Clinical characteristics of women captured by extending the definition of severe postpartum haemorrhage with 'refractoriness to treatment': a cohort study

Background: The absence of a uniform and clinically relevant definition of severe postpartum haemorrhage hampers comparative studies and optimization of clinical management. The concept of persistent postpartum haemorrhage, based on refractoriness to initial first-line treatment, was proposed as an alternative to common definitions that are either based on estimations of blood loss or transfused units of packed red blood cells (RBC). We compared characteristics and outcomes of women with severe postpartum haemorrhage captured by these three types of definitions. Methods: In this large retrospective cohort study in 61 hospitals in the Netherlands we included 1391 consecutive women with postpartum haemorrhage who received either ≥4 units of RBC or a multicomponent transfusion. Clinical characteristics and outcomes of women with severe postpartum haemorrhage defined as persistent postpartum haemorrhage were compared to definitions based on estimated blood loss or transfused units of RBC within 24 h following birth. Adverse maternal outcome was a composite of maternal mortality, hysterectomy, arterial embolisation and intensive care unit admission. Results: One thousand two hundred sixty out of 1391 women (90.6%) with postpartum haemorrhage fulfilled the definition of persistent postpartum haemorrhage. The majority, 820/1260 (65.1%), fulfilled this definition within 1 h following birth, compared to 819/1391 (58.7%) applying the definition of ≥1 L blood loss and 37/845 (4.4%) applying the definition of ≥4 units of RBC. The definition persistent postpartum haemorrhage captured 430/471 adverse maternal outcomes (91.3%), compared to 471/471 (100%) for ≥1 L blood loss and 383/471 (81.3%) for ≥4 units of RBC. Persistent postpartum haemorrhage did not capture all adverse outcomes because of missing data on timing of initial, first-line treatment. Conclusion: The definition persistent postpartum haemo

Effect of Long Term and Intensive Endurance Training in Athletes on the Age Related Decline in Left and Right Ventricular Diastolic Function as Assessed by Doppler Echocardiography

The aim of this study was to evaluate (1) the effect of endurance training on left ventricular and right ventricular diastolic function and (2) whether the normal aging effect on left ventricular and right ventricular diastolic function is slowed by endurance training. A total of 269 healthy subjects were prospectively enrolled for echocardiographic evaluation. Five groups were defined on the basis of age and athletic activities: (1) young (18 to 39 years) nonathletes (n = 62), (2) veteran (≥40 years) nonathletes (n = 33), (3) young regular athletes (9 to 18 hours of sports/week; n = 58), (4) young elite athletes (>18 hours of sports/week; n = 63), and (5) veteran athletes (≥40 years and ≥9 hours of sports/week; n = 53). Pulsed-wave Doppler indexes for diastolic function in the left and right ventricles were obtained at rest. No significant differences were found among the young controls, regular athletes, and elite athletes in left ventricular and right ventricular pulsed-wave and tissue Doppler diastolic parameters. These were also comparable between the veteran athletes and controls. In athletes and controls, similar and significant correlations were found between age and diastolic parameters. Age was the most important determinant in almost all parameters in multivariate analysis, while the influence of the amount of training did not account for >2% of the observed variance in any of these parameters. In conclusion, the amount of endurance training did not alter diastolic parameters in either ventricle in the young. Furthermore, the biventricular decreases in diastolic function observed in healthy, nonathletic subjects with age was also observed in aging athletes' hearts

A Change of Heart : Yield of Cardiac Imaging in Acute Stroke Workup

This case report describes a patient who experienced a recurrent ischemic stroke within 24 h. Dual-energy computed tomography (DECT) angiography on admission showed 2 intracardiac thrombi, 1 in the left ventricle and 1 in the left atrial appendage. Following the second ischemic event, repeated DECT angiography showed that the ventricular thrombus had considerably diminished, suggesting that the recurrent brain infarction was caused by cardioembolism. This case emphasizes (1) the potential benefit of cardiac evaluation through CT angiography in the acute stroke setting, and (2) the use of DECT angiography for the detection of thrombus and the differentiation between thrombus, the myocardial wall, and a slow flow of contrast

Normal-range thyroid-stimulating hormone levels and cardiovascular events and mortality in type 2 diabetes

