Epidemiology of cardiac amyloidosis and burden on health care system in Germany: a retrospective analysis from 2009 to 2018

Aims

Improved imaging modalities contributed to increasing disease awareness of cardiac amyloidosis. Contemporary data on frequency trends and impact on health system are lacking.

Methods and results

In a retrospective study using health claims data of the largest German statutory health insurance patients with a diagnostic code of amyloidosis and concomitant heart failure or cardiomyopathy between 2009 and 2018 were identified. Temporal trends in frequency, patient characteristics, all-cause mortality and measures of health care burden were examined.

8,279 patients were identified of whom 5,618 were incident without diagnosis of amyloidosis within the previous year. Prevalence increased from 15.5 to 47.6 per 100,000 person-years, and incidence increased from 4.8 to 11.6 per 100,000 person-years, with a continuous steepening in the slope of incidence trend. Age and male gender significantly increased whereas prevalence of myeloma and nephrotic syndrome significantly decreased over time. Median (IQR) survival time after first diagnosis was 2.5 years (0.5 to 6 years), with a 9% (95% CI 2–15%, p=0.008) reduced risk of death in the second compared to the first five years of observation. In the first year after diagnosis mean total health care costs were 21,955 € (median 9,873 €, IQR 3,922 to 24,714 €) per person.

Conclusion

The rise in patients with cardiac amyloidosis has continuously accelerated in the last decade which, based on patient characteristics, is mainly driven by underlying wildtype transthyretin amyloidosis. Considering the adverse outcome and high health care burden further effort should be put on early detection of the disease to implement treatment.

Funding Acknowledgement

Type of funding sources: None.

Sex related differences in vascular interventions and outcome of patients with critical limb threatening ischemia in a real-world cohort

Background

The prevalence of critical limb threatening ischemia (CLTI) is increasing worldwide and the focus is the reduction of outcome events like death or amputation of the lower limb (LL). Sex related differences in medical supply and outcome are a current matter of debate.

Purpose

In the present study, we included patients with CLTI in an unselected “real-world” cohort and studied sex related differences in their risk profile and vascular interventions, as well as their impact on long-term outcome.

Methods

We analyzed 119,953 unselected patients of the public health insurance in Germany (AOK), which were hospitalized between 2010 and 2017 for a main diagnosis of CLTI (Rutherford stage (RF) 4–6). In our data files, a baseline period of 2 years previous index hospitalization and a follow-up period until 2018 was included.

Results

In our cohort, more than half were male CLTI patients (57% male vs. 43% female), while female CLTI patients were at higher age (median: 73.8 years male vs. 81.4 years female). Male patients had higher ratios of diabetes, dyslipidemia, smoking, cerebrovascular disease and chronic coronary syndrome, whereas female CLTI patients show a higher prevalence of hypertension, atrial fibrillation, chronic heart failure and chronic kidney disease (all p<0.001). During index hospitalisation more than one quarter of all CLTI patients suffered from rest pain (RF 4), and approximately one third for minor (RF 5) and one third for major (RF 6) tissue lost. Female patients were more often diagnosed with RF 5 (32% male vs. 36% female), while the proportion of male patients was slightly higher at RF 4 (29% male vs. 27% female) and RF 6 (39% male vs. 37% female, all p<0.001).

During index hospitalization, almost 70% underwent any diagnostic angiography and in 63% of all patients a revascularization procedure was performed. Both were carried out more often in male patients (both p<0.001).The Kaplan Meier curve showed an increased mortality rate in female patients during follow up (figure 1), while no differences were observed for the combined endpoint amputation of the LL or death. Interestingly after adjustment for age and patients risk'constellation, female gender was associated with increased overall-survival (female HR 0.95; 95%-CI 0.94–0.96, p<0.001) and amputation-free survival which is a combined endpoint of amputation of the LL or death (female HR 0.84; 95%-CI 0.83–0.85, p<0.001).

