Introduction
In patients with peripheral artery disease (PAD) the presence of diabetes mellitus (DM) is associated with higher morbidity and mortality. Because huge efforts are made to improve ...medical care of patients with DM including chronic disease programs, the aim of the present study was to investigate temporal trends regarding the clinical burden of DM on PAD patients within a 15‐year observational period.
Methods
We analyzed all patients hospitalized because of PAD between 2005 and 2019 in Germany stratified regarding DM.
Results
Overall, 2 654 871 hospitalizations of PAD patients (865 823 with DM) were included. Hospitalizations based on PAD inclined from 142 778 in 2005 to 190 135 in 2019 (β 3956 per year; 95% confidence interval CI 3034–4878, p < .001) with simultaneous increase of hospitalizations of PAD patients with DM (2005: 41609 (29.1%) versus 2019: 65 302 (34.3%); β 2019 per year 95% CI 1593–2446, p < .001). Amputation rates (β −0.42 95% CI −0.44 to −0.40; p < .001) as well as in‐hospital case‐fatality rate (2005: 4.7%, 2019: 2.8%; β −0.64 95% CI −0.69 to −0.59; p < .001) decreased in diabetic PAD patients during the observational time. In spite of improved morbidity and mortality in the last years of the observational period, patients with DM still suffered from an increased risk for morbidity and mortality during the observational period compared to nondiabetic PAD patients.
Conclusions
Despite the progress in DM treatments, DM still was associated with an unfavorable clinical patient profile and remained a substantial risk factor for morbidity and mortality in hospitalized patients with PAD and DM in Germany between 2005 and 2019.
摘要
背景
在患有外周动脉疾病(PAD)的患者中，糖尿病(DM)的存在与较高的发病率和死亡率相关。由于为改善DM患者的医疗保健(包括慢性病项目)付出了巨大努力，本研究旨在调查15年观察期内DM对PAD患者临床负担的时间趋势。
方法
我们分析了2005年至2019年间德国根据DM分层的所有因PAD住院的患者。
结果
共有2,654,871 例 PAD住院患者(865,823 例DM)纳入分析。基于PAD的住院人数从 2005 年的 142,778 人增加到 2019 年的 190,135 人(β 3956/年 95%CI 3034‐4878，P<0.001)，同时 PAD 合并 DM 患者的住院人数增加(2005 年:41,609 人(29.1%)vs. 2019 年:65,302 (34.3%), β 2019/年 95%CI 1593‐2446，P<0.001)。截肢率(β ‐0.42 95%CI ‐0.44 to ‐0.40, P<0.001)以及住院病死率(2005:4.7%，2019:2.8%, β ‐0.64 95%CI ‐0.69 to ‐0.59, P<0.001) 在观察期间糖尿病 PAD 患者降低。尽管在观察期的最后几年发病率和死亡率有所改善，但与非糖尿病PAD 患者相比，糖尿病患者在观察期内的发病率和死亡率风险仍然增加。
结论
尽管DM治疗取得了进展，但DM仍然与不良的患者临床状况相关，并且仍然是 2005年至 2019 年间德国住院的 PAD 合并 DM 患者发病率和死亡率的重要危险因素。
Highlights
Annual numbers of hospitalizations of patients with peripheral artery disease (PAD) in coprevalence with diabetes mellitus (DM) increased significantly during the observational period from 2005 to 2019.
Age and comorbidity‐burden of PAD patients with DM aggravated over time, whereas major adverse cardiac and cerebrovascular events and in‐hospital mortality of PAD patients with DM decreased from 2005 to 2019.
The proportion of female PAD patients with DM decreased from 2005 to 2019.
Annual numbers of amputation surgeries decreased from 2005 to 2019 driven by declining numbers of major amputations.
Compared to nondiabetic persons, presence of DM was associated with poor in‐hospital outcome, which was widely unchanged over time.
Zusammenfassung
Die periphere arterielle Verschlusskrankheit (pAVK) ist eine häufige Manifestation der Atherosklerose mit hohem Risiko für kardiovaskuläre Ereignisse. Als Screening nach einer pAVK ...dient die Messung des ABI („ankle-brachial index“). Man unterscheidet das stabile Stadium der Claudicatio intermittens vom Stadium der kritischen Extremitätenischämie (CLI „critical limb ischemia“). In der Therapie sind eine Nikotinkarenz sowie die lipidsenkende Therapie mit Statinen und einem Ziel-LDL(„low-density lipoprotein“)-Cholesterin von weniger als 55 mg/dl zentrale Elemente. Bei Patienten mit symptomatischer pAVK ist eine Thrombozytenaggregationshemmung indiziert. Neben Clopidogrel 75 mg oder Acetylsalicylsäure (ASS) 100 mg kann bei hohem Risiko auch eine Kombinationstherapie von ASS 100 mg und 2‑mal 2,5 mg Rivaroxaban zum Einsatz kommen. Bei kritischer Extremitätenischämie ist immer eine Revaskularisation (perkutane Intervention, Operation) zum Extremitätenerhalt indiziert. Bei Claudicatio intermittens ist das zentrale Element der Therapie ein Gehtraining, eine Revaskularisation kommt bei hohem Leidensdruck zum Einsatz.
