Association of lithium use with rate of out-of-hospital cardiac arrest in patients with bipolar disorder

Background: Lithium has been linked with induction of proarrythmic electrocardiographical changes. However, it is unclear whether lithium use is associated with an increased rate of cardiac arrest. We investigated the rate of out-of-hospital cardiac arrest associated with lithium exposure in a nationwide cohort of patients with bipolar disorder. Methods: Data from Danish registries was used to conduct a nationwide nested case-control study assessing the rate of out-of-hospital cardiac arrest associated with lithium exposure among 47,745 bipolar disorder patients from 2001 through 2015. 284 cases with out-of-hospital cardiac arrest were matched on age, sex, and age at first diagnosis of bipolar disorder with 1,386 controls. Rate analyses were performed using Cox regression. Results: Fewer cases than controls were exposed to lithium (24.3% vs. 34.9%, p&lt;.001). In adjusted analyses, lithium monotherapy was not significantly associated with increased rate of out-of-hospital cardiac arrest compared with no mood stabilizing treatment (Hazard ratio [HR] = 0.71 [95% CI, 0.46–1.10]), atypical antipsychotic monotherapy (HR = 0.69 [95% CI, 0.41–1.15]), and anticonvulsant monotherapy (HR = 1.37 [95% confidence interval [CI], 0.65–2.88]). Combination therapy with lithium plus one or more other mood stabilizers was not associated with increased rate of out-of-hospital cardiac arrest compared with combination therapy with two or more non-lithium mood stabilizers (HR = 0.58, [95% CI, 0.31–1.08]). Limitations: Possible residual confounding due to unmeasured variables. Lack of statistical power to detect weak associations. Conclusions: Lithium was not associated with increased rate of out-of-hospital cardiac arrest in bipolar disorder patients compared with other guideline-recommended mood stabilizing pharmacotherapy, nor compared with no mood stabilizer treatment.</p

Out-of-Hospital Cardiac Arrest in Patients With and Without Psychiatric Disorders:Differences in Use of Coronary Angiography, Coronary Revascularization, and Implantable Cardioverter-Defibrillator and Survival

Background Healthcare disparities for psychiatric patients are common. Whether these inequalities apply to postresuscitation management in out‐of‐hospital cardiac arrest (OHCA) is unknown. We investigated differences in in‐hospital cardiovascular procedures following OHCA between patients with and without psychiatric disorders. Methods and Results Using the Danish nationwide registries, we identified patients admitted to the hospital following OHCA of presumed cardiac cause (2001‐2015). Psychiatric disorders were identified using hospital diagnoses or redeemed prescriptions for psychotropic drugs. We calculated age‐ and sex‐standardized incidence rates and incidence rate ratios (IRRs) of cardiovascular procedures during post‐OHCA admission in patients with and without psychiatric disorders. Differences in 30‐day and 1‐year survival were assessed by multivariable logistic regression in the overall population and among 2‐day survivors who received acute coronary angiography (CAG). We included 7288 hospitalized patients who had experienced an OHCA: 1661 (22.8%) had a psychiatric disorder. Compared with patients without psychiatric disorders, patients with psychiatric disorders had lower standardized incidence rates for acute CAG (≤1 day post‐OHCA) (IRR, 0.51; 95% CI, 0.45–0.57), subacute CAG (2–30 days post‐OHCA) (IRR, 0.40; 95% CI, 0.30–0.52), and implantable cardioverter‐defibrillator implantation (IRR, 0.67; 95% CI, 0.48–0.95). Conversely, we did not detect differences in coronary revascularization among patients undergoing CAG (IRR, 1.11; 95% CI, 0.94–1.30). Patients with psychiatric disorders had lower survival even among 2‐day survivors who received acute CAG: (odds ratio of 30‐day survival, 0.68; 95% CI, 0.52–0.91; and 1‐year survival, 0.66; 95% CI, 0.50–0.88). Conclusions Psychiatric patients had a lower probability of receiving post‐OHCA CAG and implantable cardioverter‐defibrillator implantation compared with nonpsychiatric patients but the same probability of coronary revascularization among patients undergoing CAG. However, their survival was lower irrespective of angiographic procedures

A risk score for predicting 30-day mortality in heart failure patients undergoing non-cardiac surgery

BackgroundHeart failure is an established risk factor for poor outcomes in patients undergoing non-cardiac surgery, yet risk stratification remains a clinical challenge. We developed an index for 30-day mortality risk prediction in this particular group. Methods and resultsAll individuals with heart failure undergoing non-cardiac surgery between October 23 2004 and October 31 2011 were included from Danish administrative registers (n=16827). In total, 1787 (10.6%) died within 30days. In a simple risk score based on the variables from the revised cardiac risk index, plus age, gender, acute surgery, and body mass index category the following variables predicted mortality (points): male gender (1), age 56-65years (2), age 66-75years (4), age 76-85years (5), or age >85years (7), being underweight (4), normal weight (3), or overweight (1), undergoing acute surgery (5), undergoing high-risk procedures (intra-thoracic, intra-abdominal, or suprainguinal aortic) (3), having renal disease (1), cerebrovascular disease (1), and use of insulin (1). The c-statistic was 0.79 and calibration was good. Mortality risk ranged from 50% for a score 20. Internal validation by bootstrapping (1000 re-samples) provided c-statistic of 0.79. A more complex risk score based on stepwise logistic regression including 24 variables at P<0.05 performed only slightly better, c-statistic=0.81, but was limited in use by its complexity. ConclusionsFor patients with heart failure, this simple index can accurately identify those at low risk for perioperative mortality

Survival After Out-of-Hospital Cardiac Arrest in Relation to Age and Early Identification of Patients With Minimal Chance of Long-Term Survival

Background— Survival after out-of-hospital cardiac arrest has increased during the last decade in Denmark. We aimed to study the impact of age on changes in survival and whether it was possible to identify patients with minimal chance of 30-day survival. Methods and Results— Using data from the nationwide Danish Cardiac Arrest Registry (2001─2011), we identified 21 480 patients ≥18 years old with a presumed cardiac-caused out-of-hospital cardiac arrest for which resuscitation was attempted. Patients were divided into 3 preselected age-groups: working-age patients 18 to 65 years of age (33.7%), early senior patients 66 to 80 years of age (41.5%), and late senior patients &gt;80 years of age (24.8%). Characteristics in working-age patients, early senior patients, and late senior patients were as follows: witnessed arrest in 53.8%, 51.1%, and 52.1%; bystander cardiopulmonary resuscitation in 44.7%, 30.3%, and 23.4%; and prehospital shock from a defibrillator in 54.7%, 45.0%, and 33.8% (all P &lt;0.05). Between 2001 and 2011, return of spontaneous circulation on hospital arrival increased: working-age patients, from 12.1% to 34.6%; early senior patients, from 6.4% to 21.5%; and late senior patients, from 4.0% to 15.0% (all P &lt;0.001). Furthermore, 30-day survival increased: working-age patients, 5.8% to 22.0% ( P &lt;0.001); and early senior patients, 2.7% to 8.4% ( P &lt;0.001), whereas late senior patients experienced only a minor increase (1.5% to 2.0%; P =0.01). Overall, 3 of 9499 patients achieved 30-day survival if they met 2 criteria: had not achieved return of spontaneous circulation on hospital arrival and had not received a prehospital shock from a defibrillator. Conclusions— All age groups experienced a large temporal increase in survival on hospital arrival, but the increase in 30-day survival was most prominent in the young. With the use of only 2 criteria, it was possible to identify patients with a minimal chance of 30-day survival. </jats:sec