To investigate the prognostic importance of acute kidney injury on early mortality, postoperative stroke, and mediastinitis in patients undergoing a first isolated coronary artery bypass grafting.
7594 patients undergoing coronary artery bypass grafting with information on pre- and postoperative serum-creatinine values were included. Patients were classified using the Acute Kidney Injury Network classification. Odds ratios (OR) for mortality and postoperative complications within 60 days of surgery were calculated after adjustment for confounders separately for stage 1 and for stages 2 and 3 together.
1047 (14%) patients developed acute kidney injury. There were 132 (1.7%) deaths, 103 (1.4%) strokes and 118 (1.6%) cases of mediastinitis during follow-up. Among patients in stage 1 the adjusted odds ratio for death was 4.36 (95% confidence interval 2.83-6.71) and for stage 2 plus 3; 21.5 (12.0-38.6) compared to patients without acute kidney injury. Corresponding OR for stroke were 2.34 (1.43-3.82) and 6.52 (2.97-14.3) and for mediastinitis 2.88 (1.84-4.50) and 4.68 (2.07-10.6), respectively.
Acute kidney injury following coronary artery bypass grafting is related to postoperative mortality, stroke, and mediastinitis. Patients undergoing coronary artery bypass grafting should be assessed for presence of acute kidney injury postoperatively, in order to predict early prognosis.
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.
AIM: Increased urinary albumin-excretion is a cardiovascular risk-factor. The cardiovascular risk of the metabolic syndrome (MetS) is debated. The aim of the present prospective, population-based study of non-diabetic individuals was to examine the association between low-grade urinary albumin-excretion, MetS, and cardiovascular morbidity and all-cause mortality. METHODS: 5215 non-diabetic, non-proteinuric men and women participating in the Tromsø Study 1994-1995 were included. Urinary albumin-creatinine ratio (ACR) was measured in three urine samples. The participants were categorized into four groups by the presence/absence of MetS (the International Diabetes Federation definition) and ACR in the upper tertile (>or=0.75 mg/mmol). RESULTS: Median follow-up time was 9.6 years for first ever myocardial infarction, 9.7 years for ischemic stroke and 12.4 years for mortality. High ACR (upper tertile)/MetS was associated with increased risk of myocardial infarction (hazard ratio (HR) 1.75; 95% confidence interval (CI): 1.30-2.37, por=0.75 mg/mmol was associated with cardiovascular morbidity and all-cause mortality independently of MetS. MetS was not associated with any end-point beyond what was predicted from its components. Thus, low-grade albuminuria, but not MetS, may be used for risk stratification in non-diabetic subjects.
For all climatic regions, mortality due to cold exceeds mortality due to heat. A separate line of research indicates that season of birth predicts lifespan after age 50. This and other literature implies the hypothesis that ambient temperature during gestation may influence cold-related adult mortality. We use data on over 13,500 Swedes from the Uppsala Birth Cohort Study to test whether cold-related mortality in adulthood varies positively with unusually benign ambient temperature during gestation. We linked daily thermometer temperatures in Uppsala, Sweden (1915-2002) to subjects beginning at their estimated date of conception and ending at death or the end of follow-up. We specified a Cox proportional hazards model with time-dependent covariates to analyze the two leading causes of cold-related death in adulthood: ischemic heart disease (IHD) and stroke. Over 540,450 person-years, 1313 IHD and 406 stroke deaths occurred. For a one standard deviation increase in our measure of warm temperatures during gestation, we observe an increased hazard ratio of 1.16 for cold-related IHD death (95% confidence interval: 1.03-1.29). We, however, observe no relation for cold-related stroke mortality. Additional analyses show that birthweight percentile and/or gestational age do not mediate discovered findings. The IHD results indicate that ambient temperature during gestation--independent of birth month--modifies the relation between cold and adult mortality. We encourage longitudinal studies of the adult sequelae of ambient temperature during gestation among populations not sufficiently sheltered from heat or cold waves.
