Periprocedural prognostic factors in coronary interventions – retrospective studies

Background: Approximately 11,000 revascularization procedures, either percutaneous coronary interventions (PCI) or coronary artery bypass grafting surgery (CABG), are performed yearly in Finland for coronary artery disease. Periprocedural risk factors for mortality and morbidity as well as long-term outcome have been extensively studied in general populations undergoing revascularization. Treatment choice between PCI and CABG in many high risk groups and risk-stratification, however, needs clarification and there is still room for improvement in periprocedural outcomes. Materials and methods: Cohorts of patients from Finnish hospitals revascularized between 2001 and 2011 were retrospectively analyzed. Patient records were reviewed for baseline variables and postprocedural outcomes (stroke, myocardial infarction, quality of life measured by the EQ-5D –questionnaire, repeat revascularization, bleeding episodes). Data on date and mode of death was acquired from Statistics Finland. Statistical analysis was performed to identify predictors of adverse events and compare procedures. Results: Postoperative administration of blood products (red blood cells, fresh frozen plasma, platelets) after isolated CABG independently and dose-dependently increases the risk of stroke. Patients 80 years or older who underwent CABG had better survival at 5 years compared to those who underwent PCI. After adjusting for baseline differences survival was similar. Patients on oral anticoagulation (OAC) for atrial fibrillation (AF) treated with CABG had better survival and overall outcome at 3 years compared to PCI patients. There was no difference in incidence of stroke or bleeding episodes. Differences in outcome remained significant after adjusting for propensity score. Lower health-related quality of life (HRQOL) scores as measured by the visual analogue scale (VAS) of the EQ-5D questionnaire at 6 months after CABG predicted later major adverse cardiac and cerebrovascular events (MACCE). Deteriorating function and VAS scores between 0 and 6 months on the EQ-5D also independently predicted later MACCE. Conclusions: Administration of blood products can increase the risk of stroke after CABG and liberal use of transfusions should be avoided. In the frail subpopulations of patients on OAC and octogenarians CABG appears to offer superior long-term outcome as compared to PCI. Deteriorating HRQOL scores predict later adverse events after CABG. Keywords: percutaneous coronary intervention, coronary artery bypass grafting, age over 80, transfusion, anticoagulants, coronary artery disease, health-related quality of life, outcome.Sepelvaltimotoimenpiteiden ennusteelliset tekijät – retrospektiivisiä tutkimuksia Tausta: Suomessa tehdään vuosittain yli 10 000 sepelvaltimoiden pallolaajennusta (PCI) ja ohitusleikkausta (CABG). Toimenpiteeseen liittyviä riskitekijöitä ja pitkäaikaisennustetta on tutkittu laajalti tavanomaisissa potilasaineistoissa. Toimenpidevalintaa ohjaavaa tietoa riskiryhmistä sekä riskinarviointikeinoja kuitenkin tarvitaan yhä ja välittömiä toimenpiteen jälkeisiä tuloksia voi edelleenkin parantaa. Aineisto ja menetelmät: Vuosien 2001 ja 2011 välillä suomalaisissa sairaaloissa sepelvaltimoihin kohdistuvin toimenpitein hoidettuja potilaskohortteja tutkittiin taannehtivasti. Potilasasiakirjoista etsittiin toimenpidettä edeltävät sairastavuustiedot, toimenpidejakson tiedot sekä toimenpiteen jälkeisen ajan tiedot (aivo- ja sydäninfarktit, uusintatoimenpiteet, verenvuodot ja EQ-5D –lomakkeella mitattu elämänlaatu). Kuolintiedot haettiin Tilastokeskuksen rekistereistä. Tilastomatemaattisin keinoin selvitettiin myöhäissairastavuutta ja -kuolleisuutta ennakoivat tekijät ja toimenpideryhmien väliset erot. Tulokset: Leikkauksen jälkeinen verituotteiden (punasolut, jääplasma, verihiutaleet) annostelu lisää annosriippuvaisesti ja itsenäisesti toimenpiteen jälkeisen aivoinfarktin riskiä. Yli 80-vuotiaat sepelvaltimotoimenpitein hoidetut potilaat ovat todennäköisemmin elossa ohitusleikkauksen kuin pallolaajennuksen jälkeen 5 vuoden seuranta-aikana. Lähtötilanteen muuttujien samankaltaistamisen jälkeen ei tullut esille eroa ryhmien välillä. Eteisvärinän vuoksi antikoaguloitujen potilaiden elossaolo ja haittatapahtuman todennäköisyys ovat paremmat ohitusleikkauksen jälkeen. Aivoinfarkteissa tai verenvuodoissa ei ollut eroa ryhmien välillä. Tulos säilyy propensity score -korjauksen jälkeen. Huonompi visual analogue scale (VAS) -arvo EQ-5D -lomakkeella mitattuna 6 kk CABG:n jälkeen ennakoi haittatapahtumia. Huononeva VAS ja toimintakyky EQ-5D -lomakkeella mitattuna ennakoivat myöhempiä haittatapahtumia. Johtopäätökset: Verituotteiden anto ohitusleikkauksen jälkeen lisää aivoinfarktin riskiä ja sitä tulisi pyrkiä välttämään. Tutkituissa suuren riskin potilasryhmissä (yli 80-vuotiaat ja eteisvärinän vuoksi antikoaguloidut) ennuste vaikutti paremmalta sepelvaltimoiden ohitusleikkauksen kuin pallolaajennuksen jälkeen. Huononeva elämänlaatu EQ-5D -mittarilla arvioituna ennustaa ohitusleikkauksen jälkeisiä haittatapahtumia.Siirretty Doriast