BACKGROUND
Although polypharmacy is associated with a negative clinical outcome in various settings and commonly observed in patients receiving oral anticoagulation therapy, evidence on the relevance ...for the clinical outcome of anticoagulated patients is currently limited. The aim of the study was to investigate the effect of polypharmacy on the clinical outcomes among patients taking phenprocoumon.
DESIGN
Prospective cohort study.
SETTING
Regular medical care.
PARTICIPANTS
Information on 2011 individuals receiving vitamin K antagonists was available for analysis from the prospective multicenter thrombEVAL study.
MEASUREMENTS
Data were obtained from clinical visits, computer‐assisted interviews, and laboratory measurements. Information on clinical outcome was obtained during a 3‐year follow‐up period and subsequently validated via medical records.
RESULTS
The prevalence of polypharmacy (five drugs or more) was 84.1% (n = 1691). Quality of anticoagulation therapy assessed by time in therapeutic range was lower in individuals on five to eight drugs and nine drugs or more (70.7% and 64.7%, respectively) compared with subjects without polypharmacy (73.4%). In addition, a significantly higher variability of international normalized ratio measurements was found in the presence of polypharmacy. The cumulative incidence of bleeding, hospitalization, and all‐cause mortality, but not for thromboembolic events, increased across groups of medication. In adjusted Cox regression analysis, polypharmacy is an independent risk factor for bleeding (hazard ratio HR≥ 9 drugs vs 1‐4 drugs = 1.62; 95% confidence interval CI = 1.04‐2.52; p = .033); hospitalization (HR≥ 9 drugs vs 1‐4 drugs = 1.60; 95% CI = 1.26‐2.03; p < .001; and all‐cause mortality (HR≥ 9 drugs vs 1‐4 drugs = 2.16; 95% CI = 1.43‐3.27; p < .001) in a dose‐dependent relationship. Per additional drug, bleeding risk was increased by 4%.
CONCLUSIONS
Polypharmacy influences the quality of anticoagulation therapy and translates into an elevated risk of adverse events in anticoagulated patients. This suggests that additional medication intake in such patients should be critically reviewed by physicians, and it highlights the importance of initiating investigations aimed at reducing multiple medication intake. J Am Geriatr Soc 67:463–470, 2019.
Peripheral arterial occlusive disease (PAOD) is a frequent manifestation of atherosclerosis with a high risk of cardiovascular events (myocardial infarction, stroke, amputation, cardiovascular ...death). A distinction is made between the stable form of intermittent claudication and chronic limb-threatening ischemia (CLTI, pain at rest, wounds). The most frequent risk factors are diabetes mellitus and smoking. As the disease is often asymptomatic early diagnostic necessary. Measurement of the ankle-brachial index (ABI) is suitable for screening. Consistent treatment of cardiovascular risk factors and antithrombotic medication are important. At the stage of intermittent claudication, exercise training should be performed. In CLTI early endovascular or surgical revascularization must be performed to avoid amputation of the extremity.Peripheral arterial occlusive disease (PAOD) is a frequent manifestation of atherosclerosis with a high risk of cardiovascular events (myocardial infarction, stroke, amputation, cardiovascular death). A distinction is made between the stable form of intermittent claudication and chronic limb-threatening ischemia (CLTI, pain at rest, wounds). The most frequent risk factors are diabetes mellitus and smoking. As the disease is often asymptomatic early diagnostic necessary. Measurement of the ankle-brachial index (ABI) is suitable for screening. Consistent treatment of cardiovascular risk factors and antithrombotic medication are important. At the stage of intermittent claudication, exercise training should be performed. In CLTI early endovascular or surgical revascularization must be performed to avoid amputation of the extremity.
