Guideline-directed medical therapy for secondary prevention after coronary artery bypass grafting in patients with depression

AbstractBackgroundWe hypothesized that depressed patients would have lower use of guideline-directed medical therapy for secondary prevention of cardiovascular events following coronary artery bypass grafting (CABG).MethodsWe included all patients who underwent primary isolated CABG in Sweden between 2006 and 2008. We cross-linked individual level data from national Swedish registers. Preoperative depression was defined as at least one antidepressant prescription dispensed before surgery. We defined medication use as at least two dispensed prescriptions in each medication class (antiplatelet agents, beta-blockers, angiotensin-converting enzyme inhibitors (ACEI)/angiotensin II receptor blocker (ARB), and statins) within a rolling 12 month period. We calculated adjusted risk ratios (RR) for the use of each medication class, and for all four classes, after one and four years, respectively.ResultsDuring the first year after CABG, 93% of all patients (n = 10,586) had at least two dispensed prescriptions for an antiplatelet agent, 68% for an ACEI/ARB, 91% for a beta-blocker, and 92% for a statin. 57% had prescriptions for all four medication classes. After four years (n = 4034), 44% had filled prescriptions for all four medication classes. Preoperative depression was not significantly associated with a lower use of all four medication classes after one year (RR 0.98, 95% confidence interval (CI) 0.93–1.03) or after four years (RR 0.97, 95% CI 0.86–1.09).ConclusionsPreoperative depression was not associated with lower use of guideline-directed medical therapy for secondary prevention after CABG. These findings suggest that the observed higher mortality following CABG among depressed patients is not explained by inadequate secondary prevention medication

Continuous surgical multi-level extrapleural block for video-assisted thoracoscopic surgery: a retrospective study assessing its efficacy as pain relief following lobectomy and wedge resection [version 1; peer review: 2 approved]

Background: Video-assisted thoracoscopic surgery (VATS) causes less postoperative pain than thoracotomy; however, adequate analgesia remains vital. As part of a multi-modal postoperative analgesia, a continuous surgeon-placed extrapleural block catheter is an option. The aim of this retrospective study was to evaluate the analgesic efficacy of a continuous extrapleural block as part of a multimodal analgesic regimen after VATS in general, and VATS lobectomy and wedge resection in particular. Methods: Case records for patients having undergone VATS surgery and been provided a multi-level continuous extrapleural block with an elastomeric pump infusing levobupivacaine 2.7 mg/ml at a rate of 5 ml/h during 2015 and 2016 were reviewed. Pain (Numeric Rating Scale) at rest and mobilisation as well as opioid requirement (daily, postoperative days 0-3, as well as accumulated) were analysed.    Results: In all, 454 records were reviewed: 150 wedge resections, 264 lobectomies and 40 miscellaneous cases. At rest, pain was mild median NRS rated 3-3-1-1 for postoperative day (POD) 0 to 3, during movement, pain was rated moderate during POD 0 and 1 and mild the remaining days (median NRS 4-4-3-3 for POD 0-3). The proportion of patients exhibiting mild pain at rest increased from 55% on POD 0 to 81 % on POD 3. The percentage of patients experiencing severe pain at rest decreased from 15% to 6%. Median oxycodone consumption was 10 mg per day for POD 1-3. Pain after VATS wedge resection was significantly lower at POD 1 and 3 compared to pain after VATS lobectomy. Conclusion: We found a continuous surgeon-placed extrapleural catheter block to be a valuable and seemingly safe addition to our multimodal procedure specific analgesia after VATS. Whether the efficacy of the block can be improved by increasing local anaesthetic and/or adding adjuncts warrants further investigation

