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New-onset postoperative atrial fibrillation (POAF) is the most common complication after cardiac surgery and is associated with increased long-term stroke and mortality. Anticoagulation has been suggested as a potential therapy, but data on safety and efficacy are scant.To determine the association between anticoagulation for POAF and long-term outcomes.Adult patients with POAF after isolated coronary artery bypass surgery (CABG) were identified through the Society of Thoracic Surgeons Adult Cardiac Surgery Database and linked to the Medicare Database. Propensity-matched analyses were performed for all-cause mortality, stroke, myocardial infarction, and major bleeding for patients discharged with or without anticoagulation. Interaction between anticoagulation and CHAOf 38,936 patients, 9861 (25%) were discharged on oral anticoagulation. After propensity score matching, discharge anticoagulation was associated with increased mortality (hazard ratio [HR] 1.16, 95% confidence interval [CI] 1.06-1.26). There was no difference in ischemic stroke between groups (HR 0.97, 95% CI 0.82-1.15), but there was significantly higher bleeding (HR 1.60, 95% CI 1.38-1.85) among those discharged on anticoagulation. Myocardial infarction was lower in the first 30 days for those discharged on anticoagulation, but this effect decreased over time. The incidence of all complications was higher for patients with CHAAnticoagulation is associated with increased mortality after new-onset POAF following CABG. There was no reduction in ischemic stroke among those discharged on anticoagulation regardless of CHA

1. Understand the limitations of the modeling of survival data, especially as pertains to the Cox proportional hazards model. 2. An introduction to model-free estimates of survival, namely, the restricted mean survival time/restricted mean lost time. 3. Use R (The R Foundation for Statistical Computing, Austria) or STATA® (The STATACorp, College Station, TX, USA) to perform analyses and obtain these parameters from a dataset. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s12055-021-01167-4.

Learning objectives: 1. Understand what events can be labelled as intermediate events in survival analysis. 2. Understand why the Kaplan and Meier method cannot be used in the presence of competing events. 3. Regression analysis in the presence of competing events.

Studies evaluating average treatment effects (ATE) of an intervention could broadly be classified into those with observational and randomized designs. Observational studies are limited by confounding, in addition to selection and information bias, making the evaluation of ATE hypothesis generating and not hypothesis testing. Randomization attempts to reduce the systemic error introduced by observational studies by ensuring equal distribution of prognostic factors between the treatment and control groups, thereby confirming that any difference in outcomes observed between the two groups is attributable to the treatment. While randomized controlled trials (RCT) remain the gold standard in estimating ATE of therapeutic interventions, they do have inherent limitations due to uncertain external validity. Observational studies can have a complementary role in enhancing RCTs' ability to inform routine clinical practice. In this review, we focus on the limitations of observational studies, the need for randomization, interpretation, and the limitations of RCTs.

This study aimed to evaluate the relationship between status epilepticus (SE) and cardiorespiratory comorbidity in patients with epilepsy.We conducted a population-based study using cloud-based aggregated electronic medical records from53 million patients in the US (Explorys, IBM Watson; January 1999 to November 2020). During the study period, we identified patients with epilepsy with SE. Patients with a history of cardiac arrest, anoxic encephalopathy, and/or cerebrovascular disease were excluded. We reported the prevalences and prevalence ratios of cardiorespiratory and medical comorbidities using age- and sex-adjusted standardization.We identified 494,790 patients with epilepsy and 19,190 had SE. Cardiovascular and respiratory diseases were statistically significantly more prevalent in patients with epilepsy with SE than in those without SE (adjusted prevalence ratio (APR) 1.13, prevalence 68.7% [95% confidence interval (CI): 67.6-69.9] vs 60.9% [95% CI: 60.7-61.1]) and (APR 1.25, 73.1% [95% CI: 71.8-74.3] vs 58.4% [95% CI: 58.1-58.6]), respectively. Aspiration pneumonia (APR 3.12, 0.47% [95% CI: 0.37-0.57] vs 0.15% [95% CI: 0.14-0.16]) and acute respiratory distress syndrome (APR 2.40, 0.47% [95% CI: 0.37-0.57] vs 0.20% [95% CI: 0.18-0.21]) were more prevalent in patients with epilepsy with SE. Common cardiovascular risk factors such as diabetes mellitus (APR 1.13, 17.1% [95% CI: 16.5-17.6] vs 15.1% [95% CI: 1.50-15.2]) and hypertension (APR 1.28, 10.6% [95% CI: 10.2-11.0] vs 8.31% [95% CI: 8.23-8.39]) were also more common in patients with epilepsy with SE.In this population-based study, patients with epilepsy with SE had a statistically significantly higher prevalence of cardiorespiratory comorbidities than in those without SE.

