SY, Kutishenko NP, Sichinava DP, Kalaydzhyan EP, Kasparova EA, Zagrebelnyy AV, Lukina YV, Evdakov VA. The Main Cardiovascular Complications and Mortality Rates During the First One and a Half Years after Acute Myocardial Infarction: Data from the Prospective Outpatient Registry PROFILE-IM. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2020. [DOI: 10.20996/1819-6446-2020-06-11] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- S. Yu. Martsevich
- National Medical Research Center for Therapy and Preventive Medicine
| | - N. P. Kutishenko
- National Medical Research Center for Therapy and Preventive Medicine
| | | | | | | | - A. V. Zagrebelnyy
- National Medical Research Center for Therapy and Preventive Medicine
| | - Yu. V. Lukina
- National Medical Research Center for Therapy and Preventive Medicine
| | - V. A. Evdakov
- Federal Research Institute for Health Organization and Informatics
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18
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Kayani WT, Khan MR, Deshotels MR, Jneid H. Challenges and Controversies in the Management of ACS in Elderly Patients. Curr Cardiol Rep 2020; 22:51. [PMID: 32500287 DOI: 10.1007/s11886-020-01298-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW Elderly patients presenting with acute coronary syndrome (ACS) represent a challenging patient population. A high index of suspicion is needed for their diagnosis, as they are less likely to present with typical anginal symptoms compared to their younger counterparts. RECENT FINDINGS Disrupted coronary plaques with superimposed thrombosis are the predominant pathophysiology of ACS; however, an increased proportion of calcified nodules is encountered in elderly patients. Emergent reperfusion and revascularization remain the mainstay treatment for ST-elevation myocardial infarction or cardiogenic shock. In elderly patients with NSTE-ACS, a routine invasive strategy is generally superior to an ischemia-guided strategy, and the safety of an early invasive strategy has also been recently demonstrated. When treating elderly ACS patients with antiplatelet and antithrombotic therapies, close attention to co-morbidities, frailty and the balance of ischemia-bleeding risk should be undertaken, and medication doses should be carefully adjusted. Overall, elderly patients with ACS remain undertreated with evidence-based therapies, experience worse outcomes, and represent an opportunity for enhancing and mitigating healthcare disparities.
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Affiliation(s)
- Waleed T Kayani
- Section of Cardiology, Department of Internal Medicine, Baylor College of Medicine, Houston, TX, USA.
| | - Mahin R Khan
- Division of Cardiology, McLaren-Flint/Michigan State University, Flint, MI, USA
| | | | - Hani Jneid
- Section of Cardiology, Department of Internal Medicine, Baylor College of Medicine, Houston, TX, USA.,Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
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19
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Schmidt M, Horváth-Puhó E, Ording AG, Bøtker HE, Lash TL, Sørensen HT. The interaction effect of cardiac and non-cardiac comorbidity on myocardial infarction mortality: A nationwide cohort study. Int J Cardiol 2020; 308:1-8. [PMID: 32057473 DOI: 10.1016/j.ijcard.2020.01.059] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 01/09/2020] [Accepted: 01/24/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Whether the prognostic impact of comorbidity on myocardial infarction (MI) mortality is due to comorbidity alone or/and its interaction effect is unknown. METHODS We used Danish medical registries to conduct a nationwide cohort study of all first-time MIs during 1995-2016 (n = 179,515) and a comparison cohort matched on age, sex, and individual comorbidities (n = 880,347). We calculated age-standardized 5-year all-cause mortality rates. Interaction was examined on an additive scale by calculating interaction contrasts (difference in rate differences). RESULTS Among individuals without comorbidity, the 30-day mortality rate per 1000 person-years was 1851 (95% CI: 1818-1884) for MI patients and 22 (21-24) for comparison cohort members (rate difference = 1829). For individuals with low comorbidity, corresponding baseline mortality rates were 2498 (2436-2560) in the MI and 54 (50-57) in the comparison cohort (rate difference = 2444). The interaction contrast (616) indicated that the interaction accounted for 25% (616/2498) of the total 30-day mortality rate in MI patients with low comorbidity. This percentage increased further for moderate (35%) and severe (45%) comorbidity levels. Absolute and relative interaction effects were largest within the first 30 days and younger individuals. Dose-response patterns were also observed during 31-365 days and 1-5 years of follow-up (p-values for trends<0.002). The interaction differed substantially between individual types of cardiac and non-cardiac comorbidities. CONCLUSION Cardiac and non-cardiac comorbidities interact with MI to increase short- and long-term mortality beyond that explained by their additive effects. The interaction had a dose-response relation with comorbidity burden and a magnitude of clinical importance.
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Affiliation(s)
- Morten Schmidt
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark; Department of Cardiology, Regional Hospital West Jutland, Herning, Denmark.
| | | | - Anne Gulbech Ording
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Hans Erik Bøtker
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Timothy L Lash
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark; Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
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Sanchis J, Soler M, Núñez J, Ruiz V, Bonanad C, Formiga F, Valero E, Martínez-Sellés M, Marín F, Ruescas A, García-Blas S, Miñana G, Abu-Assi E, Bueno H, Ariza-Solé A. Comorbidity assessment for mortality risk stratification in elderly patients with acute coronary syndrome. Eur J Intern Med 2019; 62:48-53. [PMID: 30711360 DOI: 10.1016/j.ejim.2019.01.018] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 01/18/2019] [Accepted: 01/29/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND The Charlson's is the most used comorbidity index. It comprises 19 comorbidities, some of which are infrequent in elderly patients with acute coronary syndrome (ACS), while some others are manifestations of cardiac disease rather than comorbidities. Our goal was to simplify comorbidity assessment in elderly non-ST-segment elevation ACS patients. METHODS The study group consisted of 1 training (n = 920, 76 ± 7 years) and 1 testing (n = 532; 84 ± 4 years) cohorts. The end-point was all-cause mortality at 1-year follow-up. Comorbidities were assessed selecting those medical disorders other than cardiac disease that were independently associated with mortality by multivariable analysis. RESULTS A total of 130 (14%) patients died in the training cohort. Six comorbidities were predictive: renal failure, anemia, diabetes, peripheral artery disease, cerebrovascular disease and chronic lung disease. The increase in the number of comorbidities yielded a gradient of risk on top of well-known clinical predictors: ≥3 comorbidities (27% mortality, HR = 1.90, 95% CI 1.20-3.03, p = .006); 2 comorbidities (16% mortality, HR = 1.29, 95% CI 0.81-2.04, p = .30); and 0-1 comorbidities (7.6% mortality, reference category). The discrimination accuracy (C-statistic = 0.80) and calibration (Hosmer-Lemeshow test, p = .20) of the predictive model using the 6 comorbidities was comparable to the predictive model using the Charlson index (C-statistic = 0.80; Hosmer-Lemeshow test, p = .70). Similar results were reproduced in the testing cohort (≥3 comorbidities: 24% mortality, HR = 2.37, 95% CI 1.25-4.49, p = .008; 2 comorbidities: 14% mortality, HR = 1.59, 95% CI 0.82-3.07, p = .20; 0-1 comorbidities: 7.5% reference category). CONCLUSION A simplified comorbidity assessment comprising 6 comorbidities provides useful risk stratification in elderly patients with ACS.
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Affiliation(s)
- Juan Sanchis
- Servei de Cardiologia, Hospital Clínic Universitari de València, INCLIVA, Universitat de València, CIBERCV, València, Spain.
| | - Meritxell Soler
- Servei de Cardiologia, Hospital Clínic Universitari de València, INCLIVA, Universitat de València, CIBERCV, València, Spain
| | - Julio Núñez
- Servei de Cardiologia, Hospital Clínic Universitari de València, INCLIVA, Universitat de València, CIBERCV, València, Spain
| | - Vicente Ruiz
- Facultat d'Infermeria, Universitat de València, València, Spain
| | - Clara Bonanad
- Servei de Cardiologia, Hospital Clínic Universitari de València, INCLIVA, Universitat de València, CIBERCV, València, Spain
| | - Francesc Formiga
- Unitat de Medicina Geriàtrica, Servei de medicina Interna, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Ernesto Valero
- Servei de Cardiologia, Hospital Clínic Universitari de València, INCLIVA, Universitat de València, CIBERCV, València, Spain
| | - Manuel Martínez-Sellés
- Servicio de Cardiología, Hospital Universitario Gregorio Marañón, CIBERCV, Universidad Complutense, Universidad Europea, Madrid, Spain
| | - Francisco Marín
- Servicio de Cardiologı'a, Hospital Virgen de la Arrixaca, IMIB-Arrixaca, CIBERCV, El Palmar, Murcia, Spain
| | - Arancha Ruescas
- Departament de Fisioteràpia, Universitat de València, València, Spain
| | - Sergio García-Blas
- Servei de Cardiologia, Hospital Clínic Universitari de València, INCLIVA, Universitat de València, CIBERCV, València, Spain
| | - Gema Miñana
- Servei de Cardiologia, Hospital Clínic Universitari de València, INCLIVA, Universitat de València, CIBERCV, València, Spain
| | - Emad Abu-Assi
- Servicio de Cardiologia, Hospital Alvaro Cunqueiro, Vigo, Pontevedra, Spain
| | - Héctor Bueno
- Servicio de Cardiología, Hospital 12 de Octubre, Madrid, Spain
| | - Albert Ariza-Solé
- Servei de Cardiologia, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
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Jeong JS, Kong SY, Shin SD, Ro YS, Song KJ, Hong KJ, Park JH, Kim TH. Gender disparities in percutaneous coronary intervention in out-of-hospital cardiac arrest. Am J Emerg Med 2019; 37:632-638. [DOI: 10.1016/j.ajem.2018.06.068] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 06/05/2018] [Accepted: 06/29/2018] [Indexed: 11/30/2022] Open
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Estrategia invasiva frente a conservadora en pacientes frágiles con IAMSEST. Diseño del ensayo clínico MOSCA-FRAIL. Rev Esp Cardiol 2019. [DOI: 10.1016/j.recesp.2018.01.028] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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23
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Varghese T, Wenger NK. Non-ST elevation acute coronary syndrome in women and the elderly: recent updates and stones still left unturned. F1000Res 2018; 7:F1000 Faculty Rev-1865. [PMID: 30631426 PMCID: PMC6281006 DOI: 10.12688/f1000research.16492.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/19/2018] [Indexed: 12/17/2022] Open
Abstract
Despite the growing awareness of adverse events with acute coronary syndrome and vigilance to refine pharmacological and interventional therapies, the understanding of how these events present in and affect women and the elderly remains limited. Pathophysiological differences in these subgroups and under-representation in large trials create a medical gap in sex- and age-related outcomes and in our knowledge of how best to detect, diagnose, and treat acute coronary syndrome. This review provides a general overview of recent advances in non-ST elevation myocardial infarction management in women and the elderly and elucidates areas where further exploration is needed.
