Ventricular rate in atrial fibrillation and the risk of heart failure and death

AIMS

While clinical trials have suggested that a high ventricular rate is associated with increased risk of heart failure (HF) and mortality, all-comers studies are warranted.

OBJECTIVE

To assess 1-year risk of new-onset diagnosed HF and all-cause mortality among rate-control treated patients presenting with atrial fibrillation (AF) on an electrocardiogram (ECG) according to ventricular rate.

METHODS AND RESULTS

ECGs recorded at the Copenhagen General Practitioners Laboratory (2001-15) were used to identify patients with AF. Multivariate Cox proportional hazard regression models were used to compare risk of new-onset HF and all-cause mortality after first ECG presenting with AF according to ventricular rate on ECG [<60, 60-79, 80-99, and 100-110, > 110 beats per minute (bpm)]. We identified 7408 patients in treatment with rate control drugs at time of first ECG presenting with AF [median age 78 years (Q1,Q3 = 70-85 years)], 45.8% male, median ventricular rate 83 bpm, (Q1,Q3 = 71-101 bpm)]. During 1-year follow-up, 666 (9.0%) of all patients with AF developed HF and 858 (11.6%) died. Patients with AF ventricular rates 100-110 bpm and >110 bpm had a hazard ratio (HR) of 1.46 (CI: 1.10-1.95) and 2.41 (CI: 1.94-3.00) respectively for new-onset HF, compared with 60-79 bpm. Similarly, patients with AF ventricular rates 100-110 bpm and >110 bpm had a HR of 1.44 (CI: 1.13-1.82) and 1.34 (CI: 1.08-1.65) respectively for all-cause mortality, compared with 60-79 bpm.

CONCLUSIONS

Ventricular rates ≥100 bpm among patients presenting with AF on ECG in treatment with rate control drugs were associated with greater risk of both new-onset HF and all-cause mortality.

Employment Status at Time of Acute Myocardial Infarction and Risk of Death and Recurrent Acute Myocardial Infarction

BACKGROUND

Employment is important for physical and mental health and self-esteem and provides financial independence. However, little is known on the prognostic value of employment status prior to admission with acute myocardial infarction (MI).

METHODS AND RESULTS

Using Danish nationwide registries, all patients between 18 and 60 years with a first-time MI admission (2010-2018) and alive at discharge were included. Rates of all-cause mortality and recurrent MI according to workforce attachment at the time of the event was compared using multivariable Cox regression. Of the 16,060 patients included in the study, 3,520 (21.9%) patients were not part of the workforce. Patients who were not part of the workforce were older (52 versus 51 years), less often men (63% versus 77%), less likely to have higher education, more often living alone (47% versus 29%), and more often had comorbidities, including heart failure, atrial fibrillation, hypertension, diabetes, chronic kidney disease, and chronic obstructive pulmonary disease. The absolute 5-year risk of death was 3.3% and 12.8% in the workforce and non-workforce group, respectively. The corresponding rates of recurrent MI were 7.5% and 10.9%, respectively. In adjusted analyses, not being part of the workforce was associated with a significantly higher rate of all-cause mortality (HR 2.39 ([95% CI, 2.01-2.83]) and recurrent MI (1.36 [1.18-1.57]).

CONCLUSION

Among patients of working age who were admitted with MI and alive at discharge, not being part of the workforce was associated with a higher long-term rate of all-cause mortality and recurrent MI.

Risk of lead explantation after first-time implantation of cardiac implantable electronic device as a function of comorbidity: a nationwide study

Background

The benefit of cardiac implantable electronic devices (CIEDs) is challenged by the risk of procedure-related complications and lead explantation. Whether patient comorbidity burden is associated with risk of lead explantation &lt;6 months of implantation is unknown.

Purpose

We assessed the risk of lead explantation and its association with comorbidity burden within 6 months after first-time CIED implantation.