Background Patients with atrial fibrillation (AF) complicated by heart failure (HF) have a poor prognosis. We investigated whether long term loop-diuretic therapy in patients with AF and no known diagnosis of HF, as a potential surrogate marker of undiagnosed HF, is also associated with worse outcomes. Methods Adults with incident AF were identified from UK primary and secondary care records between 2004 and 2016. Repeat prescriptions for loop diuretics, without a diagnosis of HF or documented non-cardiac indication, were classified as ‘isolated’ loop diuretic use. Results Amongst 124,256 people with incident AF (median 76 years, 47% women), 22,001 (17.7%) had a diagnosis of HF, and 22,325 (18.0%) had isolated loop diuretic use. During 2.9 (LQ-UQ 1–6) years’ follow-up, 12,182 patients were diagnosed with HF (incidence rate 3.2 [95% CI 3.1–3.3]/100 person-years). Of these, 3999 (32.8%) had prior isolated loop diuretic use, including 31% of patients diagnosed with HF following an emergency hospitalisation. The median time from AF to HF diagnosis was 3.6 (1.2–7.7) years in men versus 5.1 (1.8–9.9) years in women (p = 0.0001). In adjusted models, patients with isolated loop diuretic use had higher mortality (HR 1.42 [95% CI 1.37–1.47], p < 0.0005) and risk of HF hospitalisation (HR 1.60 [95% CI 1.42–1.80], p < 0.0005) than patients with no HF or loop diuretic use, and comparably poor survival to patients with diagnosed HF. Conclusions Loop diuretics are commonly prescribed to patients with AF and may indicate increased cardiovascular risk. Targeted evaluation of these patients may allow earlier HF diagnosis, timely intervention, and better outcomes, particularly amongst women with AF, in whom HF appears to be under-recognised and diagnosed later than in men.

Registries show international variations in the characteristics and outcome of patients with heart failure (HF), but national samples are rarely large, and case selection may be biased owing to enrolment in academic centers. National administrative datasets provide large samples with a low risk of bias. In this study, we compared the characteristics, health care resource use (HRU) and outcomes of patients with primary HF hospitalizations (HFH) using electronic health records (EHR) from 4 high-income countries (United States, UK, Taiwan, Japan) on 3 continents.We used electronic health record to identify unplanned HFH between 2012 and 2014. We identified 231,512, 10,991, 36,900, and 133,982 patients with a primary HFH from the United States, the UK, Taiwan, and Japan, respectively. HFH per 100,000 population was highest in the United States and lowest in Taiwan. Fewer patients in Taiwan and Japan were obese or had chronic kidney disease. The length of hospital stay was shortest in the United States (median 4 days) and longer in the UK, Taiwan, and Japan (medians of 7, 9, and 17 days, respectively). HRU during hospitalization was highest in Japan and lowest in UK. Crude and direct standardized in-hospital mortality was lowest in the United States (direct standardized rates 1.8, 95% confidence interval 1.7%-1.9%) and progressively higher in Taiwan (direct standardized rates 3.9, 95% CI 3.8%-4.1%), the UK (direct standardized rates 6.4, 95% CI 6.1%-6.7%), and Japan (direct standardized rates 6.7, 95% CI 6.6%-6.8%). The 30-day all-cause (25.8%) and HF (7.2%) readmissions were highest in the United States and lowest in Japan (11.9% and 5.1%, respectively).Marked international variations in patient characteristics, HRU, and clinical outcomes exist; understanding them might inform health care policy and international trial design.

With the advent of medical technology, coronary angiography is a common practice to evaluate patient for coronary artery disease. Normally, patients undergoing angiogram receive antiplatelets, anticoagulants, and platelet aggregation inhibitor agents. Glycoprotein IIb/IIIa receptor inhibitors are a type of platelets antiaggregant agents that can cause severe thrombocytopenia in very few cases. We present a case of a 69-year-old female who presented with chest pain, underwent an angiography and had two stents placed. She was administered tirofiban during angiogram that caused acute severe thrombocytopenia decreasing her platelets count from 224 to 2 k/mm3 within 1 day. Patients platelets gradually recovered after trial of steroid and platelets transfusion. Antiplatelets (Aspirin and Clopidogrel) were resumed; however, patient’s platelets remained stable.