Conclusion

Female patients with CLTI were older and showed lower rates of diagnostic angiography and revascularization procedures of the LL during index hopsitalization. Nevertheless, male sex was an independent risk factor for all-cause mortality and the combined endpoint amputation of the LL or death during long-term follow-up. These results indicate that further analyses are needed to determine the various individual needs of male and female CLTI patients.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The project upon which this publication is based was funded by The Federal Joint Committee, Innovation Committee (G-BA, Innovationsfonds, number 01VSF18051).

Contemporary in-hospital and long-term prognosis of patients with acute ST-elevation myocardial infarction and chronic kidney disease in Germany

Background

Although acute myocardial infarction (AMI) incidence and mortality have decreased over the last decades, survival rates of AMI patients remain rather stable. About 25% of patients with ST-elevation myocardial infarction (STEMI) suffer from chronic kidney disease (CKD).

Purpose

We sought to determine short- and long-term mortality in STEMI patients with different stages of CKD.

Methods

We identified all patients who were hospitalised with a main diagnosis of STEMI between 2010 and 2017 from the dataset of the Federal Association of the Local Health Insurance Funds (Allgemeine Ortskasse), Germany. The patients were grouped according to their CKD stage at index hospitalisation. We analysed concomitant diseases, in-hospital treatment and complications. Overall survival was analysed using Kaplan Meier methods and predictors for overall survival were identified by Cox regression analysis.

Results

A total of 175,187 patients were identified with an index hospitalisation for STEMI, thereof 137,682 (78.6%) patients without CKD, 8,347 (4.8%) patients with CKD stage 2, 20,459 (11.7%) patients with CKD stage 3, and 4,960 (2.8%) patients with CKD stage 4. The CKD stages 1, 5 and 5d (dialysis dependent CKD) each comprised less than 1,500 patients (<1.0%). STEMI patients with CKD were older and had more often cardiovascular risk factors, e.g. diabetes (no CKD: 33.2% vs CKD stage 5: 66.1%, p<0.001). Overall, patients with CKD received percutaneous coronary interventions (no CKD: 84.4% vs CKD stage 4: 62.0%, p<0.001) less frequently, and suffered more often from complications like shock (no CKD: 12.5% vs. CKD stage 5: 27.7%, p<0.001) or requirement of invasive/non-invasive ventilation (no CKD: 17.3% vs. CKD stage 5: 42.7%, p<0.001) than patients without CKD. With increasing CKD stages, patients were more likely to die within 30 days after STEMI (30-day mortality no CKD: 13.7% vs. CKD stage 5d: 37.2%, p<0.001). Kaplan-Meier estimates showed dramatically decreasing survival with decreasing renal function (Figure 1). Multivariable time-dependent Cox regression analysis for overall survival showed that the CKD stages 4, 5 and 5d, as well as chronic limb threatening ischemia (CLTI) were associated with a higher risk for death (CKD stage 5d: hazard ratio (HR) 5.64; 95% CI 5.42–5.86; CKD stage 5: HR 2.55; 95% CI 2.37–2.73; CKD stage 4: 1.72; 95% CI 1.66–1.78; CLTI: 2.06; 95% CI 1.98–2.13; all p<0.001).

Conclusion

CKD is a frequent co-morbidity in patients with STEMI which is associated with a devastating prognosis especially for patients with advanced CKD stages. More research is needed to gain evidence on optimized treatment strategies for patients with STEMI and concomitant CKD in this highly vulnerable cohort.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The project upon which this publication is based was funded by The Federal Joint Committee, Innovation Committee (G-BA, Innovationsfonds, number 01VSF18051). Figure 1. Unadjusted Kaplan-Meier survival curves

Sex-specific differences in first event of st- elevation myocardial infarction; new insights on age-related mortality

Background

For patients with ST-elevation myocardial infarction (STEMI) as the primary manifestation of coronary artery disease (CAD), data on predictors and outcome are limited. We hypothesized that specifically age and sex influence short- and long-term outcome in patients after first event of STEMI.

Methods and results

Based on claims data of the Federal Association of the Local Health Insurance Funds (Allgemeine Ortskrankenkasse) (≈26 million insurance holders in Germany with ≈83 million inhabitants), adults with STEMI between 01/2014 to 12/2015 and no history of CAD were selected for further analysis. Patient demographics, details on in-hospital treatment as well as age- and sex-related differences in 30-day mortality, re-infarction/ death, major adverse cardiovascular events (MACE), overall and long-term survival were assessed.

