The neutrophil/lymphocyte ratio (NLR) has recently been described as a predictor of mortality in patients who undergo percutaneous coronary intervention. The aim of this study was to investigate the ...utility of admission NLRs in predicting outcomes in patients with acute coronary syndromes (ACS). A total of 2,833 patients admitted to the University of Michigan Health System with diagnoses of ACS from December 1998 to October 2004 were followed. Patients were divided into tertiles according to NLR. The primary end point was all-cause in-hospital and 6-month mortality. The ACS cohort comprised 564 patients with ST-segment elevation myocardial infarctions and 2,269 patients with non–ST-segment elevation ACS. Patients in tertile 3 had higher in-hospital (8.5% vs 1.8%) and 6-month (11.5% vs 2.5%) mortality compared with those in tertile 1 (p <0.001). After adjusting for Global Registry of Acute Coronary Events risk profile, patients in the highest tertile were at an exaggerated risk for in-hospital (odds ratio 2.04, p = 0.013) and 6-month (odds ratio 3.88, p <0.001) mortality. Admission NLR is an independent predictor of in-hospital and 6-month mortality in patients with ACS. This relatively inexpensive marker of inflammation can aid in the risk stratification and prognosis of patients diagnosed with ACS.
Background
Differences in clinical outcomes following a temporary interruption of warfarin or a direct oral anticoagulant (DOAC) for a surgical procedure are not well described. Differences in ...patient characteristics from practice‐based cohorts have not typically been accounted for in prior analyses.
Aim
To describe risk‐adjusted differences in postoperative outcomes following an interruption of warfarin vs DOACs.
Methods
Patients receiving care at six anticoagulation clinics participating in the Michigan Anticoagulation Quality Improvement Initiative were included if they had at least one oral anticoagulant interruption for a procedure. Inverse probability of treatment weighting (IPTW) was used to balance baseline differences between the warfarin cohort and DOAC cohort. Bleeding and thromboembolic events within 30 days following the procedure were compared between the IPTW cohorts using the Poisson distribution test.
Results
A total of 525 DOAC patients were matched with 1323 warfarin patients, of which 923 were nonbridged warfarin patients and 400 were bridged warfarin patients. The occurrence of postoperative minor bleeding (10.8% vs. 4.7%, p < .001), major bleeding (2.9% vs. 1.1%, p = .01) and clinically relevant nonmajor bleeding (CRNMB) (6.5% vs. 3.0%, p = .002) was greater in the DOAC cohort compared with the nonbridged warfarin cohort. The rates of postoperative bleeding outcomes were similar between the DOAC and the bridged warfarin cohorts.
Conclusion
Perioperative interruption of DOACs, compared with warfarin without bridging, is associated with a higher incidence of 30‐day minor bleeds, major bleeds, and CRNMBs. Further research investigating the perioperative outcomes of these two classes of anticoagulants is warranted.
Background
Use of bridging anticoagulation increases a patient's bleeding risk without clear evidence of thrombotic prevention among warfarin‐treated patients with atrial fibrillation. Contemporary ...use of bridging anticoagulation among warfarin‐treated patients with venous thromboembolism (VTE) has not been studied.
Methods
We identified warfarin‐treated patients with VTE who temporarily stopped warfarin for a surgical procedure between 2010 and 2018 at six health systems. Using the 2012 American College of Chest Physicians guideline, we assessed use of periprocedural bridging anticoagulation based on recurrent VTE risk. Recurrent VTE risk and 30‐day outcomes (bleeding, thromboembolism, emergency department visit) were each assessed using logistic regression adjusted for multiple procedures per patient.