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Affiliation(s)
- Tina Varghese
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Nanette K. Wenger
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
- Emory Heart and Vascular Center, Emory Women's Heart Center, Atlanta, GA, USA
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Rashid M, Kwok CS, Gale CP, Doherty P, Olier I, Sperrin M, Kontopantelis E, Peat G, Mamas MA. Impact of co-morbid burden on mortality in patients with coronary heart disease, heart failure, and cerebrovascular accident: a systematic review and meta-analysis. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2018; 3:20-36. [PMID: 28927187 DOI: 10.1093/ehjqcco/qcw025] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 05/05/2016] [Indexed: 01/02/2023]
Abstract
Aims We sought to investigate the prognostic impact of co-morbid burden as defined by the Charlson Co-morbidity Index (CCI) in patients with a range of prevalent cardiovascular diseases. Methods and results We searched MEDLINE and EMBASE to identify studies that evaluated the impact of CCI on mortality in patients with cardiovascular disease. A random-effects meta-analysis was undertaken to evaluate the impact of CCI on mortality in patients with coronary heart disease (CHD), heart failure (HF), and cerebrovascular accident (CVA). A total of 11 studies of acute coronary syndrome (ACS), 2 stable coronary disease, 5 percutaneous coronary intervention (PCI), 13 HF, and 4 CVA met the inclusion criteria. An increase in CCI score per point was significantly associated with a greater risk of mortality in patients with ACS [pooled relative risk ratio (RR) 1.33; 95% CI 1.15-1.54], PCI (RR 1.21; 95% CI 1.12-1.31), stable coronary artery disease (RR 1.38; 95% CI 1.29-1.48), and HF (RR 1.21; 95% CI 1.13-1.29), but not CVA. A CCI score of >2 significantly increased the risk of mortality in ACS (RR 2.52; 95% CI 1.58-4.04), PCI (RR 3.36; 95% CI 2.14-5.29), HF (RR 1.76; 95% CI 1.65-1.87), and CVA (RR 3.80; 95% CI 1.20-12.01). Conclusion Increasing co-morbid burden as defined by CCI is associated with a significant increase in risk of mortality in patients with underlying CHD, HF, and CVA. CCI provides a simple way of predicting adverse outcomes in patients with cardiovascular disease and should be incorporated into decision-making processes when counselling patients.
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Affiliation(s)
- Muhammad Rashid
- Keele Cardiovascular Research Group, Institute for Science and Technology in Medicine, Guy Hilton Research Centre, Keele University, Thornburrow Drive, Hartshill, Stoke-on-Trent ST4 7QB, UK
| | - Chun Shing Kwok
- Keele Cardiovascular Research Group, Institute for Science and Technology in Medicine, Guy Hilton Research Centre, Keele University, Thornburrow Drive, Hartshill, Stoke-on-Trent ST4 7QB, UK
| | - Chris P Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | | | - Ivan Olier
- Keele Cardiovascular Research Group, Institute for Science and Technology in Medicine, Guy Hilton Research Centre, Keele University, Thornburrow Drive, Hartshill, Stoke-on-Trent ST4 7QB, UK
| | - Matthew Sperrin
- Far Institute, Institute of Population Health, University of Manchester, Manchester, UK
| | | | - George Peat
- Institute for Primary Care and Health Sciences, University of Keele, Keele, UK
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Institute for Science and Technology in Medicine, Guy Hilton Research Centre, Keele University, Thornburrow Drive, Hartshill, Stoke-on-Trent ST4 7QB, UK.,Royal Stoke Hospital, University Hospital North Midlands, Stoke-on-Trent, UK
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25
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Karabağ T, Altuntaş E, Kalaycı B, Şahіn B, Somuncu MU, Çakır MO. The relationship of Charlson comorbidity index with stent restenosis and extent of coronary artery disease. Interv Med Appl Sci 2018; 10:70-75. [PMID: 30363352 PMCID: PMC6167624 DOI: 10.1556/1646.10.2018.20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Objectives The objective of this study is to investigate the effect of comorbid conditions [Charlson comorbidity index (CCI)] on stent restenosis who underwent coronary angioplasty earlier. Methods Patients were divided into two groups; patients with critical restenosis [recurrent diameter stenosis >50% at the stent segment or its edges (5-mm segments adjacent to the stent) (Group 1; n = 53, mean age: 63.8 ± 9.9 years)] and patients with no critical restenosis [<50% obstruction (Group 2; n = 94, mean age: 62.1 ± 9.1 years)]. The CCI and modified CCI were used for the presence of comorbid conditions. The Gensini scoring system was used to assess the extent of coronary artery disease (CAD). Results Group 1 had a significantly greater CCI and modified CCI score compared to Group 2 (7.1 ± 3.7 vs. 5.6 ± 1.6, p = 0.006; 6.9 ± 3.6 vs. 4.5 ± 1.5, p = 0.008, respectively). There was a weak correlation, albeit significant, between the modified CCI score and restenosis percentage (r = 0.29, p < 0.001; r = 0.25, p = 0.003, respectively). Conclusions In conclusion, the CCI score is greater among patients with stent restenosis than those without. CCI score is higher among patients with a more diffuse CAD than with a milder disease extent.
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Affiliation(s)
- Turgut Karabağ
- Faculty of Medicine, Department of Cardiology, Bulent Ecevit University, Zonguldak, Turkey
| | - Emіne Altuntaş
- Department of Cardiology, Ataturk State Hospital, Zonguldak, Turkey
| | - Belma Kalaycı
- Faculty of Medicine, Department of Cardiology, Bulent Ecevit University, Zonguldak, Turkey
| | - Bahar Şahіn
- Faculty of Medicine, Department of Cardiology, Bulent Ecevit University, Zonguldak, Turkey
| | - Mustafa Umut Somuncu
- Faculty of Medicine, Department of Cardiology, Bulent Ecevit University, Zonguldak, Turkey
| | - Mustafa Ozan Çakır
- Faculty of Medicine, Department of Cardiology, Bulent Ecevit University, Zonguldak, Turkey
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Chuang AMY, Hancock DG, Halabi A, Horsfall M, Vaile J, De Pasquale C, Sinhal A, Jones D, Brogan R, Chew DP. Invasive management of acute coronary syndrome: Interaction with competing risks. Int J Cardiol 2018; 269:13-18. [PMID: 30037631 DOI: 10.1016/j.ijcard.2018.07.078] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Revised: 05/24/2018] [Accepted: 07/17/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND The aim of this study was to characterise the interaction between ACS- and non-ACS-risk on the benefits of invasive management in patients presenting with acute coronary syndrome (ACS). METHODS Consecutive patients admitted to a tertiary hospital's Cardiac Care Unit in the months of July-December, 2003-2011 with troponin elevation (>30 ng/L) were included. "ACS-specific-risk" was estimated using the GRACE score and "non-ACS-risk" was estimated using the Charlson-Comorbidity-Index (CCI). Inverse-probability-of-treatment weighting was used to adjust for baseline differences between patients who did or did not receive invasive management. A multivariable flexible parametric model was used to characterise the time-varying hazard. RESULTS In total, 3057 patients were included with a median follow-up of 9.0 years. Based on CCI, 1783 patients were classified as 'low-non-ACS risk' (CCI ≤ 1; invasive management 81%; 12-month mortality 5%), 820 as 'medium-non-ACS risk' (CCI 2-3; invasive management 68%; 12-month mortality 13%), and 468 as 'high-non-ACS risk' (CCI ≥ 4; invasive management 47%; 12-month mortality 29%). After adjustment, invasive management was associated with a significant reduction in one-year overall-mortality in the 'low-risk' and 'medium-risk' groups (HR = 0.38, 95%CI:0.26-0.56; HR = 0.46, 95%CI:0.32-0.67); but not in the 'high-risk' group (HR = 1.02, 95%CI:0.67-1.56). The absolute benefit of invasive management was greatest with higher baseline ACS-risk, with a non-linear interaction between ACS- and non-ACS-risk. CONCLUSIONS There is a complex interaction between ACS- and non-ACS-risk on the benefit of invasive management. These results highlight the need to develop robust methods to objectively quantify risk attributable to non-ACS comorbidities in order to make informed decisions regarding the use of invasive management in individuals with numerous comorbidities.
