Association between hemodialysis and patient characteristics, microbiological etiology, cardiac surgery, and mortality in patients with infective endocarditis: a nationwide study

Background

Hemodialysis and infective endocarditis are both associated with poor patient outcome. However, despite high mortality rates for each disease entity, little attention is given to patients on hemodialysis who develop infective endocarditis.

Purpose

To examine patient characteristics, microbiological etiology, cardiac surgery, and outcome among patients on hemodialysis with infective endocarditis compared with patients with infective endocarditis without hemodialysis treatment.

Methods

With Danish nationwide registries, we identified patients with infective endocarditis between 2010–2018 and linked them to microbiological data from a nationwide microbiological registry with complete blood culture data. We included patients in the hemodialysis group if they received hemodialysis treatment within 6 months prior to their first-time infective endocarditis admission. Patients not meeting this criteria were put in the non-hemodialysis group. We used Kaplan-Meier estimates for difference in mortality and Cox regression for adjusted analysis.

Results

We included 4,106 patients with infective endocarditis of which 265 (6.5%) patients were also in hemodialysis treatment (66.8% men). Patients on hemodialysis were younger (median age 66 years [IQR=54.2–74.9] vs. 72.3 years [IQR=62.3–80.4]) and had a higher burden of comorbidities including hypertension (68.7 vs. 56.9%), diabetes (47.2% vs. 18.8%), and ischemic heart disease (41.1% vs. 32.2%) compared to patients without hemodialysis treatment, all p-values <0.01. Cardiac surgery was less frequently performed in patients in the hemodialysis group than in the non-hemodialysis group (11.9% vs. 19.4%, respectively, p<0.001) and Staphylococcus aureus was more frequently the microbiological etiology of infective endocarditis in the hemodialysis group than in the non-hemodialysis group (57.0% vs. 25.3%, respectively, p<0.0001). No statistically significant difference for in-hospital mortality was found. Figure 1 shows difference in mortality between the two groups. 1- and 5-year mortality were significantly higher in the hemodialysis group than in the non-hemodialysis group (34.3% vs. 17.2% and 50.5% vs. 33.9%, respectively, p<0.00001) and in adjusted analysis hemodialysis was associated with higher 1- and 5-year mortality (hazard ratio of 2.41, 95% CI 1.85–3.13 and 2.50, 95% CI 2.05–3.05, respectively), as compared with patients in the non-hemodialysis group.

Conclusion

Patients on hemodialysis with infective endocarditis are younger, sicker and have Staphylococcus aureus as causing agent more than twice as often as patients with infective endocarditis without hemodialysis treatment. This patient group have a higher mortality and by 5 years, 75% of patients in our hemodialysis group were dead.

Funding Acknowledgement

Type of funding sources: None.

Trends in percutaneous left atrial appendage occlusion and 1-year mortality: a nationwide cohort study

Background

Percutaneous left atrial appendage occlusion (LAAO) is increasingly used for stroke prevention in high-risk patients with atrial fibrillation and contraindication for oral anticoagulation. However, studies evaluating comorbidities and mortality remain scarce.

Objectives

The aim of this study was to evaluate changes in patient characteristic over time and 1-year risk of death.

Methods

Using Danish nationwide registers, we included all patients undergoing first-time LAAO between 2013 and 2021. To evaluate changes in patient characteristics, the study population was stratified according to calendar year of LAAO procedure: 2013–2015, 2016–2018, and 2019–2021. Baseline patient characteristics were defined from 10 years prior to date of LAAO procedure. Antithrombotic therapy was defined as claimed prescriptions within 180 days prior to LAAO procedure. Patients were then followed until either emigration, death, one year of full follow-up, or end of study period. Baseline frailty risk was estimated with The Hospital Frailty Risk Score, a validated frailty risk assessment tool based on ICD-10 codes. The 1-year unadjusted risk of death was estimated with the Aalen-Johansen method.

Results

In total, 1,306 patients underwent LAAO. The number of LAAO increased from 201 procedures in 2013–2015 to 586 in 2019–2021. During follow-up, the age of the patients remained stable (2013–2015: median age: 70 years; 2016–2018: median age 69 years; 2019–2021: median age 69 years). Fewer patients had a history of ischemic stroke (2013–2015: 44.3% vs 2019–2021: 27.6%), hemorrhagic stroke (2013–2015: 32.8% vs 2019–2021: 21.0%), and previous bleeding (2013–2015: 71.1% vs 2019–2021: 59.2%). Median CHA2DS2-VASs score decreased over time (2013–2015: 4 vs 2019–2021: 3) and same trend was found in median HAS-BLED score (2013–2015: 3 vs 2019–2021: 2).