Data regarding 10-year survival and adverse cardiovascular events in patients with metabolic syndrome (MET) after coronary artery bypass grafting (CABG) is limited.We compared 10-year events rates for veterans undergoing isolated CABG (January 1, 2005, to December 31, 2014, follow-up October 31, 2019) stratified by presence of metabolic syndrome (MET+) versus without (MET-). A multivariable weighted Cox model was used to analyze all-cause mortality. Competing risk analysis was used to calculate cumulative event rates for congestive heart failure, myocardial infarction, and cerebrovascular events. The Fine-Gray subhazard model was used to determine adjusted association of MET with myocardial infarction and stroke. Congestive heart failure was modeled as a recurrent-event analysis.Nationally, 9615 adults (median age, 60 years; 98.9% men) underwent isolated coronary artery bypass grafting at 41 centers); among them, 3121 out of 9615 (32.5%) had MET. The prevalence of MET increased from (27.88% in 2005 to 34.02% in 2014; P = .02). MET+ group members were likely younger (median age, 63 vs 64 years; P .01), White (72% vs 68%), and had more peripheral vascular disease (30% vs 28%; P = .04). Multivessel (72% vs 70%; P = .23) and multiarterial (4% vs 4%; P = .14) grafting was performed equally. With a median follow-up of 6.5 years, survival was similar (P = .26); however, MET was associated with higher risks for myocardial infarction (21% vs 16%; hazard ratio, 1.3; P .01) and recurrent admissions for congestive heart failure.Patients with metabolic syndrome undergoing coronary artery bypass grafting have higher 10-year cardiovascular event rates.

Background Limited literature exists that evaluated outcomes of kidney transplant–eligible patients who are having dialysis and who are undergoing valve replacement. Our main objective in this study was to compare mortality, reoperation, and bleeding episodes between bioprosthetic and mechanical valve procedures among kidney transplant–eligible patients who are having dialysis. Methods and Results We studied 887 and 1925 dialysis patients from the United States Renal Data System, who underwent mitral valve replacement and aortic valve replacement (AVR) after being waitlisted for a kidney transplant (2000–2015), respectively. Time to death, time to reoperation, and time to bleeding requiring hospitalizations were compared separately for AVR and mitral valve replacement. Kaplan–Meier survival curves, Cox proportional hazards model for time to death, accelerated time to event model for time to reoperation, and counting process model for time to recurrent bleeding were used. There were no differences in mortality (hazard ratio [HR], 0.92; 95% CI, 0.77–1.09) or risk of reoperation or risk of significant bleeding events between bioprosthetic and mechanical mitral valve replacement. However, mechanical AVR was associated with a modestly significant less hazard of death (HR, 0.83; 95% CI, 0.74–0.94) compared with bioprosthetic AVR. There were no differences in time to reoperation, or time to significant bleeding events between bioprosthetic and mechanical AVR. Conclusions For kidney transplant waitlisted patients who are on dialysis and who are undergoing surgical valve replacement, bioprosthetic and mechanical valves have comparable survival, reoperation rates, and bleeding episodes requiring hospitalizations at both mitral and aortic locations. These findings emphasize that an individualized informed decision is recommended when choosing the type of valve for this special group of patients having dialysis.

A myriad of the population has adapted to the evolving technology, which includes text communication. Users advertently or inadvertently share emotions. As we know, emotions are one of the most critical aspects of human life; they impact human's behavior, thinking, compelling of action, and most important, decision making. There are many alleged emotions known to us, and each having its significance. In this era of modern technology, it is hard to find any unexplored area; this applies to emotion. People express their emotions through text a lot nowadays, which has led the Emotion Recognition as an important research area. Extracting emotion is a very complicated task. This paper shows a new approach to detect emotion based on TFIDF, and it is a measure that reflects the value a word holds in a document. In this method, emotion is classified into six types. There are other researches on the simple distinction between positive and negative emotion, but this does not add much to understanding human emotion. Emotion is extracted from different sentences, and data representation is based on semantic structure. It generalizes each sentence into six major predefined emotion sets. The evaluation shows that this method is well accomplished to categorize a sentence into different emotion categories and with a reasonable accuracy rate.

OBJECTIVES We analysed the Veteran Affairs data to evaluate the association of pre-operative glycated haemoglobin (HbA1c) and long-term outcome after isolated coronary artery bypass grafting (CABG). METHODS Veterans with diabetes mellitus and isolated CABG (2006–2018) were divided into 4 groups (I: HbA1c 10%). The relationship of pre-operative HbA1c and long-term survival was evaluated with a multivariable Cox proportional hazards model and reported as hazard ratios (HR). The cumulative incidence of secondary end-points [myocardial infarction (MI) and repeat revascularization (percutaneous intervention)] for each group was modelled as competing events with cause-specific Cox proportional hazards models. RESULTS Overall, 16 190 patients (mean age 64.9 years, male 98%; insulin dependent 53%) with diabetes mellitus underwent isolated CABG. We observed 19.4%, 45.4%, 27% and 8.2% patients in groups I, II, III and IV, respectively. Patients with HbA1c >10% were the youngest (mean age 60.9 years) and had high rates of Insulin dependence (78%). In patients with HbA1c >10%, improvement in levels was observed in 76%. The median follow-up observed was 5.8 (3.2–8.8) years. Compared to the study mean HbA1c (7.3%), mortality rate increased with HbA1c levels >8%, and especially with pre-operative HbA1c levels >9%. Compared to patients with HbA1c 10% were associated with increased MI (HR 1.24 and HR 1.39, respectively) and need for reintervention (HR 1.20 and HR 1.24, respectively). CONCLUSIONS In patients undergoing CABG, pre-operative HbA1c >8% is associated with the increased risk of mortality and adverse cardiac events.