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Affiliation(s)
- Anthony Ming-Yu Chuang
- School of Medicine, Flinders University of South Australia, Adelaide, Australia; Department of Cardiovascular Medicine, Southern Adelaide Local Health Network, Adelaide, Australia.
| | - David G Hancock
- School of Medicine, Flinders University of South Australia, Adelaide, Australia; Department of Cardiovascular Medicine, Southern Adelaide Local Health Network, Adelaide, Australia
| | - Amera Halabi
- School of Medicine, Flinders University of South Australia, Adelaide, Australia; Department of Cardiovascular Medicine, Southern Adelaide Local Health Network, Adelaide, Australia
| | - Matthew Horsfall
- School of Medicine, Flinders University of South Australia, Adelaide, Australia; Department of Cardiovascular Medicine, Southern Adelaide Local Health Network, Adelaide, Australia
| | - Julian Vaile
- School of Medicine, Flinders University of South Australia, Adelaide, Australia; Department of Cardiovascular Medicine, Southern Adelaide Local Health Network, Adelaide, Australia
| | - Carmine De Pasquale
- School of Medicine, Flinders University of South Australia, Adelaide, Australia; Department of Cardiovascular Medicine, Southern Adelaide Local Health Network, Adelaide, Australia
| | - Ajay Sinhal
- School of Medicine, Flinders University of South Australia, Adelaide, Australia; Department of Cardiovascular Medicine, Southern Adelaide Local Health Network, Adelaide, Australia
| | - Dylan Jones
- School of Medicine, Flinders University of South Australia, Adelaide, Australia; Department of Cardiovascular Medicine, Southern Adelaide Local Health Network, Adelaide, Australia
| | - Richard Brogan
- Department of Cardiovascular Medicine, Southern Adelaide Local Health Network, Adelaide, Australia
| | - Derek P Chew
- School of Medicine, Flinders University of South Australia, Adelaide, Australia; Department of Cardiovascular Medicine, Southern Adelaide Local Health Network, Adelaide, Australia
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Sanchis J, Ariza-Solé A, Abu-Assi E, Alegre O, Alfonso F, Barrabés JA, Baz JA, Carol A, Díez Villanueva P, García Del Blanco B, Elízaga J, Fernandez E, García Del Egido A, García Picard J, Gómez Blázquez I, Gómez Hospital JA, Hernández-Antolín R, Llibre C, Marín F, Martí Sánchez D, Martín R, Martínez Sellés M, Miñana G, Morales Gallardo MJ, Núñez J, Pérez de Prado A, Pinar E, Sanmartín M, Sionis A, Villa A, Marrugat J, Bueno H. Invasive Versus Conservative Strategy in Frail Patients With NSTEMI: The MOSCA-FRAIL Clinical Trial Study Design. ACTA ACUST UNITED AC 2018. [PMID: 29525724 DOI: 10.1016/j.rec.2018.02.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION AND OBJECTIVES Although clinical guidelines recommend invasive management in non-ST-segment elevation myocardial infarction (NSTEMI), this strategy is underused in frail elderly patients in the real world. Furthermore, these patients are underrepresented in clinical trials and therefore the evidence is scarce. Our hypothesis is that an invasive strategy will improve prognosis in elderly frail patients with NSTEMI. METHODS This will be a prospective, multicenter, randomized trial, in which the conservative and invasive strategies will be compared in patients meeting all of the following inclusion criteria: NSTEMI diagnosis, age ≥ 70 years, and frailty defined by a category ≥ 4 in the Clinical Frailty Scale. Participants will be randomized to an invasive (coronary angiogram and revascularization if anatomically amenable) or conservative (medical treatment and coronary angiogram only if persistent clinical instability) strategy. The primary endpoint will be the number of days alive out of hospital during the first year. The coprimary endpoint will be the time until the first cardiac event (cardiac death, reinfarction or postdischarge revascularization). We estimate a sample size of 178 patients (89 per arm), considering an increase of 20% in the proportion of days alive out of hospital with the invasive management. RESULTS The results of this study will add important knowledge to inform the management of frail elderly patients hospitalized with NSTEMI. CONCLUSIONS We hypothesize that the invasive strategy will improve outcomes in frail elderly patients with NSTEMI. If this is confirmed, frailty status should not dissuade physicians from implementing an invasive management strategy. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov.Identifier: NCT03208153.
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Affiliation(s)
- Juan Sanchis
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, INCLIVA, Universidad de Valencia, CIBERCV, Valencia, Spain.
| | - Albert Ariza-Solé
- Servicio de Cardiología, Hospital Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Emad Abu-Assi
- Servicio de Cardiología, Hospital Álvaro Cunqueiro, Vigo, Pontevedra, Spain
| | - Oriol Alegre
- Servicio de Cardiología, Hospital Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Fernando Alfonso
- Servicio de Cardiología, Hospital Universitario La Princesa, Madrid, Spain
| | - José Antonio Barrabés
- Servicio de Cardiología, Hospital Universitario Vall d'Hebron, CIBERCV, Barcelona, Spain
| | - José Antonio Baz
- Servicio de Cardiología, Hospital Álvaro Cunqueiro, Vigo, Pontevedra, Spain
| | - Antonio Carol
- Servicio de Cardiología, Hospital Moisès Broggi, Sant Joan Despí, Barcelona, Spain
| | | | | | - Jaime Elízaga
- Servicio de Cardiología, Hospital Universitario Gregorio Marañón, CIBERCV, Universidad Complutense, Universidad Europea, Madrid, Spain
| | - Eduard Fernandez
- Servicio de Cardiología, Hospital Germans Trias i Pujol, CIBERCV, Badalona, Barcelona, Spain
| | | | | | | | | | | | - Cinta Llibre
- Servicio de Cardiología, Hospital Germans Trias i Pujol, CIBERCV, Badalona, Barcelona, Spain
| | - Francisco Marín
- Servicio de Cardiología, Hospital Virgen de la Arrixaca, CIBERCV, El Palmar, Murcia, Spain
| | | | - Roberto Martín
- Servicio de Cardiología, Hospital 12 de Octubre, Madrid, Spain
| | - Manuel Martínez Sellés
- Servicio de Cardiología, Hospital Universitario Gregorio Marañón, CIBERCV, Universidad Complutense, Universidad Europea, Madrid, Spain
| | - Gema Miñana
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, INCLIVA, Universidad de Valencia, CIBERCV, Valencia, Spain
| | | | - Julio Núñez
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, INCLIVA, Universidad de Valencia, CIBERCV, Valencia, Spain
| | | | - Eduardo Pinar
- Servicio de Cardiología, Hospital Virgen de la Arrixaca, CIBERCV, El Palmar, Murcia, Spain
| | - Marcelo Sanmartín
- Servicio de Cardiología, Hospital Ramon y Cajal, CIBERCV, Madrid, Spain
| | - Alessandro Sionis
- Servicio de Cardiología, Hospital Sant Pau, CIBERCV, Barcelona, Spain
| | - Adolfo Villa
- Servicio de Cardiología, Hospital Universitario del Sureste, Arganda del Rey, Madrid, Spain
| | - Jaume Marrugat
- Grupo de Epidemiología y Genética Cardiovascular, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), CIBERCV, Barcelona, Spain
| | - Héctor Bueno
- Servicio de Cardiología, Hospital 12 de Octubre, Madrid, Spain
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Hall M, Dondo TB, Yan AT, Mamas MA, Timmis AD, Deanfield JE, Jernberg T, Hemingway H, Fox KAA, Gale CP. Multimorbidity and survival for patients with acute myocardial infarction in England and Wales: Latent class analysis of a nationwide population-based cohort. PLoS Med 2018; 15:e1002501. [PMID: 29509764 PMCID: PMC5839532 DOI: 10.1371/journal.pmed.1002501] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 01/08/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND There is limited knowledge of the scale and impact of multimorbidity for patients who have had an acute myocardial infarction (AMI). Therefore, this study aimed to determine the extent to which multimorbidity is associated with long-term survival following AMI. METHODS AND FINDINGS This national observational study included 693,388 patients (median age 70.7 years, 452,896 [65.5%] male) from the Myocardial Ischaemia National Audit Project (England and Wales) who were admitted with AMI between 1 January 2003 and 30 June 2013. There were 412,809 (59.5%) patients with multimorbidity at the time of admission with AMI, i.e., having at least 1 of the following long-term health conditions: diabetes, chronic obstructive pulmonary disease or asthma, heart failure, renal failure, cerebrovascular disease, peripheral vascular disease, or hypertension. Those with heart failure, renal failure, or cerebrovascular disease had the worst outcomes (39.5 [95% CI 39.0-40.0], 38.2 [27.7-26.8], and 26.6 [25.2-26.4] deaths per 100 person-years, respectively). Latent class analysis revealed 3 multimorbidity phenotype clusters: (1) a high multimorbidity class, with concomitant heart failure, peripheral vascular disease, and hypertension, (2) a medium multimorbidity class, with peripheral vascular disease and hypertension, and (3) a low multimorbidity class. Patients in class 1 were less likely to receive pharmacological therapies compared with class 2 and 3 patients (including aspirin, 83.8% versus 87.3% and 87.2%, respectively; β-blockers, 74.0% versus 80.9% and 81.4%; and statins, 80.6% versus 85.9% and 85.2%). Flexible parametric survival modelling indicated that patients in class 1 and class 2 had a 2.4-fold (95% CI 2.3-2.5) and 1.5-fold (95% CI 1.4-1.5) increased risk of death and a loss in life expectancy of 2.89 and 1.52 years, respectively, compared with those in class 3 over the 8.4-year follow-up period. The study was limited to all-cause mortality due to the lack of available cause-specific mortality data. However, we isolated the disease-specific association with mortality by providing the loss in life expectancy following AMI according to multimorbidity phenotype cluster compared with the general age-, sex-, and year-matched population. CONCLUSIONS Multimorbidity among patients with AMI was common, and conferred an accumulative increased risk of death. Three multimorbidity phenotype clusters that were significantly associated with loss in life expectancy were identified and should be a concomitant treatment target to improve cardiovascular outcomes. TRIAL REGISTRATION ClinicalTrials.gov NCT03037255.
