Impact of neuraminidase inhibitors on influenza A(H1N1)pdm09‐related pneumonia: an individual participant data meta‐analysis

BACKGROUND: The impact of neuraminidase inhibitors (NAIs) on influenza‐related pneumonia (IRP) is not established. Our objective was to investigate the association between NAI treatment and IRP incidence and outcomes in patients hospitalised with A(H1N1)pdm09 virus infection. METHODS: A worldwide meta‐analysis of individual participant data from 20 634 hospitalised patients with laboratory‐confirmed A(H1N1)pdm09 (n = 20 021) or clinically diagnosed (n = 613) ‘pandemic influenza’. The primary outcome was radiologically confirmed IRP. Odds ratios (OR) were estimated using generalised linear mixed modelling, adjusting for NAI treatment propensity, antibiotics and corticosteroids. RESULTS: Of 20 634 included participants, 5978 (29·0%) had IRP; conversely, 3349 (16·2%) had confirmed the absence of radiographic pneumonia (the comparator). Early NAI treatment (within 2 days of symptom onset) versus no NAI was not significantly associated with IRP [adj. OR 0·83 (95% CI 0·64–1·06; P = 0·136)]. Among the 5978 patients with IRP, early NAI treatment versus none did not impact on mortality [adj. OR = 0·72 (0·44–1·17; P = 0·180)] or likelihood of requiring ventilatory support [adj. OR = 1·17 (0·71–1·92; P = 0·537)], but early treatment versus later significantly reduced mortality [adj. OR = 0·70 (0·55–0·88; P = 0·003)] and likelihood of requiring ventilatory support [adj. OR = 0·68 (0·54–0·85; P = 0·001)]. CONCLUSIONS: Early NAI treatment of patients hospitalised with A(H1N1)pdm09 virus infection versus no treatment did not reduce the likelihood of IRP. However, in patients who developed IRP, early NAI treatment versus later reduced the likelihood of mortality and needing ventilatory support

Neuraminidase Inhibitors and Hospital Length of Stay: A Meta-analysis of Individual Participant Data to Determine Treatment Effectiveness Among Patients Hospitalized With Nonfatal 2009 Pandemic Influenza A(H1N1) Virus Infection

© The Author(s) 2019. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: [email protected]. BACKGROUND: The effect of neuraminidase inhibitor (NAI) treatment on length of stay (LoS) in patients hospitalized with influenza is unclear. METHODS: We conducted a one-stage individual participant data (IPD) meta-analysis exploring the association between NAI treatment and LoS in patients hospitalized with 2009 influenza A(H1N1) virus (A[H1N1]pdm09) infection. Using mixed-effects negative binomial regression and adjusting for the propensity to receive NAI, antibiotic, and corticosteroid treatment, we calculated incidence rate ratios (IRRs) and 95% confidence intervals (CIs). Patients with a LoS o

Coronary heart disease in women : diagnostic and prognostic markers

The main part of this thesis investigated a cohort of women younger than 66 years who had recovered from an event of acute coronary syndrome. It assessed the relationship between traditional coronary risk factors, basic clinical parameters, exercise testing results, coronary angiographic findings and recurrent cardiac events during a five-year follow up period. The role of oestrogen on exercise induced myocardial ischemia and exercise capacity in postmenopausal women with coronary artery disease was also assessed. The main findings in the different substudies were as follows: Non-significant coronary lesions were present in a high proportion (37%) of younger female patients with a history of acute coronary syndrome despite the high probability of significant coronary artery disease. Low exercise capacity, low rate pressure product, history of acute myocardial infarction, history of diabetes mellitus, high waist-to-hip ratio and low high-density lipoprotein cholesterol were the parameters that best correlated with the presence of angiographically documented coronary artery disease. Poor exercise capacity and inability to reach high rate pressure product were the exercise test parameters that were the strongest predictors of recurrent cardiac events. History of diabetes mellitus was the strongest independent predictor of adverse cardiac prognosis. Other important predictive factors were history of acute myocardial infarction, angiographically documented left ventricular dysfunction, low level of high-density lipoprotein cholesterol and high level of triglycerides. Female patients admitted for acute myocardial infarction but with a normal coronary angiogram or non-significant coronary lesions were examined with intracoronary ultrasound, which revealed diffuse atherosclerosis with predominantly soft, eccentric and poorly calcified plaques. It is reasonable to assume stimulation of a thrombotic mechanism as responsible for evoking the acute coronary event. Administration of oestrogen to postmenopausal women with stable coronary artery disease did not show any improvement in exercise capacity and did not attenuate the expression of myocardial ischemia

Validity of daily self-pulse palpation for atrial fibrillation screening in patients 65 years and older: A cross-sectional study.

