Administrative discharge codes are widely used in epidemiology, but the specificity and sensitivity of this coding is unknown and must be validated. We assessed the validity of the discharge diagnosis of syncope in administrative registers and reviewed the etiology of syncope after workup.
Two samples were investigated. One sample consisted of 5262 randomly selected medical patients. The other sample consisted of 750 patients admitted or seen in the emergency department (ED) for syncope (ICD-10: R55.9) in three hospitals in Denmark. All charts were reviewed for baseline characteristics and to confirm the presence/absence of syncope and to compare with the administrative coding. In a sample of 600 admitted patients 570 (95%) and of 150 patients from ED 140 (93%) had syncope representing the positive predictive values. Median age of the population was 69 years (IQR: ± 14). In the second sample of 5262 randomly selected medical patients, 75 (1.4%) had syncope, of which 47 were coded as R55.9 yielding a sensitivity of 62.7%, a negative predictive value of 99.5%, and a specificity of 99.9%.
ED and hospital discharge diagnostic coding for syncope has a positive predictive value of 95% and a sensitivity of 63%.
The revised cardiac risk index (RCRI) holds a central role in preoperative cardiac risk stratification in noncardiac surgery. Its performance in unselected populations, including different age groups, has, however, not been systematically investigated. We assessed the relationship of RCRI with major adverse cardiovascular events in an unselected cohort of patients undergoing elective, noncardiac surgery overall and in different age groups.
We followed up all individuals = 25 years who underwent major elective noncardiac surgery in Denmark (January 1, 2005, to November 30, 2011) for the 30-day risk of major adverse cardiovascular events (ischemic stroke, myocardial infarction, or cardiovascular death). There were 742 of 357,396 (0.2%), 755 of 74.889 (1.0%), 521 of 11,921 (4%), and 257 of 3146 (8%) major adverse cardiovascular events occurring in RCRI classes I, II, III, and IV. Multivariable odds ratio estimates were as follows: ischemic heart disease 3.30 (95% confidence interval, 2.96-3.69), high-risk surgery 2.70 (2.46-2.96), congestive heart failure 2.65 (2.29-3.06), cerebrovascular disease 10.02 (9.08-11.05), insulin therapy 1.62 (1.37-1.93), and kidney disease 1.45 (1.33-1.59). Modeling RCRI classes as a continuous variable, C statistic was highest among age group 56 to 65 years (0.772) and lowest for those aged >85 years (0.683). Sensitivity of RCRI class >I (ie, having = 1 risk factor) for capturing major adverse cardiovascular events was 59%, 71%, 64%, 66%, and 67% in patients aged = 55, 56 to 65, 66 to 75, 76 to 85, and >85 years, respectively; the negative predictive values were >98% across all age groups.
In a nationwide unselected cohort, the performance of the RCRI was similar to that of the original cohort. Having = 1 risk factor was of moderate sensitivity, but high negative predictive value for all ages.
The cumulative burden and importance of cardiovascular risk factors have changed over the past decades. Specifically, obesity rates have increased among younger people, whereas cardiovascular health has improved in the elderly. Little is known regarding how these changes have impacted the incidence and the mortality rates of heart failure. Therefore, we aimed to investigate the age-specific trends in the incidence and 1-year mortality rates following a first-time diagnosis of heart failure in Denmark between 1995 and 2012.
We included all Danish individuals >18 years of age with a first-time in-hospital diagnosis of heart failure. Data were collected from 3 nationwide Danish registries. Annual incidence rates of heart failure and 1-year standardized mortality rates were calculated under the assumption of a Poisson distribution.
We identified 210?430 individuals with a first-time diagnosis of heart failure between 1995 and 2012; the annual incidence rates per 10?000 person-years declined among older individuals (rates in 1995 versus 2012: 164 versus 115 in individuals >74 years, 63 versus 35 in individuals 65-74 years, and 20 versus 17 in individuals 55-64 years; P50 years of age, and 1.52 (95% confidence interval, 1.33-1.73; P50 years), but increased among younger (=50 years) individuals. These observations may portend a rising burden of heart failure in the community.
Severe hypokalaemia can aggravate arrhythmia tendency and prognosis, but less is known about risk of mild hypokalaemia, which is a frequent finding. We examined the associations between mild hypokalaemia and ambulatory cardiac arrhythmias and their prognosis.