Sydänpussin dreneeraus ja näytteenotto

Teema: Sydänpussin sairaudet. English summar

Long-term outcomes of mechanical versus biological valve prosthesis in native mitral valve infective endocarditis

Objectives. To study the long-term outcomes of mitral valve replacement with mechanical or biological valve prostheses in native mitral valve infective endocarditis patients. Desing. We conducted a retrospective, nationwide, multicenter cohort study with patients aged = 0.13 for secondary outcomes). Conclusion. The use of mechanical mitral valve prosthesis is associated with lower long-term mortality compared to the biological prosthesis in non-elder native mitral valve infective endocarditis patients. The routine choice of biological mitral valve prostheses for this patient group is not supported by the results.Peer reviewe

Long-Term Outcomes of Surgical Aortic Valve Replacement in Patients with Rheumatoid Arthritis

Background: Patients with rheumatoid arthritis (RA) have increased risk of developing cardiovascular disease and events. Little is, however, known about the influence of RA to the outcomes after surgical aortic valve replacement (SAVR). Methods: In a retrospective, nationwide, multicenter cohort study, RA patients (n = 109) were compared to patients without RA (n = 1090) treated with isolated SAVR for aortic valve stenosis. Propensity score-matching adjustment for baseline features was used to study the outcome differences in a median follow-up of 5.6 years. Results: Patients with RA had higher all-cause mortality (HR 1.76; CI 1.21-2.57; p = 0.003), higher incidence of major adverse cardiovascular events (HR 1.63; CI 1.06-2.49; p = 0.025), and they needed more often coronary artery revascularization for coronary artery disease (HR 3.96; CI 1.21-12.90; p = 0.027) in long-term follow-up after SAVR. As well, cardiovascular mortality rate was higher in patients with RA (35.7% vs. 23.4%, p = 0.023). There was no difference in 30-day mortality (2.8% vs. 1.8%, p = 0.518) or in the need for aortic valve reoperations (3.7% vs. 4.0%, p = 0.532). Conclusions: Patients with rheumatoid arthritis had impaired long-term results and increased cardiovascular mortality after SAVR for aortic valve stenosis. Special attention is needed to improve outcomes of aortic valve stenosis patients with RA after SAVR.Peer reviewe

Impaired long-term outcomes of patients with schizophrenia spectrum disorder after coronary artery bypass surgery : nationwide case-control study

