Return to the workforce following first hospitalization for heart failure: a Danish nationwide cohort study

Background: Return to work is important financially, as a marker of functional status and for self-esteem in patients developing chronic illness. We examined return to work after first heart failure (HF) hospitalization. Methods: By individual-level linkage of nationwide Danish registries, we identified 21455 patients of working age (18-60 years) with a first HF hospitalization in the period of 1997-2012. Of these 11880 (55%) were in the workforce prior to HF hospitalization and comprised the study population. We applied logistic regression to estimate odds ratios (OR) for associations between age, sex, length of hospital stay, level of education, income, comorbidity and return to work. Results: One year after first HF hospitalization, 8040 (67.7%) returned to the workforce, 2981 (25.1%) did not, 805 (6.7%) died and 54 (0.5%) emigrated. Predictors of return to work included younger age (18-30 vs. 51-60 years, OR 3.12; 95% CI 2.42-4.03), male sex (OR 1.22 [1.18-1.34]) and level of education (long-higher vs. basic school OR 2.06 [1.63-2.60]). Conversely, hospital stay >7 days (OR 0.56 [0.51-0.62]) and comorbidity including history of stroke (OR 0.55 [0.45-0.69]), chronic kidney disease (OR 0.46 [0.36-0.59]), chronic obstructive pulmonary disease (OR 0.62 [0.52-0.75]), diabetes (OR 0.76 [0.68-0.85]) and cancer (OR 0.49 [0.40-0.61]) were all significantly associated with lower chance of return to work. Conclusions: Patients in the workforce prior to HF hospitalization had low mortality but high risk of detachment from the workforce one year later. Young age, male sex, and higher level of education were predictors of return to work

Long-Term Prognostic Importance of Diabetes After a Myocardial Infarction Depends on Left Ventricular Systolic Function

Objective: This study was performed to understand how left ventricular function modulates the prognostic importance of diabetes after myocardial infarction (MI). Research Design and Methods: Consecutively hospitalized MI patients screened for three clinical trials were followed for a median of 7 years. Multivariable Cox regression models were used to assess the risk of mortality associated with diabetes, and the importance of diabetes was examined independently within defined left ventricular ejection fraction (LVEF) subgroups. Results: A total of 16,912 patients were included; 1,819 (11%) had diabetes. Diabetes and 15% unit depression in LVEF were of similar prognostic importance: hazard ratios (HRs) were 1.45 (95% CI 1.37–1.54) and 1.41 (1.37–1.45) for diabetes and LVEF depression, respectively. LVEF modified the outcomes associated with diabetes, with HRs being 1.29 (1.19–1.40) and 1.61 (1.49–1.74) in patients with LVEF <40% and LVEF ≥40%, respectively (P = 0.03). Conclusions: Patients within the higher LVEF categories have a greater mortality risk attributable to diabetes than patients within the lower LVEF categories

Perhevapaat 2013 -väestökyselyn toteutus : Tiedonkeruu, aineiston edustavuus ja perustietoja vastaajista