Methods

The study population comprised patients ≥18 years old with first-time CIED implantation (i.e., pacemaker [PM], implantable cardioverter defibrillator [ICD], and cardiac resynchronisation therapy with defibrillator [CRT-D] or without [CRT-P]) using Danish nationwide registries including the Danish Pacemaker and ICD registry (1 January 2000 to 30 June 2018). Patients were followed from their first-time CIED implantation and 6 months forward. Patient comorbidity burden was categorised in four groups according to the Charlson Comorbidity Index (CCI) score: 0 (none), 1–2 (mild), 3–4 (moderate), and ≥5 (severe). Multivariable cause-specific Cox regression was performed to assess risk of lead explantation according to comorbidity burden, with death as competing risk. Comorbidity burden was adjusted for sex, age, type of CIED, and body mass index categories.

Results

We identified 73,491 patients with first-time CIED implantation including 55,733 (75.8%) with PM, 11,351 (15.5%) with ICD, 2,989 (4.1%) with CRT-P, and 3,418 (4.7%) with CRT-D. In total, 1,049 (1.4%) patients underwent lead explantation. The median age of the study population was 75.1 years [25th-75th percentile 66.2–82.5 years], and 62.1% were male. Patients undergoing lead explantation had higher median CCI score, compared with those not undergoing lead explantation (2 [1–3] and 1 [0–3], respectively). The median age and distribution of sex were similar in both groups. In the multivariable Cox regression model (Figure 1), an increase in patient comorbidity burden was associated with higher hazard ratio [HR] of lead explantation, compared with CCI score 0 (CCI score 1–2: HR=1.38 [95% confidence interval [CI]: 1.12–1.69], CCI score 3–4: HR=1.61 [95% CI: 1.28–2.03], and CCI score ≥5: HR=1.60 [95% CI: 1.25–2.05]).

Conclusion

Risk of lead explantation within 6 months after first-time implantation of cardiac implantable electronic device was 1.4% and associated with higher comorbidity burden.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Independent Research Fund Denmark

Severity of chronic obstructive pulmonary disease and risk of one-year mortality after first-time implantation of implantable cardioverter defibrillator: a nationwide study

Background

Current guidelines, on implantable cardioverter defibrillator (ICD), recommend implantation in patients with an expected survival beyond one year. Information on risk of all-cause mortality among ICD recipients with chronic obstructive pulmonary disease (COPD) according to severity of COPD is lacking.

Purpose

We examined the association between the severity of COPD and risk of all-cause mortality within one year after first-time ICD implantation.

Methods

We identified patients ≥18 years old undergoing first-time ICD implantation with COPD using Danish nationwide registries (1 January 2000 to 31 December 2018). All patients were eligible for one-year follow-up. We used concomitant COPD-related pharmacotherapy six months prior to ICD implantation and COPD hospitalisations one year prior to ICD implantation to determine severity of COPD from mild to very severe according to Table 1. Multivariable Cox regression was used to assess risk of one-year all-cause mortality according to severity of COPD. Severity of COPD was adjusted for sex, age, year of implantation, primary prevention, type of ICD, history of atrial fibrillation, stroke, peripheral artery disease, diabetes, cancer, chronic renal disease, and dialysis.

Results

The study population included 1,536 patients with first-time ICD and COPD. The median age was 69.5 years [25th-75th percentile 63.5–74.3 years], and the majority of patients were males (79.4%). Of these, 896 (58.3%) received an ICD for primary prevention, and 485 (31.6%) had cardiac resynchronisation therapy device with defibrillator (CRT-D). In total, 1,348 (87.8%) patients were diagnosed with heart failure. Patients were grouped according to severity of COPD from mild to very severe: Group 1 (N=666), Group 2 (N=72), Group 3 (N=149), Group 4 (N=445), and Group 5 (N=204). Overall, 154/1,536 (10.0%) ICD recipients with COPD died within one year after first-time ICD implantation. No difference in sex and comorbidities was identified according to the five groups of COPD severity. However, ICD recipients with mild intermittent COPD (Group 1) were the youngest (68.3 years [61.8–73.0 years]). According to our multivariable cox regression in Figure 1, patients with very severe COPD (Group 5) were associated with increased risk of all-cause mortality within one year after first-time ICD implantation (adjusted hazard ratio [HR] 1.90 [95% confidence interval [CI]: 1.21–2.98]), compared with mild intermittent COPD (Group 1). The most common causes of death within one year after ICD implantation were attributed to cardiovascular diseases 95/154 (61.7%), respiratory diseases 15/154 (9.7%), and endocrine disorders 12/154 (7.8%).