In addition, fewer patients were categorized as high frailty risk (2013–2015: 16.9% vs 2019–2021: 8.9%). However, there was an increase in patients with a history of cancer (2013–2015: 11.9% vs 2019–2021: 18.9%). The use of antiplatelet therapy prior to LAAO decreased while the use of oral anticoagulation increased (2013–2015: 50.2% vs 2019–2021: 68.9%) due to a marked increase in non-vitamin K antagonist oral anticoagulants and a decrease in vitamin K antagonists (Figure 1).

In total, 88 (7.22%) patients died within one year of LAAO procedure. The 1-year all-cause mortality risk in each period were similar (2013–2015: 7.0%; 2016–2018: 7.1%; 2019–2021: 6.9%). [Figure 2]

Conclusion

In the years 2013–2021, the annual number of LAAO procedures increased. The age of patients remained stable. Comorbidity burden decreased and fewer patients were at high frailty risk, but the 1-year mortality risks were similar. Our real-life data suggest that profiles of patients undergoing LAAO has changed considerably over time.

Funding Acknowledgement

Type of funding sources: None.

Oral fluoroquinolones and risk of aortic dissection and aortic aneurysm: a nationwide nested case-control study

Background

Oral fluoroquinolones are commonly prescribed antibiotics. Observational studies have shown an association between fluoroquinolone-use and subsequent risk of aortic aneurysm (AA) and aortic dissection (AD) due to a potential collagen degrading effect of fluoroquinolones.

Purpose

To investigate if fluoroquinolone-use was associated with increased rates of AA or AD in patients without known aortic disease. Secondly, to investigate if fluoroquinolone-use was associated with increased all-cause mortality and aortic interventions in high-risk patients with known aortic disease.

Methods

We used a nested case-control study design in which individuals aged 30–100 years from 2003 to 2018 were included from Danish nationwide registers. Exclusion criteria were bicuspid aortic valve, coarctation of the aorta, and connective tissue disease. A main cohort and a secondary high-risk cohort were defined. The main cohort comprised patients without history of AA/AD in which two case definitions were used: 1) A broad case definition of first-time AA/AD. 2) A severe case definition of ruptured AA/AD. The high-risk cohort comprised patients surviving index AA/AD admission in which cases were defined as all-cause mortality and aortic interventions.

Cases were matched on age, sex, and year of inclusion in a 1:30 ratio with controls. For the main cohort, a potential dose-response effect was investigated using groups of cumulative defined daily doses (cDDD) of fluoroquinolones. Hazard ratios (HR) with 95% confidence intervals (CI) for fluoroquinolone-use compared with amoxicillin as an active comparator were obtained from time-dependent Cox regression models using multiple exposure windows.

Results

The main cohort comprised 4.81 million individuals with 43,280 cases. Short-term 30-day, intermediate-term 90-day, and long-term 1-year fluoroquinolone use were all not associated with AA/AD (30-day HR 1.18 [95% CI: 0.84 to 1.66]; 90-day HR 1.12 [95% CI 0.96 to 1.30]; 1-year HR 1.00 [95% CI 0.93 to 1.07]). Using a severe case definition of ruptured AA/AD yielded comparable results. For the dose-response analysis, increasing cDDD did not confer increased rates of AA/AD (1–5 cDDD: Reference group; 6–10 cDDD: HR 1.03 [95% CI: 0.87 to 1.23]; >10 cDDD: HR 1.00 [95% CI 0.83 to 1.29]) (Figure 1).

The secondary high-risk cohort included 20,195 patients surviving index admission with 9,183 cases of all-cause mortality and 1,768 cases of aortic interventions. The 30-day HR for all-cause mortality was 1.21 (95% CI 0.92 to 1.60) and the 60-day HR 1.06 (95% CI 0.89 to 1.26). No association with aortic interventions was found either (Figure 2).

Conclusion

Fluroquinolone-use was not associated with AA/AD. Furthermore, fluoroquinolone-use was not associated with all-cause mortality or aortic interventions in potentially susceptible patients with known aortic disease. These findings do not support an increased risk of AA/AD with fluoroquinolone-use.

Funding Acknowledgement

Type of funding sources: None.

Incidence of atrial fibrillation/flutter, one-year re-admission rates, and practice patterns among patients <65 years of age: a Danish nationwide study

Background/Introduction

The general atrial fibrillation/flutter (AF) population is well explored and described, but there is sparse data on temporal changes in the incidence, AF-readmission rates, and practice patterns in patients with AF under 65 years of age from unselected cohorts.

Purpose

To investigate temporal changes, AF readmission rates, and practice patterns in patients under 65 years of age with first-time AF diagnosed between 2000–2018.