Introduction: We analyzed the national Veteran Affairs (VA) data to evaluate the association of preoperative glycated Hemoglobin (HbA1c) and long-term outcome after isolated coronary artery bypass grafting (CABG). Methods: Between January 2007 - December 2014, Veterans with diabetes mellitus (DM) that underwent isolated CABG were divided on into three groups (I: HbA1c < 8%, II: HbA1c 8 - 10% and III: HbA1c > 10%). Demographic and clinical differences between groups were evaluated with the t-test or chi-square test. The relationship of preoperative HbA1c and long-term survival was evaluated with a multivariable proportional hazards model; restricted cubic splines were used to model non-linear effects. The cumulative incidence of secondary end-points (myocardial infarction, urgent revascularization) for each group was modeled as a competing-risk analysis. Results: Overall, 3,210 patients (mean age 64.6 years, male 98.8%; insulin dependent - 53%) with DM underwent isolated CABG. Group III patients were younger (61 vs 65 years in group I). Median HbA1c levels were similar between races (white - 7.3% and blacks - 7.35%). Insulin dependence was higher in group III (79.3%) vs groups I (43.5%) and II (69.9%). In groups I,II and III, 5 and 10 year survival was 76.2%, 74.4%, 75.4% and 38.9%, 36.9% and 30.2% respectively. HbA1c was observed to have a J-shaped association with mortality with values < 6% and > 9% at higher risk of death. Left ventricular systolic dysfunction [HR 1.5 (1.3 - 1.7)], prior myocardial infarction [HR 1.3 (1.2 - 1.5)] and insulin dependence [HR 1.4 (1.2 - 1.5)] were also associated with lower survival. Myocardial infarction was observed in 9.8% , 13.4% and 12.8% patients in groups I, II and III respectively. Conclusions: Pre-operative HbA1c impacts long-term survival among diabetic patients undergoing CABG. We observed a J-shaped relationship between HbA1c and survival with values < 6% and > 9% associated with increased mortality.

Learning objectives: 1. To understand the log-rank test and limitations of the log-rank test in comparing survival between groups. 2. To understand the fundamental concepts of the proportional hazards assumption. 3. To understand basic steps in the development of the Cox proportional hazards model and reported hazard ratios. 4. To understand how results of a Cox model run using STATA© (a commonly used proprietary statistical software) can be understood and interpreted. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s12055-020-01108-7.

Background Coronary artery bypass grafting (CABG) improves survival in patients with heart failure and severely reduced left ventricular systolic function (LVEF). Limited data exist regarding adverse cardiovascular event rates after CABG in patients with heart failure with midrange ejection fraction (HFmrEF; LVEF > 40% and Methods We analyzed data on isolated CABG patients from the Veterans Affairs national database (2010-2019). We stratified patients into control (normal LVEF and no heart failure), HFmrEF, and heart failure with reduced LVEF (HFrEF) groups. We compared all-cause mortality and heart failure hospitalization rates between groups with a Cox model and recurrent events analysis, respectively. Results In 6533 veterans, HFmrEF and HFrEF was present in 1715 (26.3%) and 566 (8.6%) respectively; the control group had 4252 (65.1%) patients. HFrEF patients were more likely to have diabetes mellitus (59%), insulin therapy (36%), and previous myocardial infarction (31%). Anemia was more prevalent in patients with HFrEF (49%) as was a lower serum albumin (mean, 3.6 mg/dL). Compared with the control group, a higher risk of death was observed in the HFmrEF (hazard ratio [HR], 1.3 [1.2-1.5)] and HFrEF (HR, 1.5 [1.2-1.7]) groups. HFmrEF patients had the higher risk of myocardial infarction (subdistribution HR, 1.2 [1-1.6]; P = .04). Risk of heart failure hospitalization was higher in patients with HFmrEF (HR, 4.1 [3.5-4.7]) and patients with HFrEF (HR, 7.2 [6.2-8.5]). Conclusions Heart failure with midrange ejection fraction negatively affects survival after CABG. These patients also experience higher rates myocardial infarction and heart failure hospitalization.