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Affiliation(s)
- Marlous Hall
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
- * E-mail:
| | - Tatendashe B. Dondo
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Andrew T. Yan
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mamas A. Mamas
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom
| | - Adam D. Timmis
- NIHR Cardiovascular Biomedical Research Unit, Barts Heart Centre, London, United Kingdom
| | - John E. Deanfield
- National Institute for Cardiovascular Outcomes Research, University College London, London, United Kingdom
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Harry Hemingway
- Farr Institute of Health Informatics Research, University College London, London, United Kingdom
- NIHR Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, University College London, London, United Kingdom
| | - Keith A. A. Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Chris P. Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
- York Teaching Hospital NHS Foundation Trust, York, United Kingdom
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Walker DM, Gale CP, Lip G, Martin-Sanchez FJ, McIntyre HF, Mueller C, Price S, Sanchis J, Vidan MT, Wilkinson C, Zeymer U, Bueno H. Editor's Choice - Frailty and the management of patients with acute cardiovascular disease: A position paper from the Acute Cardiovascular Care Association. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2018; 7:176-193. [PMID: 29451402 DOI: 10.1177/2048872618758931] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Frailty is increasingly seen among patients with acute cardiovascular disease. A combination of an ageing population, improved disease survival, treatable long-term conditions as well as a greater recognition of the syndrome has accelerated the prevalence of frailty in the modern world. Yet, this has not been matched by an expansion of research. National and international bodies have identified acute cardiovascular disease in the frail as a priority area for care and an entity that requires careful clinical decisions, but there remains a paucity of guidance on treatment efficacy and safety, and how to manage this complex group. This position paper from the Acute Cardiovascular Care Association presents the latest evidence about frailty and the management of frail patients with acute cardiovascular disease, and suggests avenues for future research.
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Affiliation(s)
| | - C P Gale
- 2 Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, UK
| | - G Lip
- 3 Institute for Cardiovascular Sciences, University of Birmingham, UK.,4 Aalborg Thrombosis Research Unit, Aalborg University, Denmark
| | | | | | - C Mueller
- 6 Cardiovascular Research Institute Basel, University of Basel, Switzerland
| | - S Price
- 7 Royal Brompton Hospital, UK
| | - J Sanchis
- 8 Department of Cardiology, University of Valencia, Spain.,9 University of Valencia, CIBER CV, Spain
| | - M T Vidan
- 10 Department of Geriatrics, Universidad Complutense de Madrid Dr Esquerdo, Spain
| | - C Wilkinson
- 2 Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, UK
| | - U Zeymer
- 11 Klinikum Ludwigshafen und Institut for Herzinfarktforschung, Germany
| | - H Bueno
- 12 National Centre for Cardiovascular Research, Spain
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Nguyen T, Le KK, Cao HTK, Tran DTT, Ho LM, Thai TND, Pham HTK, Pham PT, Nguyen TH, Hak E, Pham TT, Taxis K. Association between in-hospital guideline adherence and postdischarge major adverse outcomes of patients with acute coronary syndrome in Vietnam: a prospective cohort study. BMJ Open 2017; 7:e017008. [PMID: 28982823 PMCID: PMC5640016 DOI: 10.1136/bmjopen-2017-017008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 07/05/2017] [Accepted: 08/02/2017] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE We aimed to determine the association between physician adherence to prescribing guideline-recommended medications during hospitalisation and 6-month major adverse outcomes of patients with acute coronary syndrome in Vietnam. DESIGN Prospective cohort study. SETTING The study was carried out in two public hospitals in Vietnam between January and October 2015. Patients were followed for 6 months after discharge. PARTICIPANTS Patients who survived during hospitalisation with a discharge diagnosis of acute coronary syndrome and who were eligible for receiving at least one of the four guideline-recommended medications. EXPOSURES Guideline adherence was defined as prescribing all guideline-recommended medications at both hospital admission and discharge for eligible patients. Medications were antiplatelet agents, beta-blockers, ACE inhibitors or angiotensin II receptor blockers and statins. MAIN OUTCOME MEASURE Six-month major adverse outcomes were defined as all-cause mortality or hospital readmission due to cardiovascular causes occurring during 6 months after discharge. Cox regression models were used to estimate the association between guideline adherence and 6-month major adverse outcomes. RESULTS Overall, 512 patients were included. Of those, there were 242 patients (47.3%) in the guideline adherence group and 270 patients (52.3%) in the non-adherence group. The rate of 6-month major adverse outcomes was 30.5%. A 29% reduction in major adverse outcomes at 6 months after discharge was found for patients of the guideline adherence group compared with the non-adherence group (adjusted HR, 0.71; 95% CI, 0.51 to 0.98; p=0.039). Covariates significantly associated with the major adverse outcomes were percutaneous coronary intervention, prior heart failure and renal insufficiency. CONCLUSIONS In-hospital guideline adherence was associated with a significant decrease in major adverse outcomes up to 6 months after discharge. It supports the need for improving adherence to guidelines in hospital practice in low-income and middle-income countries like Vietnam.
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Affiliation(s)
- Thang Nguyen
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Can Tho University of Medicine and Pharmacy, Can Tho, Vietnam
- Groningen Research Institute of Pharmacy, Unit of PharmacoTherapy, Epidemiology & Economics, University of Groningen, Groningen, The Netherlands
| | - Khanh K Le
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Can Tho University of Medicine and Pharmacy, Can Tho, Vietnam
| | - Hoang T K Cao
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Can Tho University of Medicine and Pharmacy, Can Tho, Vietnam
| | - Dao T T Tran
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Can Tho University of Medicine and Pharmacy, Can Tho, Vietnam
| | - Linh M Ho
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Can Tho University of Medicine and Pharmacy, Can Tho, Vietnam
| | - Trang N D Thai
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Can Tho University of Medicine and Pharmacy, Can Tho, Vietnam
| | - Hoa T K Pham
- Cardiac Ward, Can Tho General Hospital, Can Tho, Vietnam
| | - Phong T Pham
- Cardiac Ward, Can Tho Central General Hospital, Can Tho, Vietnam
| | - Thao H Nguyen
- Department of Clinical Pharmacy, School of Pharmacy, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh, Vietnam
| | - Eelko Hak
- Groningen Research Institute of Pharmacy, Unit of PharmacoTherapy, Epidemiology & Economics, University of Groningen, Groningen, The Netherlands
| | - Tam T Pham
- Faculty of Public Health, Can Tho University of Medicine and Pharmacy, Can Tho, Vietnam
| | - Katja Taxis
- Groningen Research Institute of Pharmacy, Unit of PharmacoTherapy, Epidemiology & Economics, University of Groningen, Groningen, The Netherlands
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Kim K, Lee TA, Ardati AK, DiDomenico RJ, Touchette DR, Walton SM. Comparative Effectiveness of Oral Antiplatelet Agents in Patients with Acute Coronary Syndrome. Pharmacotherapy 2017; 37:877-887. [DOI: 10.1002/phar.1961] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Kibum Kim
- Pharmacotherapy Outcomes Research Center; University of Utah; Salt Lake City Utah
- Department of Pathology; University of Utah; Salt Lake City Utah
| | - Todd A. Lee
- Department of Pharmacy Systems, Outcomes and Policy; College of Pharmacy; University of Illinois at Chicago (UIC); Chicago Illinois
- Center for Pharmacoepidemiology and Pharmacoeconomic Research; UIC; Chicago Illinois
| | - Amer K. Ardati
- Division of Cardiology; College of Medicine; UIC; Chicago Illinois
| | - Robert J. DiDomenico
- Center for Pharmacoepidemiology and Pharmacoeconomic Research; UIC; Chicago Illinois
- Department of Pharmacy Practice; College of Pharmacy; UIC; Chicago Illinois
| | - Daniel R. Touchette
- Department of Pharmacy Systems, Outcomes and Policy; College of Pharmacy; University of Illinois at Chicago (UIC); Chicago Illinois
- Center for Pharmacoepidemiology and Pharmacoeconomic Research; UIC; Chicago Illinois
| | - Surrey M. Walton
- Department of Pharmacy Systems, Outcomes and Policy; College of Pharmacy; University of Illinois at Chicago (UIC); Chicago Illinois
- Center for Pharmacoepidemiology and Pharmacoeconomic Research; UIC; Chicago Illinois
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Sanchis J, Ruiz V, Bonanad C, Valero E, Ruescas-Nicolau MA, Ezzatvar Y, Sastre C, García-Blas S, Mollar A, Bertomeu-González V, Miñana G, Núñez J. Prognostic Value of Geriatric Conditions Beyond Age After Acute Coronary Syndrome. Mayo Clin Proc 2017; 92:934-939. [PMID: 28389067 DOI: 10.1016/j.mayocp.2017.01.018] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 01/20/2017] [Accepted: 01/27/2017] [Indexed: 01/17/2023]
Abstract
The aim of the present study was to investigate the prognostic value of geriatric conditions beyond age after acute coronary syndrome. This was a prospective cohort design including 342 patients (from October 1, 2010, to February 1, 2012) hospitalized for acute coronary syndrome, older than 65 years, in whom 5 geriatric conditions were evaluated at discharge: frailty (Fried and Green scales), comorbidity (Charlson and simple comorbidity indexes), cognitive impairment (Pfeiffer test), physical disability (Barthel index), and instrumental disability (Lawton-Brody scale). The primary end point was all-cause mortality. The median follow-up for the entire population was 4.7 years (range, 3-2178 days). A total of 156 patients (46%) died. Among the geriatric conditions, frailty (Green score, per point; hazard ratio, 1.11; 95% CI, 1.02-1.20; P=.01) and comorbidity (Charlson index, per point; hazard ratio, 1.18; 95% CI, 1.0-1.40; P=.05) were the independent predictors. The introduction of age in a basic model using well-established prognostic clinical variables resulted in an increase in discrimination accuracy (C-statistic=.716-.744; P=.05), though the addition of frailty and comorbidity provided a nonsignificant further increase (C-statistic=.759; P=.36). Likewise, the addition of age to the clinical model led to a significant risk reclassification (continuous net reclassification improvement, 0.46; 95% CI, 0.21-0.67; and integrated discrimination improvement, 0.04; 95% CI, 0.01-0.09). However, the addition of frailty and comorbidity provided a further significant risk reclassification in comparison to the clinical model with age (continuous net reclassification improvement, 0.40; 95% CI, 0.16-0.65; and integrated discrimination improvement, 0.04; 95% CI, 0.01-0.10). In conclusion, frailty and comorbidity are mortality predictors that significantly reclassify risk beyond age after acute coronary syndrome.