Background Patients with schizophrenia spectrum disorder have increased risk of coronary artery disease. Aims To investigate long-term outcomes of patients with schizophrenia spectrum disorder and coronary artery disease after coronary artery bypass grafting surgery (CABG). Method Data from patients with schizophrenia spectrum disorder (n = 126) were retrospectively compared with propensity-matched (1:20) control patients without schizophrenia spectrum disorder (n = 2520) in a multicentre study in Finland. All patients were treated with CABG. The median follow-up was 7.1 years. The primary outcome was all-cause mortality. Results Patients with diagnosed schizophrenia spectrum disorder had an elevated risk of 10-year mortality after CABG, compared with control patients (42.7 v. 30.3%; hazard ratio 1.56; 95% CI 1.13-2.17; P = 0.008). Schizophrenia spectrum diagnosis was associated with a higher risk of major adverse cardiovascular events during follow-up (49.9 v. 32.6%, subdistribution hazard ratio 1.59; 95% CI 1.18-2.15; P = 0.003). Myocardial infarction (subdistribution hazard ratio 1.86; P = 0.003) and cardiovascular mortality (subdistribution hazard ratio 1.65; P = 0.017) were more frequent in patients with versus those without schizophrenia spectrum disorder, but there was no difference for stroke. Psychiatric ward admission, antipsychotic medication, antidepressant use and benzodiazepine use before CABG were not associated with outcome differences. After CABG, patients with schizophrenia spectrum disorder received statin therapy less often and had lower doses; the use of other cardiovascular medications was similar between schizophrenia spectrum and control groups. Conclusions Patients with schizophrenia spectrum disorder have higher long-term risks of death and major adverse cardiovascular events after CABG. The results underline the vulnerability of these patients and highlight the importance of intensive secondary prevention and risk factor optimisation.Peer reviewe

Long-term outcomes after coronary artery bypass surgery in patients with rheumatoid arthritis

Objective To investigate the long-term outcomes of coronary artery bypass grafting surgery (CABG) in patients with rheumatoid arthritis (RA). Methods Patients with RA (n = 378) were retrospectively compared to patients without RA (n = 7560), all treated with CABG in a multicentre, population-based cohort register study in Finland. The outcomes were studied with propensity score-matching adjustment for baseline features. The median follow-up was 9.7 years. Results Diagnosis of RA was associated with an increased risk of mortality after CABG compared to patients without RA (HR 1.50; CI 1.28-1.77; p < .0001). In addition, patients with RA were in higher risk of myocardial infarction during the follow-up period (HR 1.61; CI 1.28-2.04; p < .0001). Cumulative rate of repeated revascularization after CABG was 14.4% in RA patients and 12.0% in control patients (p = .060). Duration of RA before CABG (p = .011) and preoperative corticosteroid usage in RA (p = .041) were independently associated with higher mortality after CABG. There were no differences between the study groups in 30-d mortality or in the post-operative usage of cardiovascular medications. Conclusions RA is independently associated with worse prognosis in coronary artery disease treated with CABG. Preoperative corticosteroid use and longer RA disease duration are additional risk factors for mortality. Key messages Patients with rheumatoid arthritis (RA) have impaired long-term outcomes after coronary artery bypass surgery (CABG). Glucocorticoid use before CABG and duration of RA are associated with higher mortality. Special attention should be paid in secondary prevention of cardiovascular disease in RA patients after CABG.Peer reviewe

Acute kidney injury following hip fracture

BACKGROUND: Hip fracture causes disability and excess mortality in the aging population. Acute kidney injury (AKI), is known to diminish survival of critically ill and trauma patients. AKI is also a common perioperative complication among surgical patients. We examined the effect of AKI on the survival of hip fracture patients in a Finnish hip fracture population and the risk factors for AKI in a prospective study.METHODS: The study cohort constituted of 486 consecutive low-energy trauma hip fracture patients referred to Satakunta Central Hospital (Pori, Finland) and Turku University Hospital (Turku, Finland). The patients underwent standard diagnostics and treatment in the emergency department (ER) and were operated according to the local treatment protocol. Serum creatinine (sCr) was analyzed daily pre- and post-operatively during the hospital stay. Patients were divided into groups; AKI and non-AKI based on Kidney Disease: Improving Global Outcomes (KDIGO) criteria.RESULTS: The incidence of AKI in the study cohort was 8.4% (40/475). Eleven patients were excluded due to missing sCr data. The baseline characteristics of AKI and non-AKI groups differed significantly concerning baseline sCr but were otherwise similar. At 90-day follow-up, the overall mortality was 14.4%. Patients with AKI had a significantly higher mortality (35.0%) than those with no AKI (12.7%) (p < 0.001). Dementia, preoperative sCr and any stage of AKI were independent predictors for mortality. Dementia and preoperative sCr were independently associated with post-operative AKI.CONCLUSION: In this study AKI was a significant factor associated with a 3 -fold mortality during the first three months after surgery for low-energy trauma hip fracture.</p

Outcome of acute myocardial infarction versus stable coronary artery disease patients treated with coronary bypass surgery