Zusammenfassung
Die periphere arterielle Verschlusskrankheit (pAVK) ist eine häufige Manifestation der Atherosklerose mit hohem Risiko für kardiovaskuläre Ereignisse (Myokardinfarkt, Schlaganfall, ...Amputation, kardiovaskulärer Tod). Man unterscheidet die stabile Form der Claudicatio intermittens von der chronisch kritischen Extremitätenischämie („chronic limb-threatening ischemia“ CLTI; Ruheschmerz, Wunden). Die häufigsten Risikofaktoren sind Diabetes mellitus und Rauchen. Da die Erkrankung oft asymptomatisch verläuft, ist eine frühzeitige Diagnostik notwendig. Zum Screening eignet sich die Messung des Knöchel-Arm-Index („ankle-brachial index“, ABI). In der Therapie sind die konsequente Behandlung der Risikofaktoren und eine antithrombotische Medikation wichtig. Im Stadium der Claudicatio intermittens sollte Gefäßsport durchgeführt werden. Bei CLTI muss eine rasche endovaskuläre oder chirurgische Revaskularisation erfolgen, um die Amputation der Extremität zu verhindern.
Background
Pulmonary embolism (PE) is a life‐threatening acute disease accompanied by high morbidity and mortality. Regarding hospitalizations of patients with PE, risk stratification of these ...patients is crucial. Thus, risk stratification tools like risk scores are of key interest.
Methods
The nationwide German inpatient sample of the years 2005–2018 was used for this present analysis. Hospitalized PE patients were stratified according to Mansoor's Self‐Report Tool for Cardiovascular Risk Assessment class, and the performance of this score was evaluated to predict adverse in‐hospital events.
Results
Overall, 1 174 196 hospitalizations of PE patients (53.5% females; 56.4% ≥70 years) were registered in Germany between 2005 and 2018. According to the Mansoor's self‐report tool for cardiovascular risk assessment, 346 126 (29.5%) PE patients were classified as high risk.
Higher Mansoor's Self‐Report Tool for Cardiovascular Risk Assessment class was predictive for in‐hospital death (OR 1.129 95%CI 1.117–1.141, P < 0.001), shock (OR 1.117 95%CI 1.095–1.140, P < 0.001), cardiopulmonary resuscitation (OR 1.109 95%CI 1.092–1.126, P < 0.001), right ventricular dysfunction (OR 1.039 95%CI 1.030–1.048, P < 0.001), intracerebral bleeding (OR 1.316 95%CI 1.275–1.358, P < 0.001), and gastro‐intestinal bleeding (OR 1.316 95%CI 1.275–1.358, P < 0.001). Systemic thrombolysis was not associated with lower in‐hospital mortality in high‐risk class (OR 5.139 95%CI 4.961–5.323, P < 0.001).
Conclusions
Prognostic performance of the Mansoor's Self‐Report Tool for Cardiovascular Risk Assessment for risk stratification of PE patients was poor and not able to identify those PE patients, who might benefit from systemic thrombolysis. However, the Mansoor's Self‐Report Tool for Cardiovascular Risk Assessment was moderately helpful to identify PE patients at higher risk for bleeding events.
Prognostic performance of the Mansoor's Self‐Report Tool for Cardiovascular Risk Assessment to identify PE patients with higher risk for in‐hospital death and adverse events during in‐hospital stay.
Abstract
Aims
Evidence regarding the health burden of chronic venous insufficiency (CVI), its clinical determinants, and impact on outcome is scarce.
Methods and results
Systematic phenotyping of ...CVI according to established CEAP (Clinical-Etiologic-Anatomic-Pathophysiologic) classification was performed in 12 423 participants (age range: 40–80 years) of the Gutenberg Health Study from April 2012 to April 2017. Prevalence was calculated age- and sex-specifically. Multivariable Poisson regression models were calculated to evaluate the relation of CVI with cardiovascular comorbidities. Survival analyses were carried out to assess the CVI-associated risk of death. Replication of findings was done in an independent cohort study (MyoVasc, NCT04064450). The prevalence of telangiectasia/reticular, varicose veins, and CVI was 36.5% 95% confidence interval (CI), 35.6–37.4%, 13.3% 12.6–13.9%, and 40.8% 39.9–41.7%, respectively. Age, female sex, arterial hypertension, obesity, smoking, and clinically overt cardiovascular disease were identified as clinical determinants of CVI. Higher CEAP classes were associated with a higher predicted 10-year risk for incident cardiovascular disease in individuals free of cardiovascular disease (n = 9923). During a mean follow-up of 6.4 ± 1.6 years, CVI was a strong predictor of all-cause death independent of the concomitant clinical profile and medication hazard ratio (HR) 1.46 (95% CI 1.19–1.79), P = 0. 0003. The association of CVI with an increased risk of all-cause death was externally validated in the MyoVasc cohort HR 1.51 (95% CI 1.11–2.05), P = 0.009.