Results
During the study period, 789 warfarin‐treated patients with VTE underwent 1529 procedures (median, 2; interquartile range, 1‐4). Unadjusted use of bridging anticoagulation was more common in patients at high risk for VTE recurrence (99/171, 57.9%) than for patients at moderate (515/1078, 47.8%) or low risk of recurrence (134/280, 47.86%). Bridging anticoagulation use was higher in high‐risk patients compared with low‐ or moderate‐risk patients in both unadjusted (P = .013) and patient‐level cluster‐adjusted analyses (P = .031). Adherence to American College of Chest Physicians guidelines in high‐ and low‐risk patients did not change during the study period (odds ratio, 0.98 per year; 95% confidence interval, 0.91‐1.05). Adverse events were rare and not statistically different between the two treatment groups.
Conclusions
Bridging anticoagulation was commonly overused among low‐risk patients and underused among high‐risk patients treated with warfarin for VTE. Adverse events were rare and not different between the two treatment groups.
Mental Health and Cardiovascular Disease Chaddha, Ashish, MD; Robinson, Elizabeth A., PhD, MSW; Kline-Rogers, Eva, NP ...
The American journal of medicine,
11/2016, Letnik:
129, Številka:
11
Journal Article
Recenzirano
Odprti dostop
For centuries, the mind-body relationship has been postulated. These findings suggest that depression and anxiety are not simply "in the mind." They are real illnesses, like any other physical ...illnesses, and can negatively impact the entire body, including the cardiovascular system. Despite the abundance of investigation and demonstration of a clear relationship between mental health and cardiovascular diseases, patients with coronary disease, myocardial infarction, heart failure, and arthythmias are rarely assessed for psychological distress or mental illness as a contributor to or resulting from the cardiovascular disorder. Here, Chaddha et al underscores the importance of mental health and its associations with cardiovascular disease.
Background For more than a decade, guidelines have recommended a limited 3 months of anticoagulation for the treatment of provoked venous thromboembolism (VTE). How closely real-world practice ...follows guideline recommendations is not well described. Methods and Results In our multicenter, retrospective cohort study, we evaluated trends in anticoagulation duration for patients enrolled in the MAQI
(Michigan Anticoagulation Quality Improvement Initiative) registry who were receiving anticoagulation for a provoked VTE. The MAQI
registry comprises 6 centers in Michigan that manage patients' long-term anticoagulation. We identified 474 patients on warfarin and 302 patients on direct oral anticoagulants who were receiving anticoagulation for a primary indication of provoked VTE between 2008 and 2020. Using a predefined threshold of 120 days (3 months plus a buffer period), predictors of extended anticoagulant use were identified using multivariable logistic regression. Most patients received >120 days of anticoagulation, regardless of which medication was used. The median (25th-75th percentile) length of treatment for patients taking warfarin was 142 (91-234) days and for direct oral anticoagulants was 180 (101-360) days. Recurrent VTE (odds ratio OR, 2.75 95% CI, 1.67-4.53), history of myocardial infarction (OR, 3.92 95% CI, 1.32-11.7), and direct oral anticoagulant rather than warfarin use (OR, 2.22 95% CI, 1.59-3.08) were independently associated with prolonged anticoagulation. Conclusions In our cohort of patients with provoked VTE, most patients received anticoagulation for longer than the guideline-recommended 3 months. This demonstrates a potential opportunity to improve care delivery and reduce anticoagulant-associated bleeding risk.
ABSTRACT
Despite the paucity of evidence, it is often presumed, and is physiologically plausible, that sudden, acute elevations in blood pressure may transiently increase the risk of recurrent aortic ...dissection (AD) or rupture in patients with a prior AD, because a post‐dissection aorta is almost invariably dilated and may thus experience greater associated wall stress as compared with a nondilated aorta. Few data are available regarding the specific types and intensities of exercise that may be both safe and beneficial for this escalating patient population. The purpose of this editorial/commentary is to further explore this conundrum for clinicians caring for and counseling AD survivors. Moderate‐intensity cardiovascular activity may be cardioprotective in this patient cohort. It is likely that severe physical activity restrictions may reduce functional capacity and quality of life in post‐AD patients and thus be harmful, underscoring the importance of further exploring the role of physical activity and/or structured exercise in this at‐risk patient population.