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Affiliation(s)
- Juan Sanchis
- Cardiology Department, University Clinic Hospital, INCLIVA, Valencia, Spain; CIBER-CV, University of Valencia, Valencia, Spain.
| | - Vicente Ruiz
- CIBER-CV, University of Valencia, Valencia, Spain; Nursing School, University of Valencia, Valencia, Spain
| | - Clara Bonanad
- Cardiology Department, University Clinic Hospital, INCLIVA, Valencia, Spain; CIBER-CV, University of Valencia, Valencia, Spain
| | - Ernesto Valero
- Cardiology Department, University Clinic Hospital, INCLIVA, Valencia, Spain; CIBER-CV, University of Valencia, Valencia, Spain
| | | | - Yasmin Ezzatvar
- Cardiology Department, University Clinic Hospital, INCLIVA, Valencia, Spain
| | - Clara Sastre
- Cardiology Department, University Clinic Hospital, INCLIVA, Valencia, Spain
| | - Sergio García-Blas
- Cardiology Department, University Clinic Hospital, INCLIVA, Valencia, Spain; CIBER-CV, University of Valencia, Valencia, Spain
| | - Anna Mollar
- Cardiology Department, University Clinic Hospital, INCLIVA, Valencia, Spain
| | | | - Gema Miñana
- Cardiology Department, University Clinic Hospital, INCLIVA, Valencia, Spain; CIBER-CV, University of Valencia, Valencia, Spain; Department of Medicine, University of Valencia, Valencia, Spain
| | - Julio Núñez
- Cardiology Department, University Clinic Hospital, INCLIVA, Valencia, Spain; CIBER-CV, University of Valencia, Valencia, Spain; Department of Medicine, University of Valencia, Valencia, Spain
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Burke LA, Rosenfeld AG, Daya MR, Vuckovic KM, Zegre-Hemsey JK, Felix Diaz M, Tosta Daiube Santos J, Mirzaei S, DeVon HA. Impact of comorbidities by age on symptom presentation for suspected acute coronary syndromes in the emergency department. Eur J Cardiovasc Nurs 2017; 16:511-521. [PMID: 28198635 DOI: 10.1177/1474515117693891] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND It is estimated half of acute coronary syndrome (ACS) patients have one or more associated comorbid conditions. AIMS Aims were to: 1) examine the prevalence of comorbid conditions in patients presenting to the emergency department with symptoms suggestive of ACS; 2) determine if comorbid conditions influence ACS symptoms; and 3) determine if comorbid conditions predict the likelihood of receiving an ACS diagnosis. METHODS A total of 1064 patients admitted to five emergency departments were enrolled in this prospective study. Symptoms were measured on presentation to the emergency department. The Charlson Comorbidity Index (CCI) was used to evaluate group differences in comorbidity burden across demographic traits, risk factors, clinical presentation, and diagnosis. RESULTS The most prominent comorbid conditions were prior myocardial infarction, diabetes without target organ damage, and chronic lung disease. In younger ACS patients, higher CCI predicted less chest pain, chest discomfort, unusual fatigue and a lower number of symptoms. In older ACS patients, higher CCI predicted more chest discomfort, upper back pain, abrupt symptom onset, and greater symptom distress. For younger non-ACS patients, higher CCI predicted less chest pain and symptom distress. Higher CCI was associated with a greater likelihood of receiving an ACS diagnosis for younger but not older patients with suspected ACS. CONCLUSIONS Younger patients with ACS and higher number of comorbidities report less chest pain, putting them at higher risk for delayed diagnosis and treatment since chest pain is a hallmark symptom for ACS.
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Affiliation(s)
- Larisa A Burke
- 1 Department of Biobehavioral Sciences, College of Nursing, University of Illinois at Chicago, Chicago, IL, USA
| | - Anne G Rosenfeld
- 2 Biobehavioral Health Science Division, University of Arizona College of Nursing, Tucson, AZ, USA
| | - Mohamud R Daya
- 3 Department of Emergency Medicine, Oregon Health & Sciences University, Portland, OR, USA
| | - Karen M Vuckovic
- 1 Department of Biobehavioral Sciences, College of Nursing, University of Illinois at Chicago, Chicago, IL, USA
| | | | - Maria Felix Diaz
- 1 Department of Biobehavioral Sciences, College of Nursing, University of Illinois at Chicago, Chicago, IL, USA
| | | | - Sahereh Mirzaei
- 1 Department of Biobehavioral Sciences, College of Nursing, University of Illinois at Chicago, Chicago, IL, USA
| | - Holli A DeVon
- 1 Department of Biobehavioral Sciences, College of Nursing, University of Illinois at Chicago, Chicago, IL, USA
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Protty MB, Lacey A, Smith D, Hannoodee S, Freeman P. Increased morbidity, mortality and length of in-hospital stay for patients with acute coronary syndrome with pre-morbid psychiatric diagnoses. Int J Cardiol 2017; 236:5-8. [PMID: 28111056 DOI: 10.1016/j.ijcard.2017.01.067] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Revised: 11/19/2016] [Accepted: 01/06/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Psychiatric and cardiac comorbidities form the top two budget categories for health systems in high-income countries with evidence that psychiatric pre-morbidities lead to worse outcomes in patients with acute coronary syndrome (ACS). There are no studies examining this relationship in a national multicentre population level study in the UK, and no studies examining their impact on length of in-hospital stay (LoS) in ACS. Recognizing at-risk populations and reducing LoS in ACS is an essential part of improving patient care and cost-effectiveness. METHODS We investigated the impact of psychiatric diagnoses on morbidity, all-cause mortality and LoS amongst 57,668 ACS patients between Jan-2004 and Dec-2014 using the Secure-Anonymized-Information-Linkage (SAIL) databank. Demographics, admissions, cardiac and psychiatric comorbidities were identified using coded data. RESULTS There were a total of 3857 out of 57,668 patients who had a pre-morbid psychiatric diagnosis. The mean LoS in patients without psychiatric comorbidities was 9.78days (95% CI: 9.66-9.91). This was higher (p<0.01) in the presence of any psychiatric diagnosis (14.72), dementia (20.87), schizophrenia (15.67), and mood disorders (13.41). Patients with psychiatric comorbidities had worse net adverse cardiac events (HR 1.18, 95% CI: 1.16-1.21) and mortality rates (HR 1.26, 95% CI: 1.23-1.30). CONCLUSIONS Our results demonstrate that psychiatric comorbidities have a significant and clinically important impact on morbidity, mortality and LoS in ACS patients in Wales, UK. Clinicians' awareness and active management of psychiatric conditions amongst ACS patients is needed to reduce poor outcomes and LoS and ultimately the risk for patients and financial burden for the health-service.
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Affiliation(s)
- Majd B Protty
- Institute of Population Medicine, Cardiff University, Wales, UK.
| | | | | | - Sahar Hannoodee
- Stonebow mental health unit, Wye Valley NHS Trust, Hereford, UK
| | - Phillip Freeman
- Institute of Population Medicine, Cardiff University, Wales, UK; Department of Cardiology, Aalborg University Hospital, Denmark
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Sanchis J, Núñez E, Barrabés JA, Marín F, Consuegra-Sánchez L, Ventura S, Valero E, Roqué M, Bayés-Genís A, Del Blanco BG, Dégano I, Núñez J. Randomized comparison between the invasive and conservative strategies in comorbid elderly patients with non-ST elevation myocardial infarction. Eur J Intern Med 2016; 35:89-94. [PMID: 27423981 DOI: 10.1016/j.ejim.2016.07.003] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 06/27/2016] [Accepted: 07/02/2016] [Indexed: 01/12/2023]
Abstract
BACKGROUND Comorbid elderly patients with non-ST-elevation myocardial infarction (non-STEMI) are underrepresented in randomized trials and undergo fewer cardiac catheterizations according to registries. Our aim was to compare the conservative and invasive strategies in these patients. METHODS Randomized multicenter study, including 106 patients (January 2012-March 2014) with non-STEMI, over 70years and with comorbidities defined by at least two of the following: peripheral artery disease, cerebral vascular disease, dementia, chronic pulmonary disease, chronic renal failure or anemia. Patients were randomized to invasive (routine coronary angiogram, n=52) or conservative (coronary angiogram only if recurrent ischemia or heart failure, n=54) strategy. Medical treatment was identical. The main endpoint was the composite of all-cause mortality, reinfarction and readmission for cardiac cause (postdischarge revascularization or heart failure), at long-term (2.5-year follow-up). Analysis of cumulative event rate (incidence rate ratio=IRR) and time to first event (hazard ratio=HR), were performed. RESULTS Cardiac catheterization/revascularization rates were 100%/58% in the invasive versus 20%/9% in the conservative arm. There were no differences between groups in the main endpoint (invasive vs conservative: IRR=0.946, 95% CI 0.466-1.918, p=0.877) at long-term. The invasive strategy, however, tended to improve 3-month outcomes in terms of mortality (HR=0.348, 95% CI 0.122-0.991, p=0.048), and of mortality or ischemic events (reinfarction or postdischarge revascularization) (HR=0.432, 95% CI 0.190-0.984, p=0.046). This benefit declined during follow-up. CONCLUSIONS Invasive management did not modify long-term outcome in comorbid elderly patients with non-STEMI. The finding of a tendency towards an improvement in the short-term needs confirmation in larger studies (clinicaltrials.govNCT1645943).