Aims: Thyroid dysfunction is a risk factor for cardiovascular disease. Whether thyroid function within the normal range is a risk factor for cardiovascular disease remains uncertain. The aim of this study is to evaluate whether plasma thyroid-stimulating hormone (TSH) levels in the normal range are a risk factor for cardiovascular disease and mortality in participants with type 2 diabetes mellitus with high cardiovascular risk. Methods: We included 1265 participants with high cardiovascular risk, type 2 diabetes, and TSH within the normal range (0.35–5.00 mIU/L) from the Second Manifestations of ARTerial disease cohort. The primary outcome was major cardiovascular events (MACE; vascular death, stroke and myocardial infarction). Secondary outcomes of interest were the separate vascular outcomes and all-cause mortality. Cox proportional hazard models were used to evaluate the risk of plasma TSH levels on all outcomes. Results: A total of 191 MACE occurred during a total follow-up of 8183 years. Plasma TSH levels were not associated with MACE (hazard ratio (HR) per mIU/L TSH increase 0.93; 95% confidence interval (95%CI) 0.80–1.08). With a total of 54 strokes during the study period, plasma TSH was associated with a lower risk of stroke (HR per mIU/L 0.64, 95% CI 0.45–0.89). There was no association between plasma TSH levels and risk of myocardial infarction, vascular death, or all-cause mortality. Conclusions: Higher TSH levels within the normal range are associated with a lower risk of stroke in high-risk patients with type 2 diabetes, but not associated with the risk of other cardiovascular events or mortality

Normal-range thyroid-stimulating hormone levels and cardiovascular events and mortality in type 2 diabetes

Aims: Thyroid dysfunction is a risk factor for cardiovascular disease. Whether thyroid function within the normal range is a risk factor for cardiovascular disease remains uncertain. The aim of this study is to evaluate whether plasma thyroid-stimulating hormone (TSH) levels in the normal range are a risk factor for cardiovascular disease and mortality in participants with type 2 diabetes mellitus with high cardiovascular risk. Methods: We included 1265 participants with high cardiovascular risk, type 2 diabetes, and TSH within the normal range (0.35–5.00 mIU/L) from the Second Manifestations of ARTerial disease cohort. The primary outcome was major cardiovascular events (MACE; vascular death, stroke and myocardial infarction). Secondary outcomes of interest were the separate vascular outcomes and all-cause mortality. Cox proportional hazard models were used to evaluate the risk of plasma TSH levels on all outcomes. Results: A total of 191 MACE occurred during a total follow-up of 8183 years. Plasma TSH levels were not associated with MACE (hazard ratio (HR) per mIU/L TSH increase 0.93; 95% confidence interval (95%CI) 0.80–1.08). With a total of 54 strokes during the study period, plasma TSH was associated with a lower risk of stroke (HR per mIU/L 0.64, 95% CI 0.45–0.89). There was no association between plasma TSH levels and risk of myocardial infarction, vascular death, or all-cause mortality. Conclusions: Higher TSH levels within the normal range are associated with a lower risk of stroke in high-risk patients with type 2 diabetes, but not associated with the risk of other cardiovascular events or mortality

Estimated life expectancy without recurrent cardiovascular events in patients with vascular disease : The SMART-REACH model

Background-In patients with vascular disease, risk models may support decision making on novel risk reducing interventions, such as proprotein convertase subtilisin/kexin type 9 inhibitors or anti-inflammatory agents. We developed and validated an innovative model to estimate life expectancy without recurrent cardiovascular events for individuals with coronary, cerebrovascular, and/or peripheral artery disease that enables estimation of preventive treatment effect in lifetime gained. Methods and Results-Study participants originated from prospective cohort studies: the SMART (Secondary Manifestations of Arterial Disease) cohort and REACH (Reduction of Atherothrombosis for Continued Health) cohorts of 14 259 (REACH Western Europe), 19 170 (REACH North America) and 6959 (SMART, The Netherlands) patients with cardiovascular disease. The SMARTREACH model to estimate life expectancy without recurrent events was developed in REACH Western Europe as a Fine and Gray competing risk model incorporating cardiovascular risk factors. Validation was performed in REACH North America and SMART. Outcomes were (1) cardiovascular events (myocardial infarction, stroke, cardiovascular death) and (2) noncardiovascular death. Predictors were sex, smoking, diabetes mellitus, systolic blood pressure, total cholesterol, creatinine, number of cardiovascular disease locations, atrial fibrillation, and heart failure. Calibration plots showed high agreement between estimated and observed prognosis in SMART and REACH North America. C-statistics were 0.68 (95% confidence interval, 0.67-0.70) in SMART and 0.67 (95% confidence interval, 0.66-0.68) in REACH North America. Performance of the SMART-REACH model was better compared with existing risk scores and adds the possibility of estimating lifetime gained by novel therapies. Conclusions-The externally validated SMART-REACH model could be used for estimation of anticipated improvements in life expectancy without recurrent cardiovascular events in individual patients with cardiovascular disease in Western Europe and North America