ObjectiveTo study the long-term outcome differences between acute myocardial infarction (MI) and stable coronary artery disease (CAD) patients treated with coronary artery bypass grafting (CABG). MethodsWe studied retrospectively patients with MI (n = 1882) or stable CAD (n = 13117) treated with isolated CABG between 2004 and 2014. Inverse propensity probability weight adjustment for baseline features was used. Median follow-up was 7.9 years. Results In-hospital mortality (8.6% vs. 1.6%; OR 5.94;p Conclusion MI patients have poorer short- and long-term outcomes compared to stable CAD patients after CABG and risk difference continues to increase with time.Key Messages Patients with myocardial infarction have poorer short- and long-term outcomes compared to stable coronary artery disease patients after coronary artery bypass grafting (CABG). Higher risk of death continues also in stabilized first-year myocardial infarct survivors. The importance of efficient secondary prevention and follow-up highlights in post-myocardial infarct population after CABG.</p

Long-term outcomes of mechanical versus biological valve prosthesis in native mitral valve infective endocarditis

Objectives. To study the long-term outcomes of mitral valve replacement with mechanical or biological valve prostheses in native mitral valve infective endocarditis patients. Desing. We conducted a retrospective, nationwide, multicenter cohort study with patients aged ≤70 years who were treated with mitral valve replacement for native mitral valve infective endocarditis in Finland between 2004 and 2017. Results. The endpoints were all-cause mortality, ischemic stroke, major bleeding, and mitral valve reoperations. The results were adjusted for baseline features (age, gender, comorbidities, history of drug abuse, concomitant surgeries, operational urgency, and surgical center). The median follow-up time was 6.1 years. The 12-year cumulative mortality rates were 36% for mechanical prostheses and 74% for biological prostheses (adj. HR 0.40; CI: 0.17-0.91; p = 0.03). At follow-up, the ischemic stroke had occurred in 19% of patients with mechanical prosthesis and 33% of those with a biological prosthesis (adj. p = 0.52). The major bleeding rates within the 12-year follow-up period were 30% for mechanical prosthesis and 13% for a biological prosthesis (adj. p = 0.29). The mitral valve reoperation rates were 13% for mechanical prosthesis and 12% for a biological prosthesis (adj. p = 0.50). Drug abuse history did not have a significant modifying impact on the results (interaction p = 0.51 for mortality and ≥0.13 for secondary outcomes). Conclusion. The use of mechanical mitral valve prosthesis is associated with lower long-term mortality compared to the biological prosthesis in non-elder native mitral valve infective endocarditis patients. The routine choice of biological mitral valve prostheses for this patient group is not supported by the results.</p

Aortic calcification index predicts mortality and cardiovascular events in operatively treated patients with peripheral artery disease: A prospective PURE ASO cohort follow-up study

Objective: The present study evaluates the association of aortic calcification with mortality and major adverse cardiovascular and leg events (MACEs and MALEs) in patients with peripheral artery disease (PAD). The risk for mortality and MACEs and MALEs is considered in clinical decision-making.Methods: This cohort found in 2012-2013 consists of 226 patients with symptomatic PAD referred to Turku University Hospital for invasive treatment. Follow-up data about mortality and survival without MACEs and MALEs were collected up to 5 years from the inclusion date, and aortic calcification index (ACI) was measured from patients with available imaging studies (164 of 226). ACIs' association with events and mortality was evaluated in Cox regression, Kaplan-Meier, and classification and regression tree analysis.Results: All-cause mortality at 1, 3, and 5 years was 13.7% (31), 26.1% (59), and 46.9% (106), respectively. In multivariable Cox regression analysis, ACI and ACI > 43 were independent risk factors for all-cause mortality (hazard ratio [HR]: 1.13 per 10 units, 95% confidence interval [CI]: 1.00-1.22 and HR: 1.83, 95% CI: 1.01-3.32, respectively) and for MACEs (HR: 1.10 per 10 units, 95% CI: 1.00-1.22 and HR: 3.14, 95% CI: 1.67-5.91, respectively), but not for MALEs. Classification and regression tree analysis showed that ACI = 43 best divides cohort in relation to mortality. Kaplan-Meier analyses showed that ACI > 43 is associated with greater mortality and occurrence of MACEs compared with those who have ACI ≤ 43 (log-rank P value .005 and .0012, respectively).Conclusions: Risk for mortality and MACEs is associated with high ACI. ACI can expose the risk in patients with PAD for further cardiovascular events and mortality.</p