BackgroundThe European Society of Cardiology guidelines recommend (Class IA) single-time-point screening for atrial fibrillation (AF) using pulse palpation. The role of pulse palpation for AF detection has not been validated against electrocardiogram (ECG) recordings. We aimed to study the validity of AF screening using self-pulse palpation compared with an ECG recording conducted at the same time using a handheld ECG 3 times a day for 2 weeks.Methods and findingsIn this cross-sectional screening study, patients 65 years of age and older attending 4 primary care centers (PCCs) outside Stockholm County were invited to take part in AF screening from July 2017 to December 2018. Patients were included irrespective of their reason for visiting the PCC. Handheld intermittent ECGs 3 times per day were offered to patients without AF for a period of 2 weeks, and patients were instructed in how to take their own pulse at the same time. A total of 1,010 patients (mean age 73 years, 61% female, with an average CHA2DS2-VASc score 2.9) participated in the study, and 27 (2.7%, 95% CI 1.8%-3.9%) new cases of AF were detected. Anticoagulants (ACs) could be initiated in 26 (96%, 95% CI 81%-100%) of these cases. A total of 53,782 simultaneous ECG recordings and pulse measurements were registered. AF was verified in 311 ECG recordings, of which the pulse was palpated as irregular in 77 recordings (25%, 95% CI 20%-30% sensitivity per measurement occasion). Of the 27 AF cases, 15 cases felt an irregular pulse on at least one occasion (56%, 95% CI 35%-75% sensitivity per individual). 187 individuals without AF felt an irregular pulse on at least one occasion. The specificity per measurement occasion and per individual was (98%, 95% CI 98%-98%) and (81%, 95% CI 78%-83%), respectively.ConclusionsAF screening using self-pulse palpation 3 times daily for 2 weeks has lower sensitivity compared with simultaneous intermittent ECG. Thus, it may be better to screen for AF using intermittent ECG without stepwise screening using pulse palpation. A limitation of this model could be the reduced availability of handheld ECG recorders in primary care centers

Assessment of N-terminal pro-B-type natriuretic peptide level in screening for atrial fibrillation in primary health care.

BackgroundAtrial fibrillation (AF), an important cause of thromboembolic events, is often silent and intermittent, thus presenting a diagnostic challenge. The aim of this study was to assess whether the plasma level of N-terminal pro-brain natriuretic peptide (NT-proBNP) is related to the presence of AF and thereby might be used to facilitate screening programs for AF in primary care.MethodsThis was a cross sectional screening study. A population of 70-74-year-old individuals registered at a single primary care center in Stockholm were invited to AF screening. Intermittent ECG recording, 30 seconds twice a day using a hand-held device over 2 weeks, was offered to participants without previously known AF. Of the 324 participating persons, 34 patients had already known AF and 16 new cases of AF were detected by screening. Plasma NT-proBNP was measured in patients with previously known AF, newly detected AF, and 53 control participants without AF.FindingsThe median NT-proBNP was 697 ng/L in patients with previously known AF, 335 ng/L in new cases of AF, and 146 ng/L in patients without AF. After adjustment for several clinical variables and morbidities, the differences of median NT-proBNP levels were statistically significant between cases of previously known AF and new cases of AF as well as between new cases of AF and those without AF. The area under receiver operating characteristic curve of detection of new AF was 0.68 (95% CI 0.56 to 0.79) yielding a cut-off point of 124 ng/L with 75% sensitivity, 45% specificity, and 86% negative predictive value.ConclusionsThe NT-proBNP plasma levels among patients with known AF are higher than those with newly detected AF, and the latter have higher levels than those without AF. Therefore NT-proBNP might be a useful screening marker for the detection of AF and its persistence

Feasibility and outcomes of atrial fibrillation screening using intermittent electrocardiography in a primary healthcare setting: A cross-sectional study.

