Socioeconomic disparities have been linked to survival differences in patients with lung cancer. Swedish healthcare is tax-funded and provides equal access to care, therefore, survival following lung ...cancer surgery should be unrelated to household income. The aim of this study was to investigate the association between household disposable income and survival following surgery for lung cancer in Sweden.
We conducted a nationwide population-based cohort study including all patients who underwent pulmonary resections for lung cancer in Sweden 2008-2017. Individual-level record linkages between national quality and health-data registers were performed to acquire information regarding socioeconomic status and medical history. Cox regression by quintiles of household disposable income was used to estimate the adjusted risk for all-cause mortality.
We included 5500 patients and the age-adjusted and sex-adjusted incidence rate of death per 100 person-years was 15 and 9.4 in the lowest and highest income quintile, respectively (mean follow-up time 3.2 years). Deprived patients were older, had more comorbidities and were less likely to have preoperative positron emission tomography or minimally invasive surgery, compared with patients with higher income. The adjusted HR for death was 0.77 (95% CI: 0.62 to 0.96) for the highest income quintile compared with the lowest.
We found an association between household disposable income and survival in patients who underwent surgery for lung cancer in Sweden, despite tax-funded universal health coverage. The association remained after adjustment for differences in baseline characteristics.
The primary aim was to study the association between preoperative depression and long-term survival after coronary artery bypass grafting (CABG). Our secondary objective was to analyze the ...association between depression and cardiovascular events or all-cause mortality. In a nationwide, population-based, cohort study, all patients who underwent CABG in Sweden from 1997 to 2008 were included from the Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies registry. Individual-level data were cross-linked from other national Swedish registers. Depression status and outcomes were obtained from the National Patient Register. The study population was 56,064 patients who underwent primary, isolated, nonemergent CABG. We identified 324 patients (0.6%) with depression before CABG. During a mean follow-up of 7.5 years, 114 patients (35%) with depression died, compared with 13,767 patients (25%) in the control group. Depression was significantly associated with increased mortality and the combined end point of death or rehospitalization for myocardial infarction, heart failure, or stroke (multivariate-adjusted hazard ratios 95% confidence intervals 1.65 1.37 to 1.99 and 1.61 1.38 to 1.89, respectively). In conclusion, we found a strong and significant association between depression and long-term survival in patients with established ischemic heart disease who underwent CABG. Depression was also associated with an increased risk for a combination of death or rehospitalization for heart failure, myocardial infarction, or stroke.
Abstract Background Recent clinical trials highlight the need for better models to identify patients at higher risk of sudden death. Objectives The authors hypothesized that the Seattle Heart Failure ...Model (SHFM) for overall survival and the Seattle Proportional Risk Model (SPRM) for proportional risk of sudden death, including death from ventricular arrhythmias, would predict the survival benefit with an implantable cardioverter-defibrillator (ICD). Methods Patients with primary prevention ICDs from the National Cardiovascular Data Registry (NCDR) were compared with control patients with heart failure (HF) without ICDs with respect to 5-year survival using multivariable Cox proportional hazards regression. Results Among 98,846 patients with HF (87,914 with ICDs and 10,932 without ICDs), the SHFM was strongly associated with all-cause mortality (p < 0.0001). The ICD−SPRM interaction was significant (p < 0.0001), such that SPRM quintile 5 patients had approximately twice the reduction in mortality with the ICD versus SPRM quintile 1 patients (adjusted hazard ratios HR: 0.602; 95% confidence interval CI: 0.537 to 0.675 vs. 0.793; 95% CI: 0.736 to 0.855, respectively). Among patients with SHFM-predicted annual mortality ≤5.7%, those with a SPRM-predicted risk of sudden death below the median had no reduction in mortality with the ICD (adjusted ICD HR: 0.921; 95% CI: 0.787 to 1.08; p = 0.31), whereas those with SPRM above the median derived the greatest benefit (adjusted HR: 0.599; 95% CI: 0.530 to 0.677; p < 0.0001). Conclusions The SHFM predicted all-cause mortality in a large cohort with and without ICDs, and the SPRM discriminated and calibrated the potential ICD benefit. Together, the models identified patients less likely to derive a survival benefit from primary prevention ICDs.
Acute kidney injury (AKI) is a common complication after coronary artery bypass grafting (CABG) and is associated with adverse outcomes. However, the relationship between AKI after CABG and the ...long-term risk of end-stage renal disease (ESRD) is unknown.