AIMS: Postoperative atrial fibrillation (POAF) is a frequent in-hospital complication after cardiac surgery. Surprisingly, despite its prevalence, management of this condition has not been well studied. One promising approach that has been evaluated in a limited number of studies is use of anticoagulation. However, the trends and patterns of real-world use of anticoagulation in POAF patients has not been systemically investigated. In this study, we aimed to determine real-world patterns of anticoagulation use for patients with POAF. METHODS: We identified 200 patients undergoing coronary artery bypass (CABG) or cardiac valve surgery at University Hospitals Cleveland Medical Center over a 2 year period beginning January 2016 with new onset POAF. We reviewed charts to verify candidacy for inclusion in the study and to extract data on anticoagulation use, adverse outcomes, and CHA(2)DS(2)-VASc scores. RESULTS: Anticoagulation use was low after CABG, but high after bioprosthetic valve surgery. The most common anticoagulant used was warfarin. Anticoagulation use was not correlated with CHA(2)DS(2)-VASc score or cardioversion. Stroke and mortality were higher among patients not receiving anticoagulation, however, confirmation of this finding in larger randomized studies is warranted. CONCLUSIONS: Anticoagulation use is low after CABG and this practice does not appear to be affected by CHA(2)DS(2)VASc score or cardioversion. This differs with previously reported provider attitudes towards management of this condition. Stroke and mortality appear to be elevated for patients not receiving anticoagulation but further investigation is required to confirm this observation.

Introduction Postoperative atrial fibrillation (POAF) is a common complication after cardiac surgery. Though often felt to be self-limited, this complication has been associated with increases in both short and long-term stroke and mortality. Several studies have also shown a high rate of AF recurrence. Optimal treatment strategy is not yet defined, and the role of anticoagulation (AC) is unclear. Our objective was to determine provider attitudes toward management of this common complication. Methods A survey consisting of 15 multiple choice questions was distributed to providers at Veterans Healthcare Administration hospitals nationwide. Results The majority of respondents were cardiologists. Practices varied drastically with respect to AC use for patients with POAF who were discharged in normal sinus rhythm. Less variability existed for patients discharged in AF. There was no clear consensus regarding other factors to consider when deciding on AC therapy, including length of episode, or risk factors for stroke such as CHA2 DS2 -VASc score. There was also no consensus on duration of therapy or need for post discharge cardiac monitoring. Conclusion Our data indicate a wide variability in the management of POAF. This reflects conflicting recommendations in the guidelines, as well as a paucity of prospective treatment trials in this field. Nevertheless, a growing evidence base suggests that this complication carries potentially serious long-term morbidity and mortality, and better evidence for its management is needed.

Rationale: Heart failure (HF) is a common comorbidity in the chronic obstructive pulmonary disease (COPD) population, but previous research has shown underrecognition.Objectives: The objectives of this study were to determine the incidence of HF in a prevalent COPD cohort and to determine the association of incident HF with short- and long-term mortality of patients with COPD.Methods: Crude incidence of HF in the HF-naive primary care COPD population was calculated for each year from 2006 to 2016 using UK data from the Clinical Practice Research Datalink (CPRD). Patients with COPD were identified using a validated code list and were required to be >35 years old at COPD diagnosis, have a history of smoking, and have documented airflow obstruction. The Office of National Statistics provided mortality data for England. Adjusted mortality rate ratios (aMRRs) from Poisson regression were calculated for patients with COPD and incident HF (COPD-iHF) in 2006, 2011, and 2015, and compared temporally with patients with COPD and without incident HF (COPD-no HF) in those years. Regression was adjusted for age, sex, body mass index, severity of airflow limitation, smoking status, history of cardiovascular disease, and diabetes.Results: We identified 95,987 HF-naive patients with COPD. Crude incidence of HF was steady from 2006 to 2016 (1.18 per 100 person-years; 95% confidence interval [CI], 1.09-1.27). Patients with COPD-iHF experienced greater than threefold increase in 1-year mortality and twofold increase in 5-year and 10-year mortality compared with patients with COPD-no HF, with no change on the basis of year of HF diagnosis. Mortality of patients with COPD-iHF did not improve over time, comparing incident HF in 2011 (1-yr aMRR, 1.26; 95% CI, 0.83-1.90; 5-yr aMRR, 1.26; 95% CI, 0.98-1.61) and 2015 (1-yr aMRR, 1.63; 95% CI, 0.98-2.70) with incident HF in 2006.Conclusions: The incidence of HF in the UK COPD population was stable in the last decade. Survival of patients with COPD and incident HF has not improved over time in England. Bespoke guidelines for the diagnosis and management of HF in the COPD population are needed to improve identification and survival of patients.

