Incidence of venous thromboembolism among patients who underwent major surgery in a public hospital in Singapore

<p><strong>Background:</strong> Venous thromboembolism (VTE) is a fatal yet potentially preventable complication of surgery. Routine thromboprophylaxis is still unequivocal prescription is problematic due to perception of low VTE incidence among Asian population. This study aims to investigate the incidence of VTE and thromboprophylaxis prescription among patients undergoing major surgery in a Singapore hospital.</p><p><strong>Methods:</strong> This was a cross-sectional study. Data were obtained from medical record of 1,103 patients who had underwent major orthopaedic or abdominal surgery in 2011-2012 at Khoo Teck Puat Hospital, Singapore. Incidence of VTE events either in the same admission or re-admission in less than one month time were noted as study parameters.</p><p><strong>Results:</strong> Incidence of VTE was 2.1% (95% CI: 1.67 - 2.53) of which 1.3% and 0.8% were DVT and PE cases respectively. Age, gender, history of VTE, ischemic heart disease, and mechanical prophylaxis were associated with VTE incidence based on bivariate analysis. The prescription of pharmacological thromboprophylaxis was associated with prior anticoagulant medication, type of surgery, and incidence of new bleeding. </p><p><strong>Conclusion:</strong> Subsequent to major surgeries, VTE is as common in Asian patients as published data in other populations. Pharmacologic thromboprophylaxis should be considered as recommended in non-Asian guidelines.</p><p><strong>Keywords:</strong> thromboprophylaxis, venous thromboembolism</p

Comparison of Long-Term Mortality of Patients Aged >= 40 Versus > 40 Years With Acute Myocardial Infarction

10.1016/j.amjcard.2016.05.002AMERICAN JOURNAL OF CARDIOLOGY1183319-32

Circadian Dependence of Infarct Size and Acute Heart Failure in ST Elevation Myocardial Infarction

<div><p>Objectives</p><p>There are conflicting data on the relationship between the time of symptom onset during the 24-hour cycle (circadian dependence) and infarct size in ST-elevation myocardial infarction (STEMI). Moreover, the impact of this circadian pattern of infarct size on clinical outcomes is unknown. We sought to study the circadian dependence of infarct size and its impact on clinical outcomes in STEMI.</p><p>Methods</p><p>We studied 6,710 consecutive patients hospitalized for STEMI from 2006 to 2009 in a tropical climate with non-varying day-night cycles. We categorized the time of symptom onset into four 6-hour intervals: midnight–6:00 A.M., 6:00 A.M.–noon, noon–6:00 P.M. and 6:00 P.M.–midnight. We used peak creatine kinase as a surrogate marker of infarct size.</p><p>Results</p><p>Midnight–6:00 A.M patients had the highest prevalence of diabetes mellitus (<i>P</i> = 0.03), more commonly presented with anterior MI (<i>P</i> = 0.03) and received percutaneous coronary intervention less frequently, as compared with other time intervals (<i>P</i> = 0.03). Adjusted mean peak creatine kinase was highest among midnight–6:00 A.M. patients and lowest among 6:00 A.M.–noon patients (2,590.8±2,839.1 IU/L and 2,336.3±2,386.6 IU/L, respectively, <i>P</i> = 0.04). Midnight–6:00 A.M patients were at greatest risk of acute heart failure (<i>P</i><0.001), 30-day mortality (<i>P</i> = 0.03) and 1-year mortality (<i>P</i> = 0.03), while the converse was observed in 6:00 A.M.–noon patients. After adjusting for diabetes, infarct location and performance of percutaneous coronary intervention, circadian variations in acute heart failure incidence remained strongly significant (<i>P</i> = 0.001).</p><p>Conclusion</p><p>We observed a circadian peak and nadir in infarct size during STEMI onset from midnight–6:00A.M and 6:00A.M.–noon respectively. The peak and nadir incidence of acute heart failure paralleled this circadian pattern. Differences in diabetes prevalence, infarct location and mechanical reperfusion may account partly for the observed circadian pattern of infarct size and acute heart failure.</p></div

Baseline characteristics of patients.

<p>a With Bonferroni correction.</p><p>Baseline characteristics of patients categorized according to time of symptom onset. Data expressed as mean ± SD for continuous variables, median (range) for skewed data and percentages for categorical variables. Chi-square test was performed for categorical variables, analysis of variance for parametric continuous variables, Wilcoxon Rank-Sum test for non-parametric continuous variables.</p><p>Baseline characteristics of patients.</p

Complications of AMI and clinical outcomes.

<p>a Left ventricular systolic dysfunction defined as LVEF < 50% on echocardiography</p><p>b Acute heart failure defined as Killip class ≥ II.</p><p>Short- and long-term clinical outcomes categorized according to time of symptom onset.</p><p>Complications of AMI and clinical outcomes.</p

STEMI Incidence as a function of time of symptom onset.

<p>Bar chart showing number of patients with symptom onset within each of the 4 pre specified time intervals. The peak incidence of symptom onset was observed in the 6:00-noon period (<i>P</i><0.001).</p

Long-term survival as a function of time of symptom onset.

<p>Survival curves out to 4.5 years of follow up shown above and Kaplan-Meier estimates of 12-month survival shown below.</p

Study Flow.

<p>Of 25,058 patients registered in the Singapore Myocardial Infarction Registry (SMIR), 6,710 who were diagnosed with STEMI and with known times of symptom onset were selected for analysis.</p