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Affiliation(s)
- Juan Sanchis
- Department of Cardiology, Hospital Clínico Universitario, INCLIVA, Universitat de València, Valencia, Spain.
| | - Eduardo Núñez
- Department of Cardiology, Hospital Clínico Universitario, INCLIVA, Universitat de València, Valencia, Spain
| | - José Antonio Barrabés
- Department of Cardiology, Hospital Universitari Vall d'Hebrón, VHIR, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Francisco Marín
- Department of Cardiology, Hospital Virgen Arrixaca, Murcia, Spain
| | | | - Silvia Ventura
- Department of Cardiology, Hospital Clínico Universitario, INCLIVA, Universitat de València, Valencia, Spain
| | - Ernesto Valero
- Department of Cardiology, Hospital Clínico Universitario, INCLIVA, Universitat de València, Valencia, Spain
| | - Mercè Roqué
- Department of Cardiology, Hospital Clinic, Barcelona, Spain
| | - Antoni Bayés-Genís
- Department of Cardiology, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Bruno García Del Blanco
- Department of Cardiology, Hospital Universitari Vall d'Hebrón, VHIR, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Irene Dégano
- IMIM (Hospital del Mar Medical Research Institute), Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Julio Núñez
- Department of Cardiology, Hospital Clínico Universitario, INCLIVA, Universitat de València, Valencia, Spain
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Sigurjonsdottir R, Barywani S, Albertsson P, Fu M. Long-term major adverse cardiovascular events and quality of life after coronary angiography in elderly patients with acute coronary syndrome. Int J Cardiol 2016; 222:481-485. [PMID: 27505338 DOI: 10.1016/j.ijcard.2016.07.237] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 05/30/2016] [Accepted: 07/29/2016] [Indexed: 01/30/2023]
Abstract
BACKGROUND Although the elderly comprise the majority of acute coronary syndrome (ACS) patients, limited data exist on major adverse cardiovascular events (MACEs) and quality of life (QoL). OBJECTIVES To study MACEs and QoL prospectively in ACS patients >70years referred for coronary angiography. METHODS A prospective observational study that included ACS patients >70years undergoing coronary angiography. The outcomes were MACEs and QoL 3years after inclusion. MACEs were defined as death, recurrent ACS, new-onset of heart failure and repeated revascularization by coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). A QoL questionnaire was completed by the patients along with a physical examination and a personal interview at the 3-year follow-up. Multivariate analysis was performed to identify the predictors for MACEs. RESULTS In total, 138 patients (mean age 78.8±3.8years) with ACS were included in the study. Mean follow-up was 1196±296days. In all, 42% of the patients had MACEs and 25% had post-ACS heart failure. The mortality rate was 11%. After adjusting for significant cardiovascular risk factors, the following factors were significantly associated with MACEs: Age, high-sensitive troponin T (hsTNT), use of diuretics and reduced left ventricular ejection fraction (LVEF). Furthermore, the QoL evaluated with SF-36 in survivors from ACS at the end of study was similar to the QoL in an age-matched healthy Swedish population. CONCLUSIONS In this prospective study on elderly ACS patients MACEs still occurred in 42% of the cases (despite low mortality and good QoL), with post-ACS heart failure as the most important event.
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Affiliation(s)
- R Sigurjonsdottir
- Department of Cardiology, Sahlgrenska University Hospital/Sahlgrenska, Gothenburg, Sweden; Department of Clinical and Molecular Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - S Barywani
- Section of Cardiology, Department of Medicine, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden; Department of Clinical and Molecular Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - P Albertsson
- Department of Cardiology, Sahlgrenska University Hospital/Sahlgrenska, Gothenburg, Sweden; Department of Clinical and Molecular Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - M Fu
- Section of Cardiology, Department of Medicine, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden; Department of Clinical and Molecular Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Mamas MA, Fath-Ordoubadi F, Danzi GB, Spaepen E, Kwok CS, Buchan I, Peek N, de Belder MA, Ludman PF, Paunovic D, Urban P. Prevalence and Impact of Co-morbidity Burden as Defined by the Charlson Co-morbidity Index on 30-Day and 1- and 5-Year Outcomes After Coronary Stent Implantation (from the Nobori-2 Study). Am J Cardiol 2015; 116:364-71. [PMID: 26037294 DOI: 10.1016/j.amjcard.2015.04.047] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Revised: 04/30/2015] [Accepted: 04/30/2015] [Indexed: 10/23/2022]
Abstract
Co-morbidities have typically been considered as prevalent cardiovascular risk factors and cardiovascular diseases rather than systematic measures of general co-morbidity burden in patients who underwent percutaneous coronary intervention (PCI). Charlson co-morbidity index (CCI) is a measure of co-morbidity burden providing a means of quantifying the prognostic impact of 22 co-morbid conditions on the basis of their number and prognostic impact. The study evaluated the impact of the CCI on cardiac mortality and major adverse cardiovascular events (MACE) after PCI through analysis of the Nobori-2 study. The prognostic impact of CCI was studied in 3,067 patients who underwent PCI in 4,479 lesions across 125 centers worldwide on 30-day and 1- and 5-year cardiac mortality and MACE. Data were adjusted for potential confounders using stepwise logistic regression; 2,280 of 3,067 patients (74.4%) had ≥1 co-morbid conditions. CCI (per unit increase) was independently associated with an increase in both cardiac death (odds ratio [OR] 1.47 95% confidence interval [CI] 1.20 to 1.80, p = 0.0002) and MACE (OR 1.29 95% CI 1.14 to 1.47, p ≤0.0011) at 30 days, with similar observations recorded at 1 and 5 years. CCI score ≥2 was independently associated with increased 30-day cardiac death (OR 4.25, 95% CI 1.24 to 14.56, p = 0.02) at 1 month, and this increased risk was also observed at 1 and 5 years. In conclusion, co-morbid burden, as measured using CCI, is an independent predictor of adverse outcomes in the short, medium, and long term. Co-morbidity should be considered in the decision-making process when counseling patients regarding the periprocedural risks associated with PCI, in conjunction with traditional risk factors.
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Zhang H, Goodman SG, Yan RT, Steg PG, Kornder JM, Gyenes GT, Grondin FR, Brieger D, DeYoung JP, Gallo R, Yan AT. In-hospital management and outcomes of acute coronary syndromes in relation to prior history of heart failure. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2015; 5:214-22. [PMID: 25766512 DOI: 10.1177/2048872615574109] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 02/01/2015] [Indexed: 12/18/2022]
Abstract
INTRODUCTION The prognostic significance of prior heart failure in acute coronary syndromes has not been well studied. Accordingly, we evaluated the baseline characteristics, management patterns and clinical outcomes in patients with acute coronary syndromes who had prior heart failure. METHODS AND RESULTS The study population consisted of acute coronary syndrome patients in the Global Registry of Acute Coronary Events, expanded Global Registry of Acute Coronary Events and Canadian Registry of Acute Coronary Events between 1999 and 2008. Of the 13,937 eligible patients (mean age 66±13 years, 33% female and 28.3% with ST-elevation myocardial infarction), 1498 (10.7%) patients had a history of heart failure. Those with prior heart failure tended to be older, female and had lower systolic blood pressure, higher Killip class and creatinine on presentation. Prior heart failure was also associated with significantly worse left ventricular systolic function and lower rates of cardiac catheterization and coronary revascularization. The group with previous heart failure had significantly higher rates of acute decompensated heart failure, cardiogenic shock, myocardial (re)infarction and mortality in hospital. In multivariable analysis, prior heart failure remained an independent predictor of in-hospital mortality (odds ratio 1.48, 95% confidence interval 1.08-2.03, p=0.015). CONCLUSIONS Prior heart failure was associated with high risk features on presentation and adverse outcomes including higher adjusted in-hospital mortality in acute coronary syndrome patients. However, acute coronary syndrome patients with prior heart failure were less likely to receive evidence-based therapies, suggesting potential opportunities to target more intensive treatment to improve their outcome.