Amino-terminal pro-B-type natriuretic peptide and high-sensitivity C-reactive protein but not cystatin C predict cardiovascular events in male patients with peripheral artery disease independently of ambulatory pulse pressure.
Patients with peripheral arterial disease (PAD) are at high risk for cardiovascular (CV) events. We have previously shown that ambulatory pulse pressure (APP) predicts CV events in PAD patients. The biomarkers amino-terminal pro-B-type natriuretic peptide (NT-proBNP), high-sensitivity C-reactive protein (hs-CRP), and cystatin C are related to a worse outcome in patients with CV disease, but their predictive values have not been studied in relation to APP.
Blood samples and 24-hour measurements of ambulatory blood pressure were examined in 98 men referred for PAD evaluation during 1998-2001. Patients were followed for a median of 71 months. The outcome variable was CV events defined as either CV mortality or any hospitalization for myocardial infarction, stroke, or coronary revascularization. The predictive values of log(NT-proBNP), log(hs-CRP), and log(cystatin C) alone and together with APP were assessed by multivariable Cox regression. Area under the curve (AUC) and net reclassification improvement (NRI) were calculated compared with a model containing other significant risk factors.
During follow-up, 36 patients had at least 1 CV event. APP, log(NT-proBNP), and log(hs-CRP) all predicted CV events in univariable analysis, whereas log(cystatin C) did not. In multivariable analysis log(NT-proBNP) (hazard ratio (HR) = 1.62; 95% confidence interval (CI) = 1.05-2.51) and log(hs-CRP) (HR = 1.63; 95% CI = 1.19-2.24) predicted events independently of 24-hour PP. The combination of log(NT-proBNP), log(hs-CRP), and average day PP improved risk discrimination (AUC = 0.833 vs. 0.736; P
Analysed herein are remote results of surgical management of patients presenting with atherosclerotic stenoses of carotid arteries by means of eversion carotid endarterectomy. Over the period from 2002 to 2007 specialists of the Department of Vascular Surgery of the Institute of Surgery named after A.V. Vishnevsky under the RF Ministry of Public Health carried out a total of 393 eversion carotid endarterectomies in 356 patients. We assessed the remote results of 338 (86%) operations in 303 (85%) patients, analysing survival, freedom from stroke, patency of the reconstructed internal carotid artery and effects of risk factors on these indices. The average duration of follow-up amounted to 84 ± 31 months (max - 146 mos). A total of 242 (71.2%) patients survived. The cumulative 5-year survival rate amounted to 84%, with 10-year survival equalling 63%. Severity of the initial atherosclerotic lesion of the arterial bed, progression of atherosclerosis, and control over risk factors for atherosclerosis exerted a statistically significant influence on total survival. Acute disorders of cerebral circulation (of any localization) at a median follow-up of 81 ± 33 months (max - 146 mos) developed in 38 (12.1%) patients, of whom in 15 (4.8%) it terminated with a lethal outcome. Five-year cumulative freedom from stroke amounted to 92%, equalling 80% 10 years after. The risk factors which influenced the freedom from stroke included a history of acute impairments of cerebral circulation, restenoses of the reconstructed ipsilateral internal carotid artery (>70%), and diabetes mellitus. Amongst the examined by means of ultrasonography 164 patients, patency of the reconstructed ipsilateral internal carotid artery at an average follow-up of 75 ± 28 months (max - 135 mos) amounted to 95%. Haemodynamically significant restenoses (= 70%) were revealed in eight (5%) cases. Of these, three (2%) patients had narrowing of 70-89% and the remaining five (3%) patients had narrowing of = 90% (including 2 occlusions of the reconstructed ipsilateral internal carotid artery). We revealed no risk factors influencing the development of restenosis of the reconstructed ipsilateral internal carotid artery after eversion carotid endarterectomy. The obtained findings give grounds to consider eversion carotid endarterectomy as a safe and reliable method for treatment of atherosclerotic lesions of carotid arteries and, consequently, for prevention of stroke. Control of risk factors may improve remote results of surgical treatment.
We describe initial human experience with a novel cerebral embolic protection device.