Unravelling the Difference Between Men and Women in Post-CABG Survival

OBJECTIVES: Women have a worse prognosis after coronary artery bypass grafting (CABG) surgery compared to men. We sought to quantify to what extent this difference in post-CABG survival could be attributed to sex itself, or whether this was mediated by difference between men and women at the time of intervention. Additionally, we explored to what extent these effects were homogenous across patient subgroups. METHODS: Time to all-cause mortality was available for 102,263 CABG patients, including 20,988 (21%) women, sourced through an individual participant data meta-analysis of five cohort studies. Difference between men and women in survival duration was assessed using Kaplan–Meier estimates, and Cox’s proportional hazards model. RESULTS: During a median follow-up of 5 years, 13,598 (13%) patients died, with women more likely to die than men: female HR 1.20 (95%CI 1.16; 1.25). We found that differences in patient characteristics at the time of CABG procedure mediated this sex effect, and accounting for these resulted in a neutral female HR 0.98 (95%CI 0.94; 1.02). Next we performed a priori defined subgroup analyses of the five most prominent mediators: age, creatinine, peripheral vascular disease, type 2 diabetes, and heart failure. We found that women without peripheral vascular disease (PVD) or women aged 70+, survived longer than men (interaction p-values 0.04 and 6 × 10–5, respectively), with an effect reversal in younger women. CONCLUSIONS: Sex differences in post-CABG survival were readily explained by difference in patient characteristics and comorbidities. Pre-planned analyses revealed patient subgroups (aged 70+, or without PVD) of women that survived longer than men, and a subgroup of younger women with comparatively poorer survival

Unravelling the Difference Between Men and Women in Post-CABG Survival

OBJECTIVES: Women have a worse prognosis after coronary artery bypass grafting (CABG) surgery compared to men. We sought to quantify to what extent this difference in post-CABG survival could be attributed to sex itself, or whether this was mediated by difference between men and women at the time of intervention. Additionally, we explored to what extent these effects were homogenous across patient subgroups. METHODS: Time to all-cause mortality was available for 102,263 CABG patients, including 20,988 (21%) women, sourced through an individual participant data meta-analysis of five cohort studies. Difference between men and women in survival duration was assessed using Kaplan–Meier estimates, and Cox’s proportional hazards model. RESULTS: During a median follow-up of 5 years, 13,598 (13%) patients died, with women more likely to die than men: female HR 1.20 (95%CI 1.16; 1.25). We found that differences in patient characteristics at the time of CABG procedure mediated this sex effect, and accounting for these resulted in a neutral female HR 0.98 (95%CI 0.94; 1.02). Next we performed a priori defined subgroup analyses of the five most prominent mediators: age, creatinine, peripheral vascular disease, type 2 diabetes, and heart failure. We found that women without peripheral vascular disease (PVD) or women aged 70+, survived longer than men (interaction p-values 0.04 and 6 × 10(–5), respectively), with an effect reversal in younger women. CONCLUSION: Sex differences in post-CABG survival were readily explained by difference in patient characteristics and comorbidities. Pre-planned analyses revealed patient subgroups (aged 70+, or without PVD) of women that survived longer than men, and a subgroup of younger women with comparatively poorer survival

Left ventricular reconstruction in ischemic heart disease

Objectives: [1] To review our experience with left ventricular reconstruction (LVR) regarding safety (early mortality and morbidity) and long-term survival (Study I). [2] To evaluate LVR including surgery for ventricular tachycardia in patients with preoperative spontaneous or inducible ventricular tachycardia (Study II). [3] To analyze risk factors for mortality and hospital re-admission for heart failure after LVR (Study III). [4] To prospectively investigate changes in functional status and quality of life after LVR (Study IV). [5] To prospectively investigate changes in biomarkers for heart failure (BNP and NT-pro-BNP) in relation to functional status after LVR (Study V). Background: Postinfarction cardiac remodeling with left ventricular dilatation is strongly associated with decreased survival. Surgical restoration of left ventricular size and form is proposed to improve survival, functional status, and quality of life. Methods: In three retrospective studies, 101 (Study I), 53 (Study II), and 136 (Study III) patients were included. Patients were considered for LVR if they demonstrated an enlarged, either dyskinetic or akinetic, left ventricle accompanied by left ventricular dysfunction after myocardial infarction, and had symptoms of angina or heart failure with or without ventricular tachycardia. Survival, morbidity, and freedom from re-hospitalization were ascertained by review of patients records, our institutional database, and national registers. In addition, freedom from postoperative ventricular tachycardia was evaluated by programmed ventricular stimulation in most patients in Study II. Conventional statistical methods were employed to identify factors associated with adverse outcome in Study III. Two prospective studies were conducted to investigate functional status and quality of life (Study IV, n=23) and changes in biomarkers for heart failure (Study V, n=29). Health-related quality of life and functional status was evaluated preoperatively, six months postoperatively, and at late follow-up almost two years after surgery, with the Short Form-36 questionnaire, the six-minute walk test, and New York Heart Association functional class. Blood samples were collected at equivalent timepoints for analysis of biomarkers for heart failure (BNP and NT-pro-BNP). Results and Conclusions: [1] LVR is a reproducible and safe surgical option in patients with left ventricular aneurysm or ischemic dilated cardiomyopathy. Early mortality was 7.4% and five year survival was 68%. [2] LVR including endocardiectomy and cryoablation resulted in a very high (90%) freedom from spontaneous ventricular tachycardia. [3] LVR resulted in a high degree of freedom from re-admission for heart failure. We found a strong association between increasing grade of preoperative mitral regurgitation and both long-term mortality and re-admission for heart failure. [4] Functional status and health-related quality of life improved six months after LVR and the improvement was sustained at late follow-up. [5] Severe heart failure secondary to postinfarction left ventricular remodeling can be reversed by LVR. Clinical improvement was associated with reduced levels of BNP and NT-pro- BNP six months after surgery. Clinical improvement was maintained and peptide levels were further reduced at late follow-up