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Affiliation(s)
- Hanfei Zhang
- Terrence Donnelly Heart Centre, St. Michael's Hospital, Canada University of Toronto, Canada
| | - Shaun G Goodman
- Terrence Donnelly Heart Centre, St. Michael's Hospital, Canada University of Toronto, Canada Canadian Heart Research Centre, Canada
| | | | - Ph Gabriel Steg
- DHU FIRE, Université Paris-Diderot, AP-HP, Hôpital Bichat, France
| | | | - Gabor T Gyenes
- Mazankowski Alberta Heart Institute, University of Alberta, Canada
| | | | | | - J Paul DeYoung
- Cornwall Community Hospital, Cornwall and University of Ottawa, Canada
| | | | - Andrew T Yan
- Terrence Donnelly Heart Centre, St. Michael's Hospital, Canada University of Toronto, Canada
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Marzec LN, Carey EP, Lambert-Kerzner AC, Del Giacco EJ, Melnyk SD, Bryson CL, Fahdi IE, Bosworth HB, Fiocchi F, Ho PM. Cognitive dysfunction and poor health literacy are common in veterans presenting with acute coronary syndrome: insights from the MEDICATION study. Patient Prefer Adherence 2015; 9:745-51. [PMID: 26089651 PMCID: PMC4467742 DOI: 10.2147/ppa.s75110] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Patient nonadherence to cardiac medications following acute coronary syndrome (ACS) is associated with increased risk of recurrent events. However, the prevalence of cognitive dysfunction and poor health literacy among ACS patients and their association with medication nonadherence are poorly understood. METHODS We assessed rates of cognitive dysfunction and poor health literacy among participants of a clinical trial that tested the effectiveness of an intervention to improve medication adherence in patients hospitalized with ACS. Of 254 patients, 249 completed the Rapid Estimate of Adult Literacy in Medicine, Revised (REALM-R) survey, an assessment of risk for poor literacy, and the St Louis University Mental Status (SLUMS) exam, a tool assessing for neurocognitive deficits, during ACS hospitalization. We assessed if SLUMS or REALM-R scores were associated with medication adherence. RESULTS Based on SLUMS score, 14% of patients were categorized as having dementia, and 52% with mild neurocognitive disorder (MNCD). Based on REALM-R score of ≤6, 34% of patients were categorized as at risk for poor health literacy. There was no association between poor health literacy and medication nonadherence. Of those with MNCD, 35.5% were nonadherent, compared to 17.5% with normal cognitive function and 6.7% with dementia. In multivariable analysis, cognitive dysfunction was associated with medication nonadherence (P=0.007), mainly due to an association between MNCD and nonadherence (odds ratio =12.2, 95% confidence interval =1.9 to 243; P=0.007). Cognitive status was not associated with adherence in patients randomized to the intervention. CONCLUSION Cognitive dysfunction and risk for poor health literacy are common in patients hospitalized with ACS. We found an association between MNCD and medication nonadherence in the usual care group but not in the intervention group. These findings suggest efforts to screen for MNCD are needed during ACS hospitalization to identify patients at risk for nonadherence and who may benefit from an adherence intervention.
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Affiliation(s)
- Lucas N Marzec
- Division of Cardiology, Denver VA Medical Center, Denver, CO, USA
- Correspondence: Lucas N Marzec, Academic Office 1, Room #7104, 12631 E 17th Avenue, Campus Box B-130, Aurora, CO 80045, USA, Tel +1 303 724 2105, Fax +1 303 724 2094, Email
| | - Evan P Carey
- Division of Cardiology, Denver VA Medical Center, Denver, CO, USA
| | | | - Eric J Del Giacco
- Department of Medicine, Little Rock VA Medical Center, Little Rock, AR, USA
| | | | - Chris L Bryson
- Department of Medicine, Puget Sound VA Medical Center, Seattle, WA, USA
| | - Ibrahim E Fahdi
- Department of Medicine, Little Rock VA Medical Center, Little Rock, AR, USA
| | | | - Fran Fiocchi
- American College of Cardiology, Washington, DC, USA
| | - P Michael Ho
- Division of Cardiology, Denver VA Medical Center, Denver, CO, USA
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Sanchis J, Bonanad C, Ruiz V, Fernández J, García-Blas S, Mainar L, Ventura S, Rodríguez-Borja E, Chorro FJ, Hermenegildo C, Bertomeu-González V, Núñez E, Núñez J. Frailty and other geriatric conditions for risk stratification of older patients with acute coronary syndrome. Am Heart J 2014; 168:784-91. [PMID: 25440808 DOI: 10.1016/j.ahj.2014.07.022] [Citation(s) in RCA: 128] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 07/18/2014] [Indexed: 01/05/2023]
Abstract
BACKGROUND Geriatric conditions may predict outcomes beyond age and standard risk factors. Our aim was to investigate a wide spectrum of geriatric conditions in survivors after an acute coronary syndrome. METHODS A total of 342 patients older than 65 years were included. At hospital discharge, 5 geriatric conditions were evaluated: frailty (Fried and Green scores), physical disability (Barthel index), instrumental disability (Lawton-Brody scale), cognitive impairment (Pfeiffer questionnaire), and comorbidity (Charlson and simple comorbidity indexes). The outcomes were postdischarge mortality and the composite of death/myocardial infarction during a 30-month median follow-up. RESULTS Seventy-four (22%) patients died and 105 (31%) suffered from the composite end point. Through univariable analysis, all individual geriatric indexes were associated with outcomes, mainly mortality. Of all of them, frailty using the Green score had the strongest discriminative accuracy (area under the receiver operating characteristic curve 0.76 for mortality). After full adjustment including clinical and geriatric data, the Green score was the only independent predictive geriatric condition (per point; mortality: hazard ratio 1.25, 95% CI 1.15-1.36, P = .0001; composite end point: hazard ratio 1.16, 95% CI 1.09-1.24, P = .0001). A Green score ≥ 5 points was the strongest mortality predictor. The addition of the Green score to the clinical model improved discrimination (area under the receiver operating characteristic curve 0.823 vs 0.846) and significantly reclassified mortality risk (net reclassification improvement 26.3, 95% CI 1.4-43.5; integrated discrimination improvement 4.0, 95% CI 0.8-9.0). The incremental predictive information was even greater over the GRACE score. CONCLUSIONS Frailty captures most of the prognostic information provided by geriatric conditions after acute coronary syndromes. The Green score performed better than the other geriatric indexes.
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Affiliation(s)
- Juan Sanchis
- Department of Cardiology, Hospital Clínico Universitario, School of Medicine, University of Valencia, Valencia, Spain.
| | - Clara Bonanad
- Department of Cardiology, Hospital Clínico Universitario, School of Medicine, University of Valencia, Valencia, Spain
| | - Vicente Ruiz
- Nursing School, University of Valencia, Valencia, Spain
| | | | - Sergio García-Blas
- Department of Cardiology, Hospital Clínico Universitario, School of Medicine, University of Valencia, Valencia, Spain
| | - Luis Mainar
- Department of Cardiology, Hospital Clínico Universitario, School of Medicine, University of Valencia, Valencia, Spain
| | - Silvia Ventura
- Department of Cardiology, Hospital Clínico Universitario, School of Medicine, University of Valencia, Valencia, Spain
| | | | - Francisco J Chorro
- Department of Cardiology, Hospital Clínico Universitario, School of Medicine, University of Valencia, Valencia, Spain
| | | | | | - Eduardo Núñez
- Department of Cardiology, Hospital Clínico Universitario, School of Medicine, University of Valencia, Valencia, Spain
| | - Julio Núñez
- Department of Cardiology, Hospital Clínico Universitario, School of Medicine, University of Valencia, Valencia, Spain
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García-Alvarez A, Regueiro A, Hernández J, Kasa G, Sitges M, Bosch X, Heras M. Additional value of B-type natriuretic peptide on discrimination of patients at risk for mortality after a non-ST-segment elevation acute coronary syndrome. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2014; 3:132-40. [DOI: 10.1177/2048872614520753] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
| | | | | | - Gizem Kasa
- University of Barcelona, Barcelona, Spain
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Barra S, Providência R, Paiva L, Caetano F, Almeida I, Gomes P, Marques AL. ACHTUNG-Rule: a new and improved model for prognostic assessment in myocardial infarction. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2013; 1:320-36. [PMID: 24062923 DOI: 10.1177/2048872612466536] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2012] [Accepted: 10/11/2012] [Indexed: 01/08/2023]
Abstract
BACKGROUND THROMBOLYSIS IN MYOCARDIAL INFARCTION (TIMI), PLATELET GLYCOPROTEIN IIB/IIIA IN UNSTABLE ANGINA: Receptor Suppression Using Integrilin (PURSUIT) and Global Registry of Acute Coronary Events (GRACE) scores have been developed for risk stratification in myocardial infarction (MI). The latter is the most validated score, yet active research is ongoing for improving prognostication in MI. AIM Derivation and validation of a new model for intrahospital, post-discharge and combined/total all-cause mortality prediction - ACHTUNG-Rule - and comparison with the GRACE algorithm. METHODS 1091 patients admitted for MI (age 68.4 ± 13.5, 63.2% males, 41.8% acute MI with ST-segment elevation (STEMI)) and followed for 19.7 ± 6.4 months were assigned to a derivation sample. 400 patients admitted at a later date at our institution (age 68.3 ± 13.4, 62.7% males, 38.8% STEMI) and followed for a period of 7.2 ± 4.0 months were assigned to a validation sample. Three versions of the ACHTUNG-Rule were developed for the prediction of intrahospital, post-discharge and combined (intrahospital plus post-discharge) all-cause mortality prediction. All models were evaluated for their predictive performance using the area under the receiver operating characteristic (ROC) curve, calibration through the Hosmer-Lemeshow test and predictive utility within each individual patient through the Brier score. Comparison through ROC curve analysis and measures of risk reclassification - net reclassification improvement index (NRI) or Integrated Discrimination Improvement (IDI) - was performed between the ACHTUNG versions for intrahospital, post-discharge and combined mortality prediction and the equivalent GRACE score versions for intrahospital (GRACE-IH), post-discharge (GRACE-6PD) and post-admission 6-month mortality (GRACE-6). RESULTS Assessment of calibration and overall performance of the ACHTUNG-Rule demonstrated a good fit (p value for the Hosmer-Lemeshow goodness-of-fit test of 0.258, 0.101 and 0.550 for ACHTUNG-IH, ACHTUNG-T and ACHTUNG-R, respectively) and high discriminatory power in the validation cohort for all the primary endpoints (intrahospital mortality: AUC ACHTUNG-IH 0.886 ± 0.035 vs. AUC GRACE-IH 0.906 ± 0.026; post-discharge mortality: AUC ACHTUNG-R 0.827 ± 0.036 vs. AUC GRACE-6PD 0.811 ± 0.034; combined/total mortality: AUC ACHTUNG-T 0.831 ± 0.028 vs. AUC GRACE-6 0.815 ± 0.033). Furthermore, all versions of the ACHTUNG-Rule accurately reclassified a significant number of patients in different, more appropriate, risk categories (NRI ACHTUNG-IH 17.1%, p (2-sided) = 0.0021; NRI ACHTUNG-R 22.0%, p = 0.0002; NRI ACHTUNG-T 18.6%, p = 0.0012). The prognostic performance of the ACHTUNG-Rule was similar in both derivation and validation samples. CONCLUSIONS All versions of the ACHTUNG-Rule have shown excellent discriminative power and good calibration for predicting intrahospital, post-discharge and combined in-hospital plus post-discharge mortality. The ACHTUNG version for intrahospital mortality prediction was not inferior to its equivalent GRACE model, and ACHTUNG versions for post-discharge and combined/total mortality demonstrated apparent superiority. External validation in wider, independent, preferably multicentre, registries is warranted before its potential clinical implementation.