Cerebral emboli are the major cause of procedural stroke during percutaneous aortic valve interventions.
With right radial artery access, the embolic protection device is advanced into the aortic arch. Once deployed a porous membrane shields the brachiocephalic trunk and the left carotid artery deflecting emboli away from the cerebral circulation. Embolic material is not contained or removed by the device. The device was used in 4 patients (mean age 90 years) with severe aortic stenosis undergoing aortic balloon valvuloplasty (n = 1) or transcatheter aortic valve implantation (n = 3).
Correct placement of the embolic protection device was achieved without difficulty in all patients. Continuous brachiocephalic and aortic pressure monitoring documented equal pressures without evidence of obstruction to cerebral perfusion. Additional procedural time due to the use of the device was 13 min (interquartile range: 12 to 16 min). There were no procedural complications. Pre-discharge cerebral magnetic resonance imaging found no new defects in any of 3 patients undergoing transcatheter aortic valve implantation and a new 5-mm acute cortical infarct in 1 asymptomatic patient after balloon valvuloplasty alone. No patient developed new neurological symptoms or clinical findings of stroke.
Embolic protection during transcatheter aortic valve intervention seems feasible and might have the potential to reduce the risk of cerebral embolism and stroke.
To assess whether family physicians are using the CHADS(2) (congestive heart failure, hypertension, age = 75, diabetes mellitus, and stroke or transient ischemic attack) score in the decision to initiate warfarin therapy to prevent stroke in patients with atrial fibrillation.
Retrospective analysis of the medical records of patients with atrial fibrillation.
Data were gathered from records at 3 clinics in a primary care network in Edmonton, Alta.
The medical records of patients with atrial fibrillation who were currently taking warfarin therapy.
Percentage of patients whose CHADS(2) scores indicated warfarin therapy for stroke prophylaxis compared with the actual percentage of patients taking warfarin therapy. Data on patients' age, number of medications, and number of comorbid conditions were also recorded.
Among these patients, 7% had a CHADS(2) score of 0, for which no warfarin therapy was indicated; 21% had a score of 1, for which either acetylsalicylic acid or warfarin was indicated; and 72% had a score of 2 or greater, for which warfarin therapy was indicated. About 80% of patients were taking medication to control their heart rate.
The CHADS(2) score is not being used in all cases to assess the need for warfarin therapy for preventing stroke in patients with atrial fibrillation. The CHADS(2) score might be of limited use because it is not sensitive enough to stratify patients clearly into high-, intermediate-, and low-risk groups. Although guidelines for stroke prevention should be followed, the CHADS(2) portion of the guidelines might not be the most effective way to assess patients' risk of stroke.
Post-traumatic stress disorder (PTSD) is a well-documented risk factor for cardiovascular disease (CVD). However, it is unknown whether another common stress disorder-adjustment disorder--is also associated with an increased risk of CVD and whether gender modifies these associations. The aim of this study was to examine the overall and gender-stratified associations between PTSD and adjustment disorder and 4 CVD events.
Prospective cohort study utilising Danish national registry data.
The general population of Denmark.
PTSD (n=4724) and adjustment disorder (n=64,855) cohorts compared with the general population of Denmark from 1995 to 2011.
CVD events including myocardial infarction (MI), stroke, ischaemic stroke and venous thromboembolism (VTE). Standardised incidence rates and 95% CIs were calculated.
Associations were found between PTSD and all 4 CVD events ranging from 1.5 (95% CI 1.1 to 1.9) for MI to 2.1 (95% CI 1.7 to 2.7) for VTE. Associations that were similar in magnitude were also found for adjustment disorder and all 4 CVD events: 1.5 (95% CI 1.4 to 1.6) for MI to 1.9 (95% CI 1.8 to 2.0) for VTE. No gender differences were noted.
By expanding beyond PTSD and examining a second stress disorder-adjustment disorder-this study provides evidence that stress-related psychopathology is associated with CVD events. Further, limited evidence of gender differences in associations for either of the stress disorders and CVD was found.