BACKGROUND:Atrial fibrillation (AF) is a major risk factor for ischemic stroke unless treated with an anticoagulant. Detecting AF can be difficult because AF is often paroxysmal and asymptomatic. The aims of this study were to develop a screening model to detect AF in a primary healthcare setting and to initiate oral anticoagulant therapy in high-risk patients to prevent stroke. METHODS:This was a cross-sectional study. All 70- to 74-year-old individuals registered at a single primary healthcare center in Stockholm were invited to participate in AF screening upon visiting the center during a ten-month period. Those who did not have contact with the center during this period were invited to participate by letter. Thirty-second intermittent ECG recordings were made twice a day using a handheld Zenicor device over a 2-week period in participants without AF. Oral anticoagulant therapy was offered to patients with newly detected AF. FINDINGS:Of the 415 eligible individuals, a total of 324 (78.1%) patients participated in the study. The mean age of the participants was 72 years, 52.2% were female, and the median CHA2DS2-VASc score of the participants was 3. In the target population, 34 (8.2%) individuals had previously diagnosed AF. Among participants without previously known AF, 16 (5.5%) cases of AF were detected. The final AF prevalence in the target population was 12%. Oral anticoagulant therapy was successfully initiated in 88% of these patients with newly detected AF. CONCLUSIONS:The AF screening project exhibited a high participation rate and resulted in a high rate of newly discovered AF; of these newly diagnosed patients, 88% could be treated with an oral anticoagulant

Adherence to anticoagulant treatment with apixaban and rivaroxaban in a real-world setting

Aim: Low adherence to cardiovascular medications is often difficult to monitor and is associated with adverse outcomes. We investigated whether there is a difference between the estimated adherence (EA) of the two-dosed regimens of apixaban (A) and the one-dosed regimen of rivaroxaban (R) for stroke prophylaxis in patients with non-valvular atrial fibrillation (AF). Method and results: This is a retrospective cohort study of AF patients referred to a well-structured nurse-based AF unit for the initiation of anticoagulation therapy. The adherence data was extracted from the Swedish national prescribed drug register. EA was calculated by dividing the number of daily doses dispensed from the prescription that occurred closest after 3 months from the first dispensed prescription of the respective agent until (but excluding) the last refill by the number of days in the interval. The study included 123 patients on A and 227 patients on R with a 12-month follow-up period. There were no significant demographic differences between the two patient groups except for previous vitamin K antagonist treatment, in the A patient group (n = 29, 24%) and in the R (n = 31, 14%), p = 0.025. The mean ± SD of EA after 3 months was high for both A 97 ± 7 (n = 112) and R 97 ± 9 (n = 197) p = 0.97. The EA ≥80% was for A 97% (n = 109) and for R 96% (n = 189) p = 0.43. Conclusion: The two dosed regimens of apixaban and the one dosed regimen of rivaroxaban showed similar high estimated adherence when administered for stroke prophylaxis in patients with AF in a well-structured nurse-based AF clinic

Cost-effectiveness of screening for atrial fibrillation in a single primary care center at a 3-year follow-up

Objectives The aim of this study was to estimate the cost-effectiveness of intermittent electrocardiogram (ECG) screening for atrial fibrillation (AF) among 70-74-year old individuals in primary care. We also aimed to assess adherence to anticoagulants, severe bleeding, stroke and mortality among screening-detected AF cases at three-year follow-up. Methods A post hoc analysis based on a cross-sectional screening study for AF among 70-74-year old patients, who were registered at a single primary care center, was followed for three years for mortality. Data about adherence to anticoagulants, incidence of stroke and severe bleeding among screening-detected AF cases, were collected from patients records. Markov model and Monte Carlo simulation were used to assess the cost-effectiveness of the screening program. Results The mortality rate among screening-detected AF cases (n = 16) did not differ compared to the 274 individuals with no AF (hazard ratio 0.86, CI 0.12-6.44). Adherence to anticoagulants was 92%. There was no stroke or severe bleeding. The incremental cost-effectiveness ratio of screening versus no screening was EUR 2389/quality-adjusted life year (QALY) gained. The screening showed a 99% probability of being cost-effective compared to no screening at a willingness-to-pay threshold of EUR 20,000 per QALY. Conclusion Screening for AF among 70-74-year olds in primary care using intermittent ECG appears to be cost-effective at 3-year follow-up with high anticoagulants adherence and no increased mortality.Funding: M. R. has received research grants, lecture and consulting honoraria from the following sources. Abbott, Carl Bennett AB, Bristol Myers Squibb, Medtronic, MSD, Pfizer, Roche, Sanofi, and Zenicor. L. L. has received economic support for lecturing, advisory boards and research from AstraZeneca, Bayer, Boehringer Ingelheim and Pfizer. F. A. has received lecture fees from Bristol-Myers-Squibb, Pfizer, Boehringer-Ingelheim, and Bayer. M. A. employed by AstraZeneca. </p

Demographic characteristics and morbidity of participants compared with non-participants.

<p>Demographic characteristics and morbidity of participants compared with non-participants.</p

Characteristics of participants without AF, patients with newly diagnosed AF and patients with known AF.

<p>Characteristics of participants without AF, patients with newly diagnosed AF and patients with known AF.</p