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Affiliation(s)
- Sérgio Barra
- Cardiology Department, Centro Hospitalar de Coimbra, Portugal
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Caballero-Estevez N, Dominguez-Rodriguez A, Abreu-Gonzalez P. [In-hospital prognostic value of functional assessment using the Barthel index in patients with acute coronary syndrome: initial evaluation of the nurse in the cardiac intensive care unit]. Med Intensiva 2013; 38:332-4. [PMID: 24018280 DOI: 10.1016/j.medin.2013.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Revised: 06/07/2013] [Accepted: 06/13/2013] [Indexed: 11/25/2022]
Affiliation(s)
- N Caballero-Estevez
- Servicio de Cardiología, Hospital Universitario de Canarias, Santa Cruz de Tenerife, España
| | - A Dominguez-Rodriguez
- Servicio de Cardiología, Hospital Universitario de Canarias, Santa Cruz de Tenerife, España; Facultad de Ciencias de la Salud, Universidad Europea de Canarias, Santa Cruz de Tenerife, España; Instituto Universitario de Tecnologías Biomédicas, Santa Cruz de Tenerife, España.
| | - P Abreu-Gonzalez
- Instituto Universitario de Tecnologías Biomédicas, Santa Cruz de Tenerife, España; Departamento de Fisiología, Facultad de Medicina, Universidad de La Laguna, Santa Cruz de Tenerife, España
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Lu KJ, Kearney LG, Ord M, Jones E, Burrell LM, Srivastava PM. Age adjusted Charlson Co-morbidity Index is an independent predictor of mortality over long-term follow-up in infective endocarditis. Int J Cardiol 2013; 168:5243-8. [PMID: 23978361 DOI: 10.1016/j.ijcard.2013.08.023] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Accepted: 08/03/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Infective endocarditis (IE) is associated with high morbidity and mortality. The epidemiology of IE is changing, affecting more elderly patients with increased medical comorbidities. We aimed to assess the ability of the age adjusted Charlson Co-morbidity Index (ACCI) to predict early and late outcomes. METHODS Between 1998 and 2010, adult patients with definite IE according to the modified Duke criteria were identified. The primary outcome was in-hospital and all-cause mortality. The secondary outcome was predictors of the primary outcome incorporating ACCI. RESULTS 148 patients with IE were followed up for a mean of 3.8 ± 3 years. The mean age was 57 ± 17 years and 66% were male. In-hospital mortality and all-cause mortality were 24 and 47% respectively. Comorbid conditions included diabetes mellitus (DM) (21%); ischaemic heart disease (16%); heart failure (HF) (14%); renal failure (eGFR <60 ml/min/1.73 m(2)) (19%); and anaemia (64%). The most common causative organism was Staphylococcus aureus (53%). ACCI was >3 in 59% of patients. Cardiac surgery was performed in 45% of patients. On Cox regression analysis, ACCI >3 (HR=3.0 [1.5-6.0], p<0.002), new onset HF (HR=2.2 [1.3-3.6], p<0.003), anaemia (HR=1.8 [1.1-3.2], p=0.04) and age-per decade (HR=1.4 [1.1-1.7]. p=0.004) were independently associated with all-cause mortality. ACCI >3 was the strongest predictor of in-hospital mortality (OR=8.4 [2.8-24], p<0.001). Of the individual ACCI components, prior HF, DM with complications and metastatic disease were independent predictors of all-cause mortality. CONCLUSION In-hospital and all-cause mortality of IE remain high. An ACCI >3 was a strong predictor of mortality, in addition to age, new HF and anaemia.
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Affiliation(s)
- K J Lu
- Department of Medicine, University of Melbourne and Austin Health, Victoria, Australia; Department of Cardiology, Austin Health, Victoria, Australia.
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Vazquez-Oliva G, Zamora A, Vilaseca M, Paluzie G. ¿La comorbilidad influye en la decisión de un abordaje intervencionista de pacientes ingresados con síndrome coronario agudo sin elevación del segmento ST en un hospital comarcal? Rev Clin Esp 2013. [DOI: 10.1016/j.rce.2012.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Lazzeri C, Valente S, Chiostri M, Attanà P, Mattesini A, Dini CS, Gensini GF. Comorbidities in stemi patients submitted to primary PCI: temporal trends and impact on mortality: a 6-year single center experience. Int J Cardiol 2012. [PMID: 23200270 DOI: 10.1016/j.ijcard.2012.11.091] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Niven DJ, Kirkpatrick AW, Ball CG, Laupland KB. Effect of comorbid illness on the long-term outcome of adults suffering major traumatic injury: a population-based cohort study. Am J Surg 2012; 204:151-6. [PMID: 22608670 DOI: 10.1016/j.amjsurg.2012.02.014] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Revised: 02/06/2012] [Accepted: 02/06/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND Few studies have assessed the impact of pre-existing medical comorbidities on long-term survival after major trauma. This study investigated the influence of comorbidities as measured by the Charlson Comorbidity Index (CCI) on the 1-year mortality after major traumatic injury. METHODS Adult patients who survived their initial trauma admission in Calgary, Alberta, Canada, between April 1, 2002, and March 31, 2006, defined the study population. Clinical and outcome information was obtained from regional electronic databases. RESULTS The study population consisted of 3,080 patients. The median age was 43.3 years (interquartile range, 26.9-59.3 y), and the median Injury Severity Score was 20 (interquartile range, 16-25). A total of 478 patients (15.5%) had at least one pre-existing comorbidity. The 1-year mortality rate was 2.7% (83 of 3,080). After adjusting for the confounding effects of age, the CCI was independently associated with 1-year mortality with an odds ratio of 1.24 (95% confidence interval, 1.02-1.51; P = .03) per point on the CCI. A model that included the CCI and age accurately predicted 1-year mortality (C-statistic, .83; 95% confidence interval, .78-.87; P < .0001). CONCLUSIONS Comorbid illnesses have an important influence on long-term outcomes after major trauma. Whether this represents an inherent risk for adverse outcome or an opportunity for enhanced medical co-management remains to be defined.
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Affiliation(s)
- Daniel J Niven
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Peter Lougheed Centre, 3500 26th Ave. NE, Calgary, Alberta, Canada T1Y 6J4.
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Lejos del ensayo clínico… cerca de nuestra realidad. Rev Clin Esp 2011; 211:579-80. [DOI: 10.1016/j.rce.2011.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2011] [Accepted: 07/04/2011] [Indexed: 11/23/2022]
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Palau P, Núñez J, Sanchis J, Husser O, Bodí V, Núñez E, Miñana G, Boesen L, Ventura S, Llàcer A. Differential prognostic effect of revascularization according to a simple comorbidity index in high-risk non-ST-segment elevation acute coronary syndrome. Clin Cardiol 2011; 35:237-43. [PMID: 22083556 DOI: 10.1002/clc.20996] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Accepted: 09/16/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Data on the effect of revascularization on outcome in patients with high-risk non-ST-segment elevation acute coronary syndrome (NSTEACS) and significant comorbidities are scarce. Recently, a simple comorbidity index (SCI) including 5 comorbidities (renal failure, dementia, peripheral artery disease, heart failure, and prior myocardial infarction [MI]) has shown to be a useful tool for risk stratification. Nevertheless, therapeutic implications have not been derived. HYPOTHESIS We sought to evaluate the prognostic effect attributable to revascularization in NSTEACS according the SCI score. METHODS We included 1017 consecutive patients with NSTEACS. The effect of revascularization on a combined end point of all-cause mortality or nonfatal MI was evaluated by Cox regression according to SCI categories. RESULTS A total of 560 (55.1%), 236 (23.2%), and 221 (21.7%) patients showed 0, 1, and ≥2 points according to the SCI, respectively. Coronary angiography was performed in 725 patients (71.5%), and 450 patients (44.3%) underwent revascularization. During a median follow-up of 16 months (interquartile range, 12-36 months), 305 (30%) patients experienced the combined end point (202 deaths [19.9%] and 170 MIs [16.7%]). In multivariate analysis, a differential prognostic effect of revascularization was observed comparing SCI ≥2 vs 0 (P for interaction = 0.008). Thus, revascularization was associated with a greater prognostic benefit in patients with SCI ≥2 (hazard ratio [HR]: 0.51, 95% confidence interval [CI]: 0.29-0.89), P = 0.018), whereas no significant benefit was observed in those with 0 and 1 point (HR: 1.31, 95% CI: 0.88-1.94, P = 0.171 and HR: 1.11, 95% CI: 0.70-1.76, P = 0.651, respectively). CONCLUSIONS In NSTEACS, the SCI score appears to be a useful tool for identifying a subset of patients with a significant long-term death/MI risk reduction attributable to revascularization.
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Affiliation(s)
- Patricia Palau
- Cardiology Department, Hospital Clinico Universitario, INCLIVA, Universidad de Valencia, Valencia, Spain.
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