Perhevapaat 2013 -väestökysely on Kelan tutkimusosaston ja Terveyden ja hyvinvoinnin laitoksen (THL) Politiikan seuranta- ja vaikuttavuusyksikön yhteydessä toteuttama laaja väestökysely. Kyselyn kohderyhmänä olivat vuonna 2011 lapsen saaneet äidit ja isät. Kysely oli kolmas osa vastaavien kyselyiden sarjaa, joista aiemmat on toteutettu vuosina 2001 ja 2006. Tämänkertainen kysely toteutettiin ensimmäistä kertaa täysin sähköisesti kun taas aiemmat ovat olleet perinteisiä paperikyselyitä. Kyselyn perusjoukon muodostivat vuonna 2011 lapsen saaneet äidit ja isät, jotka olivat käyttäneet vanhempainpäivärahoja eli äitiys-, isyys- tai vanhempainrahaa kyseisestä lapsesta, joille löytyi Kelaan ilmoitettu sähköpostiosoite ja jotka asuivat kyselyhetkellä Suomessa. Sähköpostiosoite löytyi kaikkiaan 75,7 prosentille etuuksia käyttäneistä äideistä ja 68,3 prosentille etuuksia käyttäneistä isistä. Otannan yhteydessä äidit jaettiin kolmeen ryhmään, perusotoksen äiteihin, monikkoäiteihin ja 18–22-vuotiaisiin nuoriin äiteihin. Perusotoksen äidit muodostavat aineiston perustan ja tästä ryhmästä tehtyyn otokseen kuului kaikkiaan 6 914 äitiä. Perusotoksen äitien lisäksi erillisaineistoja varten kyselyyn otettiin mukaan kaikki monikkoäidit ja nuorten äitien ryhmää kasvatettiin täydennysotoksilla. Kyselyyn tuli mukaan kaikkiaan 8 297 äitiä. Isien puolella isäotoksen koko oli 6 781 isää. Otos toteutettiin jakamalla isät ensin kahteen ryhmään käytettyjen perhevapaapäivien mukaan ja ottamalla näistä ositteista omat otoksensa. Äitien perusotoksessa kyselyn vastausaste oli 44,1, monikkoäideillä 38,4 ja nuorilla äideillä 34,6 prosenttia. Isien vastausaste oli 32,3 prosenttia. Äitiaineistojen edustavuus on hyvä ja sitä tullaan käyttämään varsinaisissa analyyseissä sellaisenaan, kun taas isäkyselyssä enemmän vanhempainpäivärahoja käyttäneet isät olivat aktiivisempia vastaamaan kuin vähän vanhempainpäivärahoja käyttäneet. Isäaineistossa ryhmien suhteelliset osuudet painotettiin vastaamaan perusjoukkoa. Kyselyllä saadaan paljon tietoa suomalaisista pienten lasten perheistä. Voimme kuvailla perheitä, saada tietoa syistä, miksi perheet tekivät erilaisia lapsenhoitovalintoja ja saada tietoa perheiden mielipiteistä liittyen perhevapaajärjestelmään. Esimerkiksi perusäitien kyselyssä ja isäkyselyssä saadut vastaukset olivat hyvin samankaltaisia, kun tarkasteltiin vastaajien käsitystä perheen toimeentulosta, omista tai puolison tuloista sekä perhevapaiden käytöstä. Runsaat 40 prosenttia sekä äideistä että isistä oli puolestaan sitä mieltä, että tuolloinen mahdollisuus myöhentää isäkuukautta vaikutti ainakin jonkin verran siihen, että isät käyttivät oikeuttaan. Sen sijaan isät olivat äitejä hieman useammin valmiita kehittämään perhevapaajärjestelmää. Mielipiteet, jotka koskivat päivähoito-oikeuksien rajaamista, jakautuivat työttömyystaustan mukaan. Vastaajat, joiden perheessä oli työttömyyttä, suhtautuivat muita kielteisemmin päivähoito-oikeuksien rajoittamiseen. Mielipiteisiin eri aiheista vaikuttaa niin vastaajien ja heidän perheidensä tilanne kuin heidän kokemuksensa näistä järjestelmistä. Lapsiperheet ovat erilaisia ja niiden joukossa on useita erilaisia ryhmiä. Kyselyaineistoja analysoitaessa on tärkeää huomioida nämä tekijät.2., korjattu painos (16.3.2017

Impact of proton pump inhibitor treatment on gastrointestinal bleeding associated with non-steroidal anti-inflammatory drug use among post-myocardial infarction patients taking antithrombotics: nationwide study

Study question What is the effect of proton pump inhibitors (PPIs) on the risk of gastrointestinal bleeding in post-myocardial infarction patients taking antithrombotics and treated with non-steroidal anti-inflammatory drugs (NSAIDs)? Methods This was a nationwide cohort study based on linked administrative registry data from all hospitals in Denmark between 1997 and 2011. The study included patients aged 30 years and over admitted with a first myocardial infarction who survived at least 30 days after discharge. The association between PPIs and risk of gastrointestinal bleeding according to NSAID plus antithrombotic therapy was estimated using adjusted time dependent Cox regression models. Study answer and limitations The use of PPIs was independently associated with decreased risk of gastrointestinal bleeding in post-myocardial infarction patients taking antithrombotics and treated with NSAIDs. Of 82 955 post-myocardial infarction patients (mean age 67.4 years, 64% (n=53 070) men), all of whom were taking single or dual antithrombotic therapy, 42.5% (n=35 233) filled at least one prescription for NSAIDs and 45.5% (n=37 771) received PPIs. Over a mean follow-up of 5.1 years, 3229 gastrointestinal bleeds occurred. The crude incidence rates of bleeding (events/100 person years) on NSAID plus antithrombotic therapy were 1.8 for patients taking PPIs and 2.1 for those not taking PPIs. The adjusted risk of bleeding was lower with PPI use (hazard ratio 0.72, 95% confidence interval 0.54 to 0.95) regardless of antithrombotic treatment regimen, type of NSAID, and type of PPI used. The main limitation of the study is its observational non-randomised design. The results suggest that PPI treatment probably has a beneficial effect regardless of underlying gastrointestinal risk and that when NSAIDs cannot be avoided in post-myocardial infarction patients, physicians might prescribe a PPI as well. The study does not clarify whether PPIs might be safely omitted in specific subgroups of patients with a low risk of gastrointestinal bleeding. What this study adds In post-myocardial infarction patients, bleeding complications have been associated with both antithrombotic and NSAID treatment. Concurrent use of PPIs was independently associated with a decreased risk of gastrointestinal bleeding in post-myocardial infarction patients taking antithrombotics and NSAID, regardless of antithrombotic treatment regimen, type of NSAID, and type of PPI used. Funding, competing interests, data sharing AMSO has received a grant from the Danish Council of Independent Research (grant 12-132760). GHG is supported by an unrestricted research scholarship from the Novo Nordisk Foundation