Overall, 17,444 patients presented with STEMI as the primary manifestation of CAD throughout the study period, thereof 33% were women. At index, women were older compared to men (median age 74 years vs. 60 years) and suffered from more cardiovascular comorbidities such as diabetes (35.8% vs. 25.2% in men), chronic kidney disease (26.0% vs. 14.9% in men), and arterial hypertension (84.6% vs. 72.6%; all p<0.001). Women with STEMI underwent endovascular reperfusion (78.5% vs. 88.1%) or coronary artery bypass grafting (4.2% vs. 5.5%; both p<0.001) less frequently. In-hospital complications such as shock (19.2% vs. 16.0%) and resuscitation (15.1% vs. 12.9%; both p<0.001) were observed more often in women.

Female sex was independently associated with adjusted 30-day mortality (Odds Ratio 1.17; p=0.01). Long-term outcomes revealed women to be at increased risk of the combined end-point of re-infarction and/or death (Hazard ratio (HR) 1.09; p=0.01), MACE (HR 1.09; p=0.01) and all-cause mortality (HR 1.10; p=0.01). Particularly in patients younger than 60 years, female sex was a strong predictor of adverse outcomes. Surprisingly, among patients that survived at least 90 days after STEMI, no differences between the sexes were noted regarding long-term survival (HR 0.99; p=0.91) (see Figure for adjusted odds/hazard ratios presenting the association of sex with different endpoints depending on age after first event of STEMI).

Conclusion

On non-selective data, two-thirds of patients with STEMI as the primary manifestation of CAD were male. Women were observed to receive endovascular reperfusion less frequently than men and suffered from more in-hospital complications. Being female and younger than 60 years was associated with an increased risk of adverse outcomes specifically early after STEMI.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): The study is part of the GenderVasc project funded by the joint federal committee, Germany.

Sex-specific differences in management and treatment in ST-elevation myocardial infarction – a German nationwide real-life analysis

Background/Introduction

Acute myocardial infarction (AMI) continues to be the leading cause of death in men and women worldwide. The outcome of patients with AMI improved during the last years but the impact of sex is under current debate since female sex has repeatedly to be associated with an unfavourable outcome in AMI.

Purpose

This retrospective routine-data-based analysis sought to examine sex differences of recent trends in in-patient healthcare and outcome of ST-elevation myocardial infarction (STEMI).

Methods

The dataset of the Federal Association of the Local Health Insurance Funds was used to identify patients who were hospitalized for STEMI in Germany between January 2010 and December 2017. Further, data on concomitant diseases, risk constellations, selected cardiovascular procedures, as well as in-hospital and 30-days mortality were assessed and further analyzed with regard to sex differences.

Results

In total, we identified 175,187 STEMI patients over the 8-year period, thereof about 35% female patients. Women with STEMI were older (median (interquartile range (IQR)): 76 (19) vs. 64 (20) years in men) and had more comorbidities including diabetes (44.9% vs. 35.5%), hypertension (90.9% vs. 82.8%), congestive heart failure (54.7% vs. 43.8%) and chronic kidney disease (33.5% vs. 22.3%); all p<0.001). Further, female STEMI patients underwent less often percutaneous coronary intervention during hospitalization (PCI; 75.5% vs. 85.2%; p<0.001). Complications such as shock (14.8% vs. 13.0%) and bleeding (9.3% vs. 6.6%; both p<0.001) could be observed more frequently in women.

Female sex was independently associated with a higher adjusted 30-day mortality (Odds Ratio 1.08; CI 1.05–1.12; p<0.001).

Conclusion

In a contemporary unselected cohort, one-third of STEMI patients are female. Women with STEMI are older with higher cardiovascular risk, and continue to receive less likely interventional revascularization therapy compared to male STEMI patients. Moreover, female STEMI patients were observed higher complications and death during index hospitalization and 30 days thereafter. Further analyses are urgently needed to identify causes of under-treatment and impaired outcome in women with STEMI.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): joint federal committee, Germany.