Determinants of poor life satisfaction in adolescents with congenital heart disease or early acquired cardiovascular disease: a nationwide observational study

Background

Life expectancy in patients with congenital heart disease (CHD) and patients with early acquired cardiovascular disease (CVD) has increased due to improved treatments during the last decades. As life expectancy increases, focus on long term quality of life and life satisfaction as well as determining focus areas of preventive initiatives becomes essential.

Purpose

To investigate whether poor life satisfaction in adolescents and young adults with CHD or significant CVD is 1) associated with physical and mental challenges and 2) inversely associated with social support and self-efficacy have a protective effect against low life satisfaction.

Methods

Data from a Danish nationwide cross-sectional study was used to identify all patients with either CHD or significant CVD (e.g., arrhythmia, ischemia) aged 15–24 years with at least one contact to a Danish hospital department of cardiology between 2014–2018. Life satisfaction was measured on a scale of 0–10 and dichotomized into good life satisfaction if the score was >6. Using a logistic regression model with interaction terms for sex and adjusted for age and comorbidities, we estimated the association between physical challenges (New York Heart Association classification, NYHA), mental challenges (concentration limitations or memory limitations), social support, self-efficacy, and life satisfaction.

Results

1961 patients were included, 58% had CHD. Median age was 20 years and 50% were female. NYHA-class III or IV were significantly associated with poor life satisfaction (OR: 0.42 [95CI: 0.26; 0.70]) (Figure 1). Likewise, self-reported memory limitations (OR: 0.79 [95CI: 0.68; 0.91]) and concentration difficulty (OR: 0.60 [95CI: 0.51; 0.70]) were associated with poor life satisfaction (Figure 1). In contrast, reported high self-efficacy (OR: 1.67 [95CI: 1.32; 2.12]) and good social support (OR: 2.16 [95CI: 1.60; 2.93]) were both associated with high life satisfaction (Figure 1). Finally, the association between NYHA class III (OR: 0.94 [95CI: 0.34; 2.59]), memory limitations (OR: 0.79 [95CI: 0.58; 1.07]), concentration limitations (OR: 0.71 [95CI: 0.49; 1.04]), and life satisfaction was not significant among individuals with high self-efficacy but remained significant among individuals with good social support.

Conclusions

In adolescents and young adults with CHD or early acquired heart disease, reported physical and mental challenges were associated with reduced self-reported life satisfaction. Both reported high self-efficacy and good social support were associated with increased life satisfaction. High self-efficacy among individuals reduced the negative association between mental or physical challenges and life satisfaction. These findings highlight the need for increased focus on promoting self-efficacy and the need for good social support in adolescents and young adults with functional limitations from their CHD or CVD in order to improve their long-term life satisfaction.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Danish Heart Foundation

Long-term non-cardiovascular morbidity risk remains elevated following myocardial infarction: a nationwide cohort study

Introduction

Risk of cardiovascular events following myocardial infarction (MI) is high, and secondary preventive treatment is largely focused on reducing future cardiovascular risk. As gradual implementation of guideline-based treatments successfully leads to improved survival, long-term non-cardiovascular morbidity is likely of rising importance following MI.

Purpose

To determine the long-term risk of non-cardiovascular morbidity in a contemporary MI population with the aim of informing the need for and scope of prolonged surveillance.

Methods

We included all patients with a first-time MI in Denmark from 2001–2018 matched on age, sex, and date of discharge with up to 4 general population controls. We used the Aalen-Johansen estimator to estimate 1-year and 5-year risk of non-cardiovascular morbidity with death as a competing risk. Non-cardiovascular morbidity was defined as an in-patient hospital admission for any primary cause excluding cardiovascular diagnoses (International classification of diseases, 10th revision codes: I00–99). We also calculated 2-year and 6-year risks of non-cardiovascular morbidity in a stable population of post-MI patients and matched controls, i.e., participants alive with no hospital admissions for 1 full year following study entry. Finally, we estimated 1-year and 5-year risks of cause-specific non-cardiovascular morbidity.