ObjectiveBioprosthetic valves are being used with increased frequency for valve replacement, with controversy regarding risk:benefit ratio compared with mechanical valves in younger patients. However, prior studies have been too small to provide comparative estimates of less common but serious adverse events such as infective endocarditis. We aimed to compare the incidence of infective endocarditis between bioprosthetic valves and mechanical valves.MethodsWe searched PubMed, Cochrane, EMBASE, Scopus and Web of Science from inception to April 2018 for studies comparing left-sided aortic and mitral bioprosthetic to mechanical valves for randomised trials or observational studies with propensity matching. We used random-effects model for our meta-analysis. Our primary outcome of interest was the rate of infective endocarditis at follow-up.Results13 comparison groups with 43 941 patients were included. Mean age was 59±7 years with a mean follow-up of 10.4±5.0 years. Patients with bioprosthetic valves had a higher risk of infective endocarditis compared with patients receiving mechanical valves (OR 1.59, 95% CI 1.35 to 1.88, p2=0%). Exclusion of the study with maximum weight did not change the results of the analysis (OR 1.57, 95% CI 1.14 to 2.17, p=0.006). A meta-regression of follow-up time on incidence of infective endocarditis was not statistically significant (p=0.788) indicating difference in follow-up times did not alter the pooled risk of infective endocarditis.ConclusionsBioprosthetic valves may be associated with a higher risk of infective endocarditis. These data should help guide the discussion when deciding between bioprosthetic and mechanical valves in individual patients.

Additional file 1: Figure S1. Search of MEDLINE on 05 February 2019. Figure S2. Search of Embase on 05 February 2019. Table S1. Overview of included literature.

Sleep-disordered breathing (SDB) is highly prevalent in heart failure (HF). The presence of SDB in patients with HF appears to be associated with increased risk of cardiovascular morbidity and mortality. In this article, we describe the types, pathophysiology, and consequences of SDB and discuss ways in which SDB can be diagnosed. We also lay emphasis on the recent randomized controlled trials that have had a major impact on how SDB is managed and highlight the complex relationship between SDB and outcomes.

Aims Most reports estimating national incidence rates of coronary (CAD) and peripheral arterial disease (PAD) have focused on stable outpatients or acute or elective hospital admissions, but not on the overall burden of disease. In this study, we report the changing trends in the population-level incidence of CAD and PAD, respectively from 2006 to 2015, statin utilization for secondary prevention and survival outcomes using multiple nationally representative data sources from the UK (primary care encounters, hospital admissions, and procedure-level data). Methods and results A nationally representative study of linked primary and secondary care electronic health records of 4.6 million individuals from the UK. We calculated crude and standardized annual incidence rates separately for CAD and PAD. Statin use for secondary prevention, trends in annual major vascular event rates, and mortality between 2006 and 2015, were estimated for CAD and PAD, respectively. We identified 160 376 and 70 753 patients with incident CAD and PAD, respectively. The age- and sex-standardized incidence of CAD was similar in 2006 (443 per 100 000 person-years) and 2015 [436 per 100 000 person-years; adjusted incidence rate ratio (IRR) 0.98, 95% confidence interval (CI) 0.96–1.00]. In contrast, there was a 15% decline in the standardized incidence of PAD (236 per 100 000 person-years in 2006 to 202 per 100 000 person-years in 2015; adjusted IRR 0.85, 95% CI 0.82–0.88). The proportion of incident CAD and PAD patients prescribed long-term statins, was only 66% and 55%, respectively and was less common amongst women, patients aged >70 years, with heart failure, chronic lung disease, or depression. Cardiovascular mortality declined by 43% for incident CAD (adjusted IRR 0.57, 95% CI 0.50–0.64) between 2006 and 2015 but did not decline for incident PAD (adjusted IRR 0.84, 95% CI 0.70–1.00). Conclusion and relevance In the UK, the standardized incidence of CAD appears stable but mortality rates are falling, whereas the standardized incidence of PAD is falling but mortality rates are not.