Subjects from the cohort of the 'Copenhagen Holter Study' (n = 671), with no history of manifest cardiovascular (CV) disease or stroke, were studied. All had laboratory tests and 48-h ambulatory electrocardiogram (ECG) recording. The median follow-up was 6.3 years. p-Potassium was inversely associated with frequency of premature ventricular complexes (PVCs) especially in combination with diuretic treatment (r = -0.22, P = 0.015). Hypokalaemia was not associated with supraventricular arrhythmias. Subjects at lowest quintile of p-potassium (mean 3.42, range 2.7-3.6 mmol/L) were defined as hypokalaemic. Cardiovascular mortality was higher in the hypokalaemic group (hazard ratio and 95% confidence intervals: 2.62 (1.11-6.18) after relevant adjustments). Hypokalaemia in combination with excessive PVC worsened the prognosis synergistically; event rates: 83 per 1000 patient-year in subjects with both abnormalities, 10 and 15 per 1000 patient-year in those with one abnormality, and 3 per 1000 patient-year in subjects with no abnormality. One variable combining hypokalaemia with excessive supraventricular arrhythmias gave similar results in univariate analysis, but not after multivariate adjustments.
In middle-aged and elderly subjects with no manifest heart disease, mild hypokalaemia is associated with increased rate of ventricular but not supraventricular arrhythmias. Hypokalaemia interacts synergistically with increased ventricular ectopy to increase the risk of adverse events.
To examine the risk of death associated with antiarrhythmic drug (AAD) therapy in a nationwide unselected cohort of patients with atrial fibrillation (AF).
All patients admitted with AF in Denmark from 1995 to 2004 and their subsequent use of AADs were identified by individual-level linkage of nationwide registries. Multivariable Cox proportional-hazard models with time-dependent covariates were used to analyse the risk of death associated with AAD therapy. A total of 141,500 patients were included in the study; of these 3356 (2.4%) patients received treatment with flecainide, 3745 (2.6%) propafenone, 23,346 (16.5%) sotalol, and 10,376 (7.3%) amiodarone. Annualized mortality rates were 2.54, 4.25, 5.29, and 7.42 per year per 100 person years for flecainide, propafenone, sotalol, and amiodarone, respectively. Multivariable Cox proportional-hazard models did not show increased risk of death associated with any of the AADs. Hazard ratio (95% confidence interval) for flecainide 0.38 (0.32-0.44), propafenone 0.65 (0.58-0.71), sotalol 0.65 (0.63-0.67), and amiodarone 0.94 (0.89-1.00).
In an unselected cohort of patients with AF, antiarrhythmic treatment with flecainide, propafenone, sotalol, or amiodarone was not associated with increased risk of death. From a safety perspective, this indicates appropriate selection of patients for AAD therapy.
Clinical guidelines have been criticized for encouraging the use of ß-blockers in noncardiac surgery despite weak evidence. Relevant clinical trials have been small and have not convincingly demonstrated an effect of ß-blockers on hard end points (ie, perioperative myocardial infarction, ischemic stroke, cardiovascular death, and all-cause death).
To assess the association of ß-blocker treatment with major cardiovascular adverse events (MACE) and all-cause mortality in patients with ischemic heart disease undergoing noncardiac surgery. DESIGN, SETTING, PARTICIPANTS, AND EXPOSURE: Individuals with ischemic heart disease with or without heart failure (HF) and with and without a history of myocardial infarction undergoing noncardiac surgery between October 24, 2004, and December 31, 2009, were identified from nationwide Danish registries. Adjusted Cox regression models were used to calculate the 30-day risks of MACE (ischemic stroke, myocardial infarction, or cardiovascular death) and all-cause mortality associated with ß-blocker therapy.
Thirty-day risk of MACE and all-cause mortality.
Of 28,263 patients with ischemic heart disease undergoing surgery, 7990 (28.3%) had HF and 20,273 (71.7%) did not. ß-Blockers were used in 4262 (53.3%) with and 7419 (36.6%) without HF. Overall, use of ß-blockers was associated with a hazard ratio (HR) of 0.90 (95% CI, 0.79-1.02) for MACE and 0.95 (0.85-1.06) for all-cause mortality. Among patients with HF, use of ß-blockers was associated with a significantly lower risk of MACE (HR, 0.75; 95% CI, 0.70-0.87) and all-cause mortality (0.80; 0.70-0.92), whereas among patients without HF, there was no significant association of ß-blocker use with MACE (1.11; 0.92-1.33) or mortality (1.15; 0.98-1.35) (P
Data from observational studies have raised concerns about the safety of treatment with antipsychotic agents (APs) in elderly patients with dementia, but this area has been insufficiently investigated. We performed a head-to-head comparison of the risk of major adverse cardiovascular events and noncardiovascular mortality associated with individual APs (ziprasidone, olanzapine, risperidone, quetiapine, levomepromazine, chlorprothixen, flupentixol, and haloperidol) in Danish treatment-naïve patients aged =70 years.