Conclusion

In this nationwide study, very severe chronic obstructive pulmonary disease was associated with increased risk of all-cause mortality within one year after first-time implantation of implantable cardioverter defibrillator.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Independent Research Fund Denmark

Glycated haemoglobin levels among 3295 hospitalized COVID-19 patients, with and without diabetes, and risk of severe infection, admission to an intensive care unit and all-cause mortality

AIM

To determine the risk of adverse outcomes across the spectrum of glycated haemoglobin (HbA1c) levels among hospitalized COVID-19 patients with and without diabetes.

MATERIALS AND METHODS

Danish nationwide registries were used to study the association between HbA1c levels and 30-day risk of all-cause mortality and the composite of severe COVID-19 infection, intensive care unit (ICU) admission and all-cause mortality. The study population comprised patients hospitalized with COVID-19 (3 March 2020 to 31 December 2020) with a positive polymerase chain reaction (PCR) test and an available HbA1c ≤ 6 months before the first positive PCR test. All patients had at least 30 days of follow-up. Among patients with diabetes, HbA1c was categorized as <48 mmol/mol, 48 to 53 mmol/mol, 54 to 58 mmol/mol, 59 to 64 mmol/mol (reference) and >64 mmol/mol. Among patients without diabetes, HbA1c was stratified into <31 mmol/mol, 31 to 36 mmol/mol (reference), 37 to 41 mmol/mol and 42 to 47 mmol/mol. Thirty-day standardized absolute risks and standardized absolute risk differences are reported.

RESULTS

We identified 3295 hospitalized COVID-19 patients with an available HbA1c (56.2% male, median age 73.9 years), of whom 35.8% had diabetes. The median HbA1c was 54 and 37 mmol/mol among patients with and without diabetes, respectively. Among patients with diabetes, the standardized absolute risk difference of the composite outcome was higher with HbA1c < 48 mmol/mol (12.0% [95% confidence interval {CI} 3.3% to 20.8%]) and HbA1c > 64 mmol/mol (15.1% [95% CI 6.2% to 24.0%]), compared with HbA1c 59 to 64 mmol/mol (reference). Among patients without diabetes, the standardized absolute risk difference of the composite outcome was greater with HbA1c < 31 mmol/mol (8.5% [95% CI 0.5% to 16.5%]) and HbA1c 42 to 47 mmol/mol (6.7% [95% CI 1.3% to 12.1%]), compared with HbA1c 31 to 36 mmol/mol (reference).

CONCLUSIONS

Patients with COVID-19 and HbA1c < 48 mmol/mol or HbA1c > 64 mmol/mol had a higher associated risk of the composite outcome. Similarly, among patients without diabetes, varying HbA1c levels were associated with higher risk of the composite outcome.

Time to Thrombolysis and Long-Term Outcomes in Patients With Acute Ischemic Stroke: A Nationwide Study

[Figure: see text].

Risk factors for mortality within one-year after implantable cardioverter defibrillator implantation: a nationwide study

Background

Current guidelines do not recommend implantable cardioverter defibrillator (ICD) implantation in patients with an estimated survival probability of less than one year. There is still an unmet need to identify patients who are unlikely to benefit from an ICD.

Purpose

We determined one-year mortality after ICD implantation and associated risk factors of one-year mortality.

Methods

Using Danish nationwide registries from 2000–2016, we identified patients ≥18 years old undergoing first-time ICD implantation for primary or secondary prevention. Patients were followed for up to one-year from time of ICD implantation. Risk factors associated with one-year mortality after time of ICD implantation were evaluated in multivariable logistic regression models.