Aims: Prognostic models for hospitalized heart failure (HHF) were developed predominantly for patients of European origin in the United States of America; it is unclear whether they perform similarly in other health care systems or for different ethnicities. We sought to validate published prediction models for HHF in the United Kingdom (UK) and Japan. Methods and results: Patients in the UK (n =894) and Japan (n =3158) were prospectively enrolled and were similar in terms of sex (∼60% men) and median age (∼77 years). Models predicted that British patients would have a higher mortality than Japanese, which was indeed true both for in‐hospital (4.8% vs. 2.5%) and 180‐day (20.7% vs. 9.5%) mortality. The model c‐statistics for the published/derivation (range 0.70–0.76) and Japanese (range 0.75–0.77) cohorts were similar and higher than for the UK (0.62–0.75) but models consistently overestimated mortality in Japan. For in‐hospital mortality, the OPTIMIZE‐HF model performed best, providing similar discrimination in published/derivation, UK and Japanese cohorts [c‐indices: 0.75 (0.74–0.77); 0.75 (0.68–0.81) and 0.77 (0.70–0.83), respectively], and least overestimated mortality in Japan. For 180‐day mortality, the c‐statistics for the ASCEND‐HF model were similar in published/derivation (0.70) and UK [0.69 (0.64–0.74)] cohorts but higher in Japan [0.75 (0.71–0.79)]; calibration was good in the UK but again overestimated mortality in Japan. Conclusion: Calibration of published prediction models appears moderately accurate and unbiased when applied to British patients but consistently overestimates mortality in Japan. Identifying the reason why patients in Japan have a better than predicted prognosis is of great interest.

Background More than 20% of Medicare beneficiaries receiving cardiac resynchronization therapy defibrillators (CRT-D) have a very wide (≥180 ms) QRS complex duration (QRSD). Outcomes of CRT-D in these patients are not well-established because they have been underrepresented in clinical trials. Objectives This study examined outcomes in patients with CRT-D in a very wide QRSD with left bundle branch block (LBBB) versus those without LBBB. Methods Medicare patients from the Implantable Cardioverter Defibrillator Registry (January 1, 2005, through April 30, 2006) with a CRT-D and confirmed Class I or IIa indications for CRT-D were matched to implantable cardioverter-defibrillator (ICD) patients without CRT despite having Class I or IIa indications for CRT. Mortality and heart failure hospitalizations over 4 years with CRT-D versus standard ICDs based on QRSD and morphology were analyzed. Results We analyzed 24,960 patients. Among those with LBBB, patients with a QRSD ≥180 ms had a greater adjusted survival benefit with CRT-D versus standard ICD (hazard ration [HR] for death: 0.65; 95% confidence interval [CI]: 0.59 to 0.72) compared with those having a QRSD 120 to 149 ms (HR: 0.85; 95% CI: 0.80 to 0.92) and 150 to 179 ms (HR: 0.87; 95% CI: 0.81 to 0.93). CRT-D versus ICD was associated with an improvement in survival in those with non-LBBB and a QRSD ≥180 ms (adjusted HR for death: 0.78; 95% CI: 0.68 to 0.91), but not in those with non-LBBB and a QRSD 150 to 179 ms (adjusted HR for death: 1.06; 95% CI: 0.95 to 1.19). Conclusions Improvements in both survival and heart failure hospitalizations with CRT-D were greatest in patients with a QRSD ≥180 ms with or without LBBB, whereas patients with a QRSD 150 to 179 ms without LBBB had no improvement in survival with CRT-D, and those with a QRSD 150 to 179 ms and LBBB had only a modest improvement.

Introduction We identified clinical and/or surgical factors contributing to failure of penile plication for Peyronie’s reconstruction and assessed outcomes of repeat plications. Methods We conducted a retrospective review of patients who underwent penile plication between 2007 and 2016. Plication was performed after inducing an artificial erection intraoperatively using corrective longitudinal 2-zero Ethibond™ sutures placed systematically in a uniform manner without circumcision. Penile length, and angle and direction of curvature were recorded, along with number and location of plication sutures and clinical outcome. Results Of 340 patients undergoing penile plication during the study period 7 (2.1%) underwent repeat plication for insufficient straightening. Two additional patients underwent salvage plication after initial surgery performed elsewhere. Median time to revision was 6 months (range 3.4 to 27.4). The most common clinical features at reoperation were severe erectile dysfunction in 5 cases (71%), multiplanar curvature in 5 (71%) and severe curvature (60 degrees or greater) in 3 (43%). Most revisions involved a greater number of sutures during revision (mean 9) compared to initial plication (6), and in 4 cases (44%) sutures were placed on the proximal shaft. After revision all cases were noted to be functionally straight, with a mean postoperative curvature of 4 degrees (range 0 to 20) at a median followup of 27 months (3 to 76). Conclusions Inadequate correction of Peyronie’s disease curvature by penile plication is rare but salvageable by a second plication procedure. Poor erectile response to intracavernous injection intraoperatively may mask the severity of the deformity, thus leading to inadequate numbers of corrective sutures.