Conclusion
Chronic venous insufficiency is highly prevalent in the population and is associated with the presence of cardiovascular risk factors and disease. Individuals with CVI experience an elevated risk of death, which is independent of age and sex, and present cardiovascular risk factors and comorbidities.
Graphical Abstract
Chronic venous insufficiency is highly prevalent in the general population and associated with arterial cardiovascular disease and an increased risk of all-cause mortality.
Unselected data of nationwide studies of hospitalized patients with COVID-19 are still sparse, but these data are of outstanding interest to avoid exceeding hospital capacities and overloading ...national healthcare systems. Thus, we sought to analyze seasonal/regional trends, predictors of in-hospital case-fatality, and mechanical ventilation (MV) in patients with COVID-19 in Germany. We used the German nationwide inpatient samples to analyze all hospitalized patients with a confirmed COVID-19 diagnosis in Germany between 1 January and 31 December in 2020. We analyzed data of 176,137 hospitalizations of patients with confirmed COVID-19-infection. Among those, 31,607 (17.9%) died, whereby in-hospital case-fatality grew exponentially with age. Overall, age ≥ 70 years (OR 5.91, 95%CI 5.70-6.13,
< 0.001), pneumonia (OR 4.58, 95%CI 4.42-4.74,
< 0.001) and acute respiratory distress syndrome (OR 8.51, 95%CI 8.12-8.92,
< 0.001) were strong predictors of in-hospital death. Most COVID-19 patients were treated in hospitals in urban areas (
= 92,971) associated with the lowest case-fatality (17.5%), as compared to hospitals in suburban (18.3%) or rural areas (18.8%). MV demand was highest in November/December 2020 (32.3%, 20.3%) in patients between the 6th and 8th age decade. In the first age decade, 78 of 1861 children (4.2%) with COVID-19-infection were treated with MV, and five of them died (0.3%). The results of our study indicate seasonal and regional variations concerning the number of COVID-19 patients, necessity of MV, and case fatality in Germany. These findings may help to ensure the flexible allocation of intensive care (human) resources, which is essential for managing enormous societal challenges worldwide to avoid overloaded regional healthcare systems.
Reactive oxygen and nitrogen species (ROS and RNS, e.g. H
O
, nitric oxide) confer redox regulation of essential cellular signaling pathways such as cell differentiation, proliferation, migration and ...apoptosis. At higher concentrations, ROS and RNS lead to oxidative stress and oxidative damage of biomolecules (e.g. via formation of peroxynitrite, fenton chemistry). Peripheral artery disease (PAD) is characterized by severe ischemic conditions in the periphery leading to intermittent claudication and critical limb ischemia (end stage). It is well known that redox biology and oxidative stress play an important role in this setting. We here discuss the major pathways of oxidative stress and redox signaling underlying the disease progression with special emphasis on the contribution of inflammatory processes. We also highlight therapeutic strategies comprising pharmacological (e.g. statins, angiotensin-converting enzyme inhibitors, phosphodiesterase inhibition) and non-pharmacological (e.g. exercise) interventions. Both of these strategies induce potent indirect antioxidant and anti-inflammatory mechanisms that may contribute to an improvement of PAD associated complications and disease progression by removing excess formation of ROS and RNS (e.g. by ameliorating primary complications such as hyperlipidemia and hypertension) as well as the normalization of the inflammatory phenotype suppressing the progression of atherosclerosis.
Antiplatelet and anticoagulant drugs work at different places in the coagulation system. Antiplatelet drugs are usually indicated in patients with atherosclerosis. Anticoagulant drugs are mostly used ...in patients with atrial fibrillation, venous thromboembolism, or technical heart valves. In some clinical situations, combination of antiplatelet and anticoagulant therapy can be indicated. The most recent situations are a more intensive antithrombotic therapy for risk reduction in patients with atherosclerosis and temporary addition of antiplatelet drugs in patients with indication for long-term anticoagulation. Temporary combination of antiplatelet and anticoagulant drugs is usually necessary after coronary intervention in patients with atrial fibrillation. In patients with high-risk atherosclerosis, the combination of low-dose rivaroxaban and aspirin reduces major adverse cardiovascular events (myocardial infarction, stroke, cardiovascular death) and major adverse limb events. But every combination of antiplatelet and antithrombotic drugs can increase bleeding risk. Therefore, a careful assessment of thrombotic versus bleeding risk is necessary for each patient.
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