Results

A total of 124,072 patients with MI who survived to hospital discharge were matched with 496,277 general population controls. Median age was 68 years and 35.5% were female. The 1-year and 5-year risk of non-cardiovascular morbidity was elevated for patients with MI compared to controls: 38.6% (95% confidence interval: 38.3–38.9) vs 15.3% (15.2–15.4) and 64.8% (64.6–65.1) vs 45.8% (45.7–45.9), respectively (Figure 1). Regarding cause-specific morbidity, risks of respiratory disease, gastrointestinal disease, and infectious disease particularly were high (Figure 2). For example, 1-year risk of infection was 4.5% for patients with MI and 1.8% for controls and 5-year risk of respiratory disease was 16.3% for patients with MI and 9.7% for controls. Furthermore, in the stable population (patients with MI, n=50,144; controls, n=159,467, median age 64 years, 33.0% female), risk of non-cardiovascular morbidity remained elevated at 2 years (17.2% [16.8–17.5] vs 11.3% [11.1–11.5]) and 6 years (49.2% [48.7–49.7] vs 39.8% [39.6–40.1]) post MI (Figure 1).

Conclusions

Risk of non-cardiovascular morbidity was high in patients following myocardial infarction, particularly for respiratory disease, gastrointestinal disease, and infectious disease. The risk remained elevated during long-term follow up. The study highlights the importance of additional focus on non-CV morbidity to further improve outcomes.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Danish Heart Foundation

Increased risk of out-of-hospital cardiac arrest in patients with congenital heart disease: a nationwide study

Background

The last four decades witnessed substantial improvements in treatment of congenital heart disease (CHD) leading to most children surviving into adulthood. Currently, the number of adults with CHD surpasses that of children. The shift in the CHD population's age composition necessitates focusing on long-term problems. A significant, but not well-investigated, issue is the risk of out-of-hospital cardiac arrest (OHCA) in adults with CHD.

Purpose

To investigate overall and temporal changes in the rate of OHCA associated with CHD compared with the general population.

Method

We conducted a nested case-control study matching all adult patients with OHCA of presumed cardiac cause between 2001 and 2015 with up to five controls from the entire Danish population on age, sex, date of OHCA and cardiac comorbidities status (at least one among ischemic heart disease, heart failure and presence of implantable cardioverter-defibrillator). Patients with CHD were identified using in- and out-patient hospital diagnoses any time prior to OHCA and divided into two mutually exclusive subgroups, either non-severe or severe CHD. The subclassification of CHD is based on a hierarchical approach previously used, where at least one severe CHD diagnosis is required to be classified as severe.

We used Cox regression models to compute hazard ratios (HRs) and 95% confidence intervals (CI) of OHCA. We stratified on CHD status (non-severe, severe or control), sex and OHCA year group (2001–2008 vs 2009–2015).

Results

We included 35,005 OHCA cases and 175,025 controls: the median age was 72 years, 66.9% were male and 34.6% had cardiac comorbidities. In total, among cases, we identified 103 patients with non-severe CHD and 51 with severe CHD, while, among controls, 247 with non-severe CHD and 69 with severe CHD. Both non-severe and severe CHD were overall associated with higher rates of OHCA compared with the general population: HR 2.11 (95% CI, 1.68–2.66) and HR 3.93 (95% CI, 2.71–5.69), respectively (Figure A). We found similar results when we stratified the analyses according to the presence of cardiac comorbidities at date of OHCA (Figure B) and sex.

When stratified by OHCA year group, we observed stable rates of OHCA associated with non-severe CHD: from HR 2.03 (95% CI, 1.36–3.03) in the period 2001–2008 to HR 2.15 (95% CI, 1.62–2.86) in the period 2009–2015. Conversely, we observed a trend towards decreasing rates of OHCA associated with severe CHD: from HR 5.04 (95% CI, 2.79–9.11) in the period 2001–2008 to HR 3.10 (95% CI, 1.80–5.19) in the period 2009–2015

Conclusions

Non-severe and severe CHD were both associated with higher rates of OHCA compared with the general population. While we observed decreasing rates of OHCA over calendar year for severe CHD, they remained stable for non-severe CHD.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Gentofte University Hospital, Hellerup, Denmark

Long-term mortality after myocardial infarction and stroke in a simple congenital heart disease population

Background

Congenital heart disease (CHD) is the most common major birth defect. Due to improvements in early detection and treatment during the last decades, most children survive into adulthood and currently the proportion of adults with CHD surpasses that of children. Previous studies reported an increased comorbidity prevalence in patients with simple CHD compared to a population without CHD. However, it is unclear whether these comorbidities increase the risk of death more in patients with simple CHD compared to those without.

Purpose

To investigate whether 40-years old individuals with simple CHD are at 1) an increased risk of developing stroke and acute myocardial infarction (AMI) and 2) whether AMI and stroke survivors with simple CHD have increased 10-year mortality compared to non-CHD matched controls.