ObjectivesTo characterise peak cardiac troponin levels, in patients presenting with acute myocardial infarction (AMI), according to their comorbid condition and determine the influence of peak cardiac troponin (cTn) levels on mortality.MethodsWe included patients with the first admission for AMI in the UK. We used linear regression to estimate the association between eight common comorbidities (diabetes mellitus, previous angina, peripheral arterial disease, previous myocardial infarction (MI), chronic kidney disease (CKD), cerebrovascular disease, chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD)) and peak cTn. Peak cTn levels were adjusted for age, sex, smoking status and comorbidities. Logistic regression and restricted cubic spline models were employed to investigate the association between peak cTn and 180-day mortality for each comorbidity.Results330 367 patients with ST elevation myocardial infarction and non-ST elevation myocardial infarction were identified. Adjusted peak cTn levels were significantly higher in patients with CKD (adjusted % difference in peak cTnT for CKD=42%, 95% CI 13.1 to 78.4) and significantly lower for patients with COPD, previous angina, previous MI and CHF when compared with patients without the respective comorbidities (reference group) (cTnI; COPD=−21.7%, 95% CI −29.1 to −13.4; previous angina=−24.2%, 95% CI −29.6 to −8.3; previous MI=−13.5%, 95% CI −20.6 to −5.9; CHF=−28%, 95% CI −37.2 to −17.6). Risk of 180-day mortality in most of the comorbidities did not change substantially after adjusting for peak cTn. In general, cTnI had a stronger association with mortality than cTnT.ConclusionsIn this nationwide analysis of patients presenting with AMI, comorbidities substantially influenced systemic concentrations of peak cTn. Comorbid illness is a significant predictor of mortality regardless of peak cTn levels and should be taken into consideration while interpreting cTn both as a diagnostic and prognostic biomarker.

Background Non-culprit percutaneous coronary intervention (PCI) during a ST-segment elevation myocardial infarction (STEMI) remains controversial. We performed a meta-analysis of the published literature comparing a strategy of complete revascularization (CR) with culprit or target vessel revascularization (TVR)-only after STEMI in patients with multi-vessel disease. Methods We searched PubMed/Medline, Cochrane, EMBASE, Web of Science, CINAHL, Scopus and Google-scholar databases from inception to March-2016 for clinical trials comparing CR with TVR during PCI for STEMI. Mantel–Haenszel risk ratio (MH-RR) with 95% confidence intervals (CI) for individual outcomes was calculated using random-effects model. Results A total of 7 randomized trials with 2004 patients were included in the final analysis. Mean follow-up was 25.4months. Major adverse cardiac events (MACE) (MH-RR: 0.58, 95% CI: 0.43–0.78, P Conclusions CR strategy in STEMI patients with multivessel coronary artery disease is associated with reduction in MACE, cardiac mortality and need for repeat revascularization but with no decrease in the risk of subsequent MI or all-cause mortality. CR was safe however, with no increase in adverse events including stroke, stent thrombosis or contrast nephropathy when compared to TVR.

Prior studies have suggested significant underutilization of statins in women and poorer cardiovascular outcomes. The impact of calcium scoring in improving utilization of evidence-based therapies and outcomes in large prospective studies is limited. In a prospective study of low cost or no-cost

To present results of an algorithmic approach to perineal urethrostomy (PU) based on a midline perineal incision among men with complex urethral strictures. A single surgeon retrospective review of consecutive patients who underwent PU between 2008 and 2017 was performed. Patient demographics and outcomes were collected via medical record review. After a midline perineal incision, the PU was matured either by (a) mobilization of the urethral plate (loop) alone in cases with distal strictures or low body mass index (BMI), or (b) with creation of a lateral perineal skin flap (7-flap) for those with longer urethra-to-skin distances. Success was defined as functional voiding without the need for further procedures. Patients were contacted by phone and administered validated questionnaires. Of 62 PU patients, 20 (32.3%) underwent the loop technique, and 42 (67.7%) had the 7-flap procedure, 7 of which were reoperative for prior failed PU. Median age was 61.9 years (range 23–85) and the median stricture length was 8.0 cm (range 2.5–18 cm). Mean BMI was greater among 7-flap compared to loop patients (34.9 vs. 30.0 kg/m2, p = 0.01). Success rates were 92.9% (39/42) in the 7-flap group and 100% (20/20) in the loop PU cohort during a median follow-up of 30.7 months. Among 62 PU patients, 19 (30.6%) responded to the survey—median PGI-I score was 1.0 (range 1–2) indicating that symptoms were “very much improved”. The algorithmic midline approach to PU offers a standardized, versatile solution with excellent surgical outcomes and high patient satisfaction, even in obese or refractory stricture patients.