This study included 29 330 patients who underwent primary isolated CABG in Sweden between 2000 and 2008. AKI was classified according to the Acute Kidney Injury Network (AKIN) classification: stage 1, >0.3 mg/dL (>26 μmol/L) or 50% to 100% increase; stage 2, 100% to 200% increase; and stage 3, >200% increase from the preoperative to postoperative serum creatinine level. Cox proportional hazards regression analysis was used to calculate hazard ratios with 95% confidence intervals for ESRD in AKIN stage 1 and stage 2 to 3. Postoperative AKI occurred in 13% of patients. During a mean follow-up of 4.3±2.4 years, 123 patients (0.4%) developed ESRD, including 50 (1.6%) in AKIN stage 1, 29 (5.2%) in AKIN stage 2 to 3, and 44 (0.2%) without AKI after CABG. After multivariable adjustment, the hazard ratio for ESRD was 2.92 (95% confidence interval, 1.87-4.55) for AKIN stage 1 and 3.81 (95% confidence interval, 2.14-6.79) for AKIN stage 2 to 3.
This nationwide study of patients who underwent CABG found that a small increase in the postoperative serum creatinine level was associated with an almost 3-fold increase in the long-term risk of ESRD after adjustment for a number of confounders, including preoperative renal function.
Acute kidney injury (AKI) after coronary artery bypass grafting (CABG) is associated with adverse outcomes. This study investigated if already a minimal change of 0 to 0.3 mg/dl in postoperative ...serum creatinine values was associated with early death and long-term cardiovascular outcomes and death. From the SWEDEHEART registry, we included 25,686 patients who underwent elective, isolated, primary CABG in Sweden from 2000 to 2008. AKI was categorized according to increases in postoperative creatinine values: group 1, 0 to 0.3 mg/dl; group 2, 0.3 to 0.5 mg/dl; and group 3, >0.5 mg/dl. The primary outcome measure was death from any cause. During a mean follow-up of 6 years, there were 4,350 deaths (17%) and 7,095 hospitalizations (28%) for myocardial infarction, stroke, heart failure, or death (secondary outcome). The adjusted odds ratios (95% confidence interval CI) for early mortality in AKI groups 1 to 3 were 1.37 (0.84 to 2.21), 3.64 (2.07 to 6.38), and 15.4 (9.98 to 23.9), respectively. For long-term mortality, the corresponding hazard ratios (95% CI) were 1.07 (1.00 to 1.15), 1.33 (1.19 to 1.48), and 2.11 (1.92 to 2.32), respectively. There was a significant association between each AKI group and the composite outcome (HR 1.09, 95% CI 1.03 to 1.15; HR 1.39, 95% CI 1.27 to 1.52; and HR 1.99, 95% CI 1.84 to 2.16, respectively). In conclusion, already a minimal increase in the postoperative serum creatinine level after CABG was independently associated with long-term all-cause mortality and cardiovascular outcomes, regardless of preoperative renal function.
Aims
The aim of this study was to evaluate the performance of a recently developed risk score for mortality in heart failure by external validation in a national heart failure registry.
Methods and ...results
From 13 routinely available patient characteristics, the Meta‐analysis Global Group in Chronic Heart Failure (MAGGIC) constructed a risk score for prediction of mortality in heart failure. We included 51 043 patients from the national Swedish Heart Failure Registry and calculated the MAGGIC risk score for each patient. The outcome measure was 3‐year mortality. The predicted probability of death obtained from the calculated risk score was compared with the observed 3‐year mortality, and model discrimination and calibration were assessed by formal tests and graphical means. The overall 3‐year mortality in the study population was 39.4% and the MAGGIC project heart failure risk score predicted mortality was 36.4% (observed to expected ratio: 1.08). Discrimination was excellent overall (C index = 0.741). The difference between the model‐predicted and the observed 3‐year mortality in the six risk groups varied between 5% and −12%. Calibration plots demonstrated slight overprediction for the lowest risk patients, and underprediction in high risk patients.
Conclusion
The MAGGIC project heart failure risk score demonstrated an excellent ability to categorize patients in separate risk strata. Although the predicted 3‐year mortality risk was higher in low risk groups and lower in high risk groups compared with the observed 3‐year mortality in the Swedish Heart Failure Registry, the MAGGIC project heart failure risk score performed well in a large nationwide contemporary external validation cohort.
Whether a bovine or porcine aortic valve bioprosthesis carries a higher risk of endocarditis after aortic valve replacement is unknown. The aim of this study was to compare the risk of prosthetic ...endocarditis in patients undergoing aortic valve replacement with a bovine versus porcine bioprosthesis.