Methods

Patients with simple CHD aged 40 years between 1977–2008 were identified by linking the Danish nationwide registries. Simple CHD was defined as isolated ventricular septal defect, atrial septal defect, patent ductus arteriosus or pulmonary stenosis. Patients with simple CHD were matched with 100 birthdate- and sex matched controls who did not have any CHD. We used two multiple Cox regression to compare the risk of AMI and stroke, respectively, between patients with and without simple CHD. Reported were the standardized 10-year risks for fixed comorbidity distribution according to simple CHD status. In patients who developed AMI or stroke, we used two other multiple Cox regressions to compare the risk of death between patients with and without simple CHD. Reported were the standardized 10-year risks for fixed comorbidity distribution according to simple CHD status in patients with AMI and stroke, respectively.

Results

We identified 2307 patients with simple CHD (54% females). The risk of developing AMI or stroke among 40-years old individuals with simple CHD was comparable to the risk in the background population – a trend of higher risk among simple CHD was seen but was not significant. The 10-year mortality after developing AMI was higher among the population with simple CHD than the matched controls (Figure 1) e.g. 10-year mortality: CHD 26.9% vs controls 20.6%. This was also the case for the 10-year mortality after developing a stroke (Figure 2) e.g. 10-year mortality 24.8% vs controls 22.6%.

Conclusions

Middle-aged individuals with simple CHD are not at an increased risk of developing AMI or stroke compared to the background population. However, developing stroke or AMI among individuals with simple CHD is associated with increased mortality compared to individuals without simple CHD. In the aging CHD population, the risk of atherosclerotic disease is naturally increasing. Therefore, it is of the utmost important to study long-term complications further to guide both primary and secondary prevention of cardiovascular disease in these vulnerable individuals.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Danish Heart Foundation

Decreasing mortality in patients with simple congenital heart disease: a Danish nationwide study

Background

The long-term mortality in patients with simple congenital heart disease (SCHD) compared with the general population is not well-described.

Purpose

To investigate the 10-year mortality in individuals with and without SCHD and whether it has changed since 1977 using contemporary data.

Method

By linking Danish nationwide registries, we identified all individuals with and without a SCHD diagnosis who were alive at age 40 between 1977–2006. Excluded were individuals with moderate or severe congenital heart disease. SCHD was defined as isolated ventricular septal defect (VSD), atrial septal defect (ASD), patent ductus arteriosus (PDA) or pulmonary stenosis (PS). The population was followed from age 40 until death or emigration, whichever came first. We predicted 10-year all-cause mortality according to each year of inclusion. Reported was 10-year all-cause mortality and mortality ratios (SCHD vs non-SCHD) with 95% confidence intervals (CI) by calendar year groups (1977–1986, 1987–1996, 1997–2006).

Results

We identified 2,040 individuals with SCHD (VSD: 27.5%, ASD: 62.2%, PDA 6.8%, PS: 3.5%), of which 1,121 (55.0%) were female, and 2,083,277 individuals without SCHD, of which 1,028,769 (49.4%) were female. In individuals with SCHD the 10-year all-cause mortality decreased over time in both men (1977–1986: 12.3% [11.8–12.9%], 1987–1996: 9.0% [7.4–10.5%], 1997–2006: 5.0% [4.3–5.7%]) and women (1977–1986: 7.7% [7.5–7.9%], 1987–1996: 4.9% [3.9–6.0%], 1997–2006: 1.2% [0.7–1.7%]), whereas the 10-year risks were somewhat stable in individuals without SCHD for both men (1977–1986: 3.2% [3.2–3.2%], 1987–1996: 3.3% [3.2–3.3%], 1997–2006: 2.9% [2.7–3.0%]) and women (1977–1986: 2.4% [2.3–2.4%], 1987–1996: 2.1% [2.1– 2.2%], 1997–2006: 1.7% [1.6–1.8%]) (Figure 1, panel A). The mortality ratio decreased over time in both men (1977–1986: 3.9 [3.7–4.1], 1987–1996: 2.7 [2.3–3.2], 1997–2006: 1.7 [1.5–1.9]) and women (1977–1986: 3.3 [3.2–3.3], 1987–1996: 2.3 [1.8– 2.7], 1997–2006: 0.7 [0.4–1.0]) (Figure 1, panel B) remaining significantly higher for men, but not women, in 1997–2006.

Conclusion

In individuals with simple congenital heart disease aged 40 years, the 10-year mortality decreased dramatically over time for both men and women. Despite decreasing mortality, men with SCHD, but not women, remained at a higher 10-year mortality compared to individuals without SCHD.

Figure 1. Temporal trends in 10-year mortality

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Danish Heart Foundation