Should beta-blocker therapy be reduced or withdrawn after an episode of decompensated heart failure? Results from COMET.

BACKGROUND: It is unclear whether beta-blocker therapy should be reduced or withdrawn in patients who develop acute decompensated heart failure (HF). We studied the relationship between changes in beta-blocker dose and outcome in patients surviving a HF hospitalisation in COMET. METHODS: Patients hospitalised for HF were subdivided on the basis of the beta-blocker dose administered at the visit following hospitalisation, compared to that administered before. RESULTS: In COMET, 752/3029 patients (25%, 361 carvedilol and 391 metoprolol) had a non-fatal HF hospitalisation while on study treatment. Of these, 61 patients (8%) had beta-blocker treatment withdrawn, 162 (22%) had a dose reduction and 529 (70%) were maintained on the same dose. One-and two-year cumulative mortality rates were 28.7% and 44.6% for patients withdrawn from study medication, 37.4% and 51.4% for those with a reduced dosage (n.s.) and 19.1% and 32.5% for those maintained on the same dose (HR,1.59; 95%CI, 1.28-1.98; p<0.001, compared to the others). The result remained significant in a multivariable model: (HR, 1.30; 95%CI, 1.02-1.66; p=0.0318). No interaction with the beneficial effects of carvedilol, compared to metoprolol, on outcome was observed (p=0.8436). CONCLUSIONS: HF hospitalisations are associated with a high subsequent mortality. The risk of death is higher in patients who discontinue beta-blocker therapy or have their dose reduced. The increase in mortality is only partially explained by the worse prognostic profile of these patients

Dronedarone in patients with congestive heart failure: insights from ATHENA

Dronedarone is a new multichannel blocking antiarrhythmic drug for treatment of atrial fibrillation (AF). In patients with recently decompensated congestive heart failure (CHF) and depressed LV function, the drug was associated with excess mortality compared with a placebo group. The present study aimed to analyse in detail the effects of dronedarone on mortality and morbidity in AF patients CHF. We performed a post hoc analysis of ATHENA, a large placebo-controlled outcome trial in 4628 patients with paroxysmal or persistent AF, to evaluate the relationship between clinical outcomes and dronedarone therapy in patients with stable CHF. The primary outcome was time to first cardiovascular (CV) hospitalization or death. There were 209 patients with NYHA class II/III CHF and a left ventricular ejection fraction &lt;0.40 at baseline (114 placebo, 95 dronedarone patients). A primary outcome event occurred in 59/114 placebo patients compared with 42/95 dronedarone patients [hazard ratio (HR) 0.78, 95% CI = 0.52-1.16]. Twenty of 114 placebo patients and 12/95 dronedarone patients died during the study (HR 0.71, 95% CI = 0.34-1.44). Fifty-four placebo and 42 dronedarone patients were hospitalized for an intermittent episode of NYHA class IV CHF (HR = 0.78, 95% CI = 0.52-1.17). In this post-hoc analysis of ATHENA patients with AF and stable CHF, dronedarone did not increase mortality and showed a reduction of CV hospitalization or death similar to the overall population. However, in the light of the ANtiarrhythmic trial with DROnedarone in Moderate to severe CHF Evaluating morbidity DecreAse study, dronedarone should be contraindicated in patients with NYHA class IV or unstable NYHA classes II and III CHF