Guideline-directed medical therapy for secondary prevention after coronary artery bypass grafting in patients with depression

AbstractBackgroundWe hypothesized that depressed patients would have lower use of guideline-directed medical therapy for secondary prevention of cardiovascular events following coronary artery bypass grafting (CABG).MethodsWe included all patients who underwent primary isolated CABG in Sweden between 2006 and 2008. We cross-linked individual level data from national Swedish registers. Preoperative depression was defined as at least one antidepressant prescription dispensed before surgery. We defined medication use as at least two dispensed prescriptions in each medication class (antiplatelet agents, beta-blockers, angiotensin-converting enzyme inhibitors (ACEI)/angiotensin II receptor blocker (ARB), and statins) within a rolling 12 month period. We calculated adjusted risk ratios (RR) for the use of each medication class, and for all four classes, after one and four years, respectively.ResultsDuring the first year after CABG, 93% of all patients (n = 10,586) had at least two dispensed prescriptions for an antiplatelet agent, 68% for an ACEI/ARB, 91% for a beta-blocker, and 92% for a statin. 57% had prescriptions for all four medication classes. After four years (n = 4034), 44% had filled prescriptions for all four medication classes. Preoperative depression was not significantly associated with a lower use of all four medication classes after one year (RR 0.98, 95% confidence interval (CI) 0.93–1.03) or after four years (RR 0.97, 95% CI 0.86–1.09).ConclusionsPreoperative depression was not associated with lower use of guideline-directed medical therapy for secondary prevention after CABG. These findings suggest that the observed higher mortality following CABG among depressed patients is not explained by inadequate secondary prevention medication

Quality of life and functional status after pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension: A Swedish single‐center study

Abstract Little is known about long‐term quality of life (QOL) and functional status after pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (CTEPH). We investigated QOL and functional status late after PEA. All patients who underwent PEA for CTEPH 1993–2020 at one Swedish center were included. Baseline characteristics and data from right heart catheterization, 6‐min walk test, and Cambridge Pulmonary Hypertension Outcome Review (CAMPHOR) were obtained from patient charts and national registers. The RAND 36‐Item Health Survey was sent by post, and Karnofsky Performance Status (KPS) was evaluated by telephone. A total of 110 patients were included. The survey was completed by 49/66 (74%) patients who were alive in 2020. In all domains except for bodily pain, QOL was slightly lower than that of an age‐matched reference population. The KPS score was obtained from 42/49 (86%) patients; of these, 31 patients (74%) had a KPS score of ≥80% (able to carry on normal activity). All 42 patients were able to live at home and care for personal needs. The median postoperative CAMPHOR scores were: 4 for symptoms, 4 for activity, and 2.5 for QOL. We observed that QOL after PEA approached the expected QOL in a reference population and that CAMPHOR scores were comparable to those of a large UK cohort after PEA. Functional status improved when assessed late after PEA. Three‐quarters of the study population were able to conduct normal activities at late follow‐up. Our findings suggest that many patients enjoy satisfactory QOL and high functional status late after PEA