Results

A total of 13,344 patients underwent first-time ICD implantation (median age: 66 years [25th-75th percentile 58–72 years], male=81.3%, secondary prevention=54.6%), of which 647 died (4.8%) within one year of follow-up. Compared with ICD patients who survived for one year, those who died were significantly older (72 years vs. 66 years, p&lt;0.001) and had more comorbidities, including congestive heart failure (70.8% vs. 63.4%), atrial fibrillation (36.6% vs. 23.6%), diabetes (30.8% vs. 19.9%), chronic obstructive pulmonary disease (COPD) (17.0% vs. 8.2%), chronic renal disease (13.0% vs. 4.4%), malignancy (9.9% vs. 5.4%), and dialysis (7.3% vs. 2.4%) (p&lt;0.001 for all).

Results from the multivariable logistic regression model are depicted in the Figure. There was a graded relationship between age and one-year mortality, with a greater risk of all-cause mortality with increasing age.

In addition, dialysis, chronic renal disease, COPD, malignancy, diabetes, and congestive heart failure were strongly associated with increased risk of one-year all-cause mortality. However, ischaemic heart disease was associated with a lower risk of all-cause mortality (Figure). The one-year risk of death was 13.2% for both patients receiving dialysis and patients with chronic renal disease, respectively.

The majority of deaths within one year were attributed to cardiovascular causes (408/647, 63.1%) of which chronic ischaemic heart disease (68/647, 10.5%), acute myocardial infarction (50/647, 7.7%), and atherosclerosis (40/647, 6.2%) were the most common. The most common non-cardiovascular cause of death was malignancy (10.5%).

Conclusion

In patients with a first-time ICD implantation, 95% survived for more than one year after implantation. While low mortality rates are indicative of relevant patient selection for ICD implantation, advanced age, dialysis, and several comorbidities were all strongly associated with increased one-year mortality, whereas ischaemic heart disease was associated with a lower risk of one-year mortality. Potential benefit of an ICD in such patients should be carefully evaluated before implantation.

Funding Acknowledgement

Type of funding source: None

Mortality after implantable cardioverter defibrillators in dialysis patients: a nationwide study

Background

Although randomized clinical trials have shown that implantable cardioverter defibrillators (ICDs) reduce mortality in selected patients, patients on dialysis are excluded from these trials. Thus, data on mortality risk after ICD implantation in these patients are sparse.

Purpose

To examine all-cause mortality in patients receiving an ICD according to dialysis status and to identify factors associated with all-cause mortality in patients on dialysis.

Methods

Using Danish nationwide registries from 2000–2017, all patients ≥18 years old undergoing first-time ICD implantation were included. Patients on dialysis were identified prior to ICD implantation and followed for up to five years. The cumulative incidence of all-cause mortality according to dialysis status was assessed. Factors associated with all-cause mortality after ICD implantation in dialysis patients were examined using multivariable Cox proportional hazard regression.

Results

A total of 14,681 ICD patients were identified, of which 218 (1.5%) were on dialysis prior to ICD implantation. Compared with ICD patients not on dialysis, those on dialysis were younger (median age 64 years [IQR: 58–70] vs. 66 years [IQR: 57–72], p=0.02), more likely to receive an ICD for secondary prophylaxis (69.7% vs 53.7%), and had more comorbidities including ischaemic heart disease (60.6% vs. 46.3%), diabetes (28.4% vs. 20.4%), and peripheral vascular disease (10.1% vs. 5.6%) (p for all &lt;0.05).

The median time to death among ICD patients on dialysis and not on dialysis were 1.3 years (IQR: 0.4–2.8 years] and 2.2 years [IQR: 1.0–3.5 years], respectively.

One-year mortality among ICD patients on dialysis (13.0%) was significantly higher compared with ICD patients not on dialysis (4.7%), p&lt;0.001 (Figure). Five-year mortality was significantly higher in ICD patients on dialysis than those not on dialysis (42.2% vs 23.6%), p&lt;0.001 (Figure).