We followed all treatment-naïve Danish citizens aged =70 years that initiated treatment with APs for the first time between 1997 and 2011 (n=91 774, mean age 82±7 years, 35 474 [39%] were men). Incidence rate ratios associated with use of different APs were assessed by multivariable time-dependent Poisson regression models. For the first 30 days of treatment, compared with risperidone, incidence rate ratios of major adverse cardiovascular events were higher with use of levomepromazine (3.80, 95% CI 3.43 to 4.21) and haloperidol (1.85, 95% CI 1.67 to 2.05) and lower for treatment with flupentixol (0.54, 95% CI 0.45 to 0.66), ziprasidone (0.31, 95% CI 0.10 to 0.97), chlorprothixen (0.76, 95% CI 0.61 to 0.95), and quetiapine (0.68, 95% CI 0.58 to 0.80). Relationships were generally similar for long-term treatment. The majority of agents were associated with higher risks among patients with cardiovascular disease compared with patients without cardiovascular disease (P for interaction
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Metabolic disorders are relatively uncommon in young women, but may increase with obesity. The associations between body mass index (BMI) and risks of diabetes, hypertension, and dyslipidemia in apparently healthy, young women have been insufficiently investigated, and are the aims of this study.
Women giving birth during the years 2004-2009, with no history of cardiovascular disease, renal insufficiency, pregnancy-associated metabolic disorders, diabetes, hypertension, or dyslipidemia were identified in nationwide registers. Women were categorized as underweight (BMI
Although the relation between stroke risk factors and stroke in patients with atrial fibrillation (AF) has been extensively examined, only few studies have explored the association of AF and the risk of ischaemic stroke/systemic thromboembolism/transient ischaemic attack (stroke/TE/TIA) in the presence of concomitant stroke risk factors.
From nationwide registries, all persons who turned 50, 60, 70, or 80 from 1997 to 2011 were identified. Persons receiving warfarin were excluded. The absolute risk of stroke/TE/TIA was reported for a 5-year period, as was the absolute risk ratios for AF vs. no AF according to prior stroke and the number of additional risk factors. The study cohort comprised of 3 076 355 persons without AF and 48 189 with AF. For men aged 50 years, with no risk factors, the 5-year risk of stroke was 1.1% (95% confidence interval 1.1-1.1); with AF alone 2.5% (1.8-3.2); with one risk factor and no prior stroke or AF 2.5% (2.3-2.7); and with one factor, no prior stroke and AF 2.9% (1.4-4.3). In men aged 50 years with prior stroke as the only risk factor, 5-year risk was 10.2% (9.1-11.3). In men aged 70 years, the corresponding risks were 4.8% (4.7-4.9), 6.8% (5.7-7.9), 6.6% (6.3-6.8), 8.7 (7.4-9.9), and 19.1% (18.1-20.1), respectively. In women aged 50 years, the risk was of 0.7% (0.7-0.7), 2.1% (0.9-3.2), 1.6% (1.4-1.8), 4.1% (0.6-7.6), and 7.2% (6.3-8.2), respectively, and in women aged 70 years 3.4% (3.3-3.5), 8.2% (7.0-9.5), 4.6% (4.4-4.8), 9.1% (7.5-10.6), and 15.4% (14.5-16.4), respectively.
Stroke/TE/TIA risk was particularly increased when prior stroke/TE/TIA was present. Atrial fibrillation is associated with an increase in risk of stroke/TE/TIA in the absence of other risk factors but only a moderate increase in risk when other risk factors are present.
The prognostic importance of atrial fibrillation (AF) in heart failure (HF) populations is controversial and may depend on patient selection. In the present study, we investigated the prognostic impact of AF in a large population with HF of various aetiologies.
We included 2881 patients admitted to hospital with symptoms of worsening HF over a 4-year period (2001-2004), all patients were participants in the Echocardiography and Heart Outcome Study (ECHOS). Patients were followed for up to 7 years for all-cause mortality stratified according to heart rhythm (sinus rhythm, paroxysmal, or chronic AF) and according to the presence of ischaemic heart disease (IHD). During follow-up, 1934 patients (67%) died. In HF patients with a history of IHD, chronic AF was associated with an increased risk of death [hazard ratio (HR) 1.44; 95% confidence interval (CI): 1.18-1.77; P