This nationwide, population-based cohort study included all patients who underwent surgical aortic valve replacement with a bovine or porcine bioprosthesis in Sweden from 1997 to 2018. Regression standardization was used to account for intergroup differences. The primary outcome was prosthetic valve endocarditis, and the secondary outcomes were all-cause mortality and early prosthetic valve endocarditis. During a maximum follow-up time of 22 years, we included 21 022 patients, 16 603 with a bovine valve prosthesis and 4419 with a porcine valve prosthesis. The mean age was 73 years, and 61% of the patients were men. In total, 910 patients were hospitalized for infective endocarditis: 690 (4.2%) in the bovine group and 220 (5.0%) in the porcine group. The adjusted cumulative incidence of prosthetic valve endocarditis at 15 years was 9.5% (95% CI, 6.2%-14.4%) in the bovine group and 2.8% (95% CI, 1.4%-5.6%) in the porcine group. The absolute risk difference between the groups at 15 years was 6.7% (95% CI, 0.8%-12.5%).
The risk of endocarditis was higher in patients who received a bovine compared with a porcine valve prosthesis after surgical aortic valve replacement. This association should be considered in patients undergoing both surgical and transcatheter aortic valve replacement.
Abstract Background Patients with type 1 diabetes mellitus (T1DM) have a high risk of cardiovascular events. Objectives The aim of this study was to investigate whether preoperative hemoglobin A1c ...(HbA1c ) levels could predict cardiovascular events or death after coronary artery bypass grafting (CABG). Methods This was a nationwide population-based observational cohort study that included all patients with T1DM who underwent primary isolated nonemergency CABG in Sweden between 1997 and 2012, according to the Swedish National Diabetes Register and the SWEDEHEART (Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies) register. We calculated the crude incidence rates and 95% confidence intervals (CIs) and used Cox regression and multivariable hazard ratios (HRs) to estimate the risk of both all-cause mortality and major adverse cardiovascular events (MACE), defined as myocardial infarction, stroke, heart failure, or repeat revascularization, in relation to HbA1c levels. Results In total, 764 patients with T1DM were included. During a median follow-up of 4.7 years, 334 (44%) patients died or had MACE (incidence rate: 82 events/1,000 person-years). After multivariable adjustment, the HR (95% CI) for death or MACE in patients with HbA1c levels of 7.1% to 8.0%, 8.1% to 9.0%, 9.1% to 10.0%, and >10.0% were 1.34 (0.82 to 2.21), 1.59 (1.00 to 2.54), 1.73 (1.03 to 2.90), and 2.25 (1.29 to 3.94), respectively, compared with the reference category. When HbA1c was used as a continuous variable, the HR for a 1% increase in HbA1c level was 1.18, and the 95% CI was 1.06 to 1.32. Conclusions In patients with T1DM, poor glycemic control before CABG was associated with increased long-term risk of death or MACE. (HeAlth-data Register sTudies of Risk and Outcomes in Cardiac Surgery HARTROCS; NCT02276950 )
Background The internal thoracic artery (ITA) is the most important conduit for coronary artery bypass grafting. Recent evidence suggests that skeletonized ITA harvesting yields long‐term outcomes ...inferior to those of pedicled harvesting. The aim was to investigate the impact of the ITA harvesting method on 10‐year mortality and major adverse cardiovascular events. Methods and Results In this observational cohort study, we identified all patients from the SWEDEHEART (Swedish Web‐System for Enhancement and Development of Evidence‐Based Care in Heart Disease Evaluated According to Recommended Therapies) register who underwent isolated coronary artery bypass grafting using at least 1 ITA at Karolinska University Hospital from 2012 to 2021. The main outcome was all‐cause mortality, and the secondary outcomes were a combination of myocardial infarction, repeat revascularization, heart failure, and stroke. Outcomes were ascertained using national health data registers and compared between the skeletonized and pedicled groups using weighted flexible parametric survival models. Among 3267 patients, 1657 (51%) underwent pedicled ITA harvesting and 1610 (49%) underwent skeletonized ITA harvesting. The patients' mean age was 66 years, and 15% were women. The weighted all‐cause mortality incidence rate in the pedicled versus skeletonized ITA group was 2.6% (95CI, 2.2%–3.0%) versus 2.6% (95% CI, 2.2%–3.1%), respectively (hazard ratio (HR), 1.01 95% CI, 0.81–1.27). The weighted major adverse cardiovascular events incidence rate was 7.8% (95% CI, 7.1%–8.6%) versus 7.5% (95% CI, 6.7%–8.4%), respectively (HR, 0.94 95% CI, 0.82–1.08). Conclusions We found no significant differences in all‐cause mortality or major adverse cardiovascular events rates between the 2 ITA harvesting methods.
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