Factors associated with increased risk of all-cause mortality among ICD patients on dialysis were age ≥65 years at time of implantation (reference: age &lt;65 years) (HR 1.90 [95% CI: 1.13–3.19]), primary prophylactic ICD (HR 1.81 [95% CI 1.08–3.05]), and diabetes (HR 1.87 [95% CI 1.14–3.07]). Sex, ischaemic heart disease, heart failure, stroke, chronic obstructive pulmonary disease, and malignancy were not associated with the risk of mortality (p&gt;0.05 for all).

Cardiovascular causes of death were common both in patients with- and without dialysis, 69.6% and 60.0%, respectively.

Conclusion

Five-year mortality in ICD patients on dialysis was 42% and twice as high compared with ICD patients not on dialysis. Age ≥65 years, primary prophylactic indication, and diabetes were factors associated with increased mortality. Careful evaluation of the potential benefit from an ICD implantation in dialysis patients is important considering the overall high mortality rates.

Funding Acknowledgement

Type of funding source: None

Increasing time to thrombolysis is associated with worse long-term outcomes in patients with ischaemic stroke: a nationwide study

Background

It is well-established that the short-term benefits of intravenous thrombolytic therapy are reduced with increasing treatment delay in patients with acute ischaemic stroke. However, there is a paucity of contemporary data on the association between time from symptom onset to initiation of thrombolysis and long-term outcomes. With improving post-stroke survival in the Western world, data on time to thrombolysis and subsequent long-term outcomes are warranted in order to provide further insight into the importance of time to treatment.

Purpose

To examine the long-term risk of adverse outcomes according to time from symptom onset to intravenous thrombolytic therapy in patients with acute ischaemic stroke.

Methods

In this observational cohort study, we identified all patients with first-time ischaemic stroke treated with intravenous thrombolysis between 2011–2015 and alive at discharge through the Danish National Stroke Registry. Patients who received thrombolysis after &gt;270 min were excluded. Using multivariable Cox regression, we examined associations between time from symptom onset to thrombolysis and risks of the composite of death, recurrent ischaemic stroke, and dementia, as well as each of these components separately. Patients were followed until the outcome of interest, emigration, or December 31, 2017.

Results

Of the 4,313 patients with first-time ischaemic stroke treated with intravenous thrombolysis, 4,119 were alive at discharge (median age 69 years [25th-75th percentile 59–78 years], 60% males). The median follow-up was 3.3 years (25th-75th percentile 2.3–4.7 years). The median time from symptom onset to initiation of thrombolytic therapy was 140 min (25th-75th percentile 106–187 min), and the median National Institutes of Health Stroke Scale score at presentation was 5 (25th-75th percentile 3–10). The unadjusted absolute 3-year risks of the composite outcome, death, recurrent ischaemic stroke, and dementia according to time to thrombolysis are displayed in the figure. Compared with thrombolysis within 90 min, time to thrombolysis &gt;90 min was associated with a higher relative risk of the composite outcome (91–180 min: adjusted hazard ratio [HR] 1.37 [95% confidence interval [CI], 1.13–1.68]; 181–270 min: adjusted HR 1.42 [95% CI 1.15–1.76]). The risks of each component of the composite outcome according to time to thrombolysis were similar to results for the composite endpoint, as illustrated in the figure.

Conclusions

In this nationwide cohort of patients with acute ischaemic stroke treated with thrombolysis, increasing time from symptom onset to initiation of intravenous thrombolytic therapy was associated with higher long-term risks of the composite of death, recurrent ischaemic stroke, and dementia, as well as all three outcomes separately. These data indicate that long-term outcomes of patients with ischaemic stroke treated with intravenous thrombolysis can be greatly improved by reducing treatment delay.

Time to thrombolysis and outcomes

Funding Acknowledgement

Type of funding source: None

Prognostic value of global longitudinal layer specific strain for patients with heart failure with reduced ejection fraction

Background

Novel echocardiographic software allows for layer-specific evaluation of myocardial deformation by 2-dimensional speckle tracking echocardiography. Endocardial, epicardial- and whole wall global longitudinal strain (GLS) may be superior to conventional echocardiographic parameters in predicting all-cause mortality in patients with heart failure with reduced ejection fraction (HFrEF).