Background Prior studies have shown a relationship between female gender and adverse outcomes after percutaneous coronary interventions (PCIs). Whether this relationship still exists with ...contemporary PCI remains to be determined. Methods We evaluated gender differences in clinical outcomes in a large registry of contemporary PCI. Data were prospectively collected from 22,725 consecutive PCIs in a multicenter regional consortium (Blue Cross Blue Shield of Michigan Cardiovascular Consortium) between January 2002 and December 2003. The primary end point was in-hospital all-cause mortality; other clinical outcomes evaluated included in-hospital death, vascular complications, transfusion, postprocedure myocardial infarction, stroke, and a combined major cardiovascular adverse event (MACE) end point including myocardial infarction, death, stroke, emergency coronary artery bypass grafting, and repeated PCI at the same site. Independent predictors of adverse outcomes were identified using multivariate logistic regression analysis. Results Compared with men, women were older, had a higher prevalence of comorbidities, and had a significantly higher frequency of adverse outcomes after PCI. After adjustment for baseline demographics, comorbidities, clinical presentation, and lesion characteristics, female gender was associated with an increased risk of in-hospital death, vascular complication, blood transfusion, stroke, and MACE. The relationship between female gender and increased risk of death and MACE was no longer present after further adjustment for kidney function and low body surface area. Conclusions Differences in mortality rates between men and women no longer exist after PCI. However, our data suggest that technological advancements have not completely offset the relationship between gender and adverse outcomes after PCI.
ABSTRACT
Background
Currently no research exists assessing lifestyle modifications and emotional state of acute aortic dissection (AAD) survivors. We sought to assess activity, mental health, and ...sexual function in AAD survivors.
Hypothesis
Physical and sexual activity will decrease in AAD survivors compared to pre‐dissection. Incidence of anxiety and depression will be significant after AAD.
Methods
A cross sectional survey was mailed to 197 subjects from a single academic medical center (part of larger IRAD database). Subjects were ≥18 years of age surviving a type A or B AAD between 1996 and 2011. 82 surveys were returned (overall response rate 42%).
Results
Mean age ± SD was 59.5 ± 13.7 years, with 54.9% type A and 43.9% type B patients. Walking remained the most prevalent form of physical activity (49 (60%) pre‐dissection and 47 (57%) post‐dissection). Physical inactivity increased from 14 (17%) before AAD to 20 (24%) after AAD; sexual activity decreased from 31 (38%) to 9 (11%) mostly due to fear. Most patients (66.7%) were not exerting themselves physically or emotionally at AAD onset. Systolic blood pressure (SBP) at 36 months post‐discharge for patients engaging in ≥2 sessions of aerobic activity/week was 126.67 ± 10.30 vs. 141.10 ± 11.87 (p‐value 0.012) in those who did not. Self‐reported new‐onset depression after AAD was 32% and also 32% for new‐onset anxiety.
Conclusions
Alterations in lifestyle and emotional state are frequent in AAD survivors. Clinicians should screen for unfounded fears or beliefs after dissection that may reduce function and/or quality of life for AAD survivors.
Background Previous studies have shown that adult hypertension is associated with additional cardiovascular risk factors. Students with high BP had significantly higher BMI (24.1 v. 19.0, p<0.001), ...resting (84 v. 81, p<0.001) and recovery heart rate (112 v. 105, p<0.001), triglyceride (112 v. 85, p<0.001) and total cholesterol levels (159 v. 155, p=0.021), and significantly lower HDL cholesterol levels (47 v. 52, p<0.001).
There was significant variation in OAC use by physician specialty: OAC rates of 58% among cardiologists, 53% among hospitalists and internal medicine providers, and 52% among family practice ...providers and other providers P<0.001. Conclusion Among patients hospitalized with AF and risk factors for stroke, OAC at discharge was more common for cardiologists, although fewer than 6 in 10 cardiology patients received OAC.
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