Purpose

The purpose of this study was to investigate the prognostic value of endocardial-, epicardial- and whole wall GLS in patients with HFrEF in relation to all-cause mortality.

Methods

We included and analyzed transthoracic echocardiographic examinations from 1,015 patients with HFrEF. The echocardiographic images were analyzed, and conventional and novel echocardiographic parameters were obtained. A p value in a 2-sided test &lt;0.05 was considered statistically significant. Cox proportional hazards regression models were constructed, and both univariable and multivariable hazard ratios (HRs) were calculated.

Results

During a median follow-up time of 40 months, 171 patients (16.8%) died. A lower endocardial (HR 1.17; 95% CI (1.11–1.23), per 1% decrease, p&lt;0.001), epicardial (HR 1.20; 95% CI (1.13–1.27), per 1% decrease, p&lt;0.001), and whole wall (HR 1.20; 95% CI (1.14–1.27), per 1% decrease, p&lt;0.001) GLS were all associated with higher risk of death (Figure 1). Both endocardial (HR 1.12; 95% CI (1.01–1.23), p=0.027), epicardial (HR 1.13; 95% CI (1.01–1.26), p=0.040) and whole wall (HR 1.13; 95% CI (1.01–1.27), p=0.030) GLS remained independent predictors of mortality in the multivariable models after adjusting for significant clinical parameters (age, sex, total cholesterol, mean arterial pressure, heart rate, ischemic cardiomyopathy, percutaneous transluminal coronary angioplasty and diabetes) and conventional echocardiographic parameters (left ventricular (LV) ejection fraction, LV mass index, left atrial volume index, deceleration time, E/e', E-velocity, E/A ratio and tricuspid annular plane systolic excursion). No other echocardiographic parameters remained an independent predictors after adjusting. Furthermore, endocardial, epicardial and whole wall GLS had the highest C-statistics of all the echocardiographic parameters.

Conclusion

Endocardial, epicardial and whole wall GLS are independent predictors of all-cause mortality in patients with HFrEF. Furthermore, endocardial, epicardial and whole wall GLS were superior prognosticators of all-cause mortality compared with all other echocardiographic parameters.

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Herlev and Gentofte Hospital

Cause-specific death and risk factors of one-year mortality after implantable cardioverter-defibrillator implantation: a nationwide study

AIMS

Current treatment guidelines recommend implantable cardioverter-defibrillators (ICDs) in eligible patients with an estimated survival beyond one year. There is still an unmet need to identify patients who are unlikely to benefit from an ICD.We determined cause-specific one-year mortality after ICD implantation and identified associated risk factors.

METHODS AND RESULTS

Using Danish nationwide registries (2000-2017), we identified 14,516 patients undergoing first-time ICD implantation for primary or secondary prevention. Risk factors associated with one-year mortality were evaluated using multivariable logistic regression. The median age was 66 years, 81.3% were male, and 50.3% received an ICD for secondary prevention. The one-year mortality rate was 4.8% (694/14,516). ICD recipients who died within one year were older and more comorbid compared to those who survived (72 vs. 66 years, p < 0.001). Risk factors associated with increased one-year mortality included dialysis (OR:3.26, CI:2.37-4.49), chronic renal disease (OR:2.14, CI:1.66-2.76), cancer (OR:1.51, CI:1.15-1.99), age 70-79 years (OR:1.65, CI:1.36-2.01), and age ≥80 years (OR:2.84, CI:2.15-3.77). The one-year mortality rates for the specific risk factors were: dialysis (13.8%), chronic renal disease (13.1%), cancer (8.5%), age 70-79 years (6.9%), and age ≥80 years (11.0%). Overall, the most common causes of mortality were related to cardiovascular diseases (62.5%), cancer (10.1%), and endocrine disorders (5.0%). However, the most common cause of death among patients with cancer was cancer-related (45.7%).

CONCLUSION

Among ICD recipients, mortality rates were low and could be indicative of relevant patient selection. Important risk factors of increased one-year mortality included dialysis, chronic renal disease, cancer, and advanced age.