Methods

Using Danish nationwide registries, we identified patients >18 years and <65 years with a first-time AF-diagnosis from 2000–2018. The cohort was categorized according to calendar periods; 2000–2002, 2003–2006, 2007–2010, 2011–2014 and 2015–2018. Incidence rate (IR) of AF per 100,000 person years (PY), AF-readmission, and practice patterns of medical treatment, electrical cardioversion, and catheter ablation was investigated in the first year following AF-diagnosis.

Results

In this study 60,917 patients were included; 8,150 patients (13.4%) in 2000–2002, 11,898 (19.5%) in 2003–2006, 13,560 (22.3%) in 2007–2010, 14,167 (23.3%) in 2011–2014 and 13,142 (21.6%) in 2015–2018. No major differences were seen in patient characteristics according to calendar period. A stepwise increase, as seen in the Table, in the crude IR of AF per 100,000 PY was observed across calendar periods, except for 2015–2018 (Crude IR [95% CI]: 2000–2002: 78.7 [77.0; 80.4], 2003–2006: 86.3 [84.7; 87.8], 2007–2010: 97.9 [96.3; 99.6], 2011–2014: 102.3 [100.7; 104.0], 2015–2018: 93.6 [92.0; 95.2], while no difference in AF readmission was identified (AF-readmissions: 2000–2002: 32.7%, 2003–2006: 31.1%, 2007–2010: 32.2%, 2011–2014: 32.1% and 2015–2018: 31.7%), as seen in the Figure, right panel. In the first year following AF-diagnosis, the cumulative incidence of catheter ablation increased stepwise from 1.2% in 2000–2002 to 7.6% in 2015–2018 and electrical cardioversion from 2.0% in 2000–2002 to 8.7% in 2015–2018 (Figure, left panel). Treatment with oral anticoagulant therapy (OAC) increased from 28.5% in 2000–2002 to 47.8% in 2015–2018, while there was no change in treatment with rhythm or rate medication therapy.

Conclusion

From 2000–2018, we found an increase in the incidence of atrial fibrillation/flutter (AF) in patients <65 years from 78.7/100,000 person years (PY) to 93.6/100,000 PY and an increase in the use of catheter ablation, electrical cardioversion and OAC in the first year following first-time AF-diagnosis. AF readmission rates were stable over calendar periods.

Funding Acknowledgement

Type of funding sources: None.

Prognosis and antithrombotic practice patterns in recurrent and transient atrial fibrillation following acute coronary syndrome: a nationwide study

Background

First-time detected atrial fibrillation (AF) during acute coronary syndrome (ACS) aggravates the prognosis and increases the risk of ischemic stroke. In this setting, AF may present as brief and transient or with recurrent episodes after discharge. However, data on the association between transient or recurrent AF and ischemic stroke in patients with ACS are sparse. Further, despite being associated with ischemic stroke, first-time detected AF patients have been reported with low oral anticoagulation (OAC) rates.

Purpose

To examine the associated rate of ischemic stroke and mortality in ACS survivors with transient or recurrent AF and to assess the antithrombotic practice patterns one year after ACS.

Methods

Using data from Danish nationwide registries, we identified all patients with first-time ACS, without known AF prior to ACS, from 2000–2017 who were alive one year after ACS discharge (index date). According to a grace period between ACS discharge and one year after ACS discharge, patients were categorized into: i) no AF; ii) first-time detected AF during ACS admission without AF recurrence (transient AF); and iii) first-time detected AF during ACS admission with a subsequent recurrent AF episode (recurrent AF). Patients who developed AF during the grace period were excluded. Patients were followed from one year post ACS discharge, and two-year rates of ischemic stroke and mortality were compared using multivariable adjusted Cox proportional hazards analysis. Further, we assessed the prescribed OAC rates in a three-month period following the index date.

Results

We included 116,793 patients surviving one year post ACS discharge: 111,708 (95.6%) without AF (64.9% male, median age 64 years), 2,671 (2.3%) with transient AF (58.0% male, median age 74 years), and 2,414 (2.1%) with recurrent AF (55.2% male, median age 76 years). The cumulative two-year incidence of ischemic stroke was 0.9%, 1.5%, and 2.3% for patients without AF, transient AF, and recurrent AF, respectively (Figure 1). The cumulative two-year incidence of mortality was 7.4%, 12.1%, and 20.3% for patients without AF, transient AF, and recurrent AF, respectively (Figure 1). Compared to those without AF, the adjusted two-year rates of outcomes were as follows: ischemic stroke: HR 1.15 (95% CI: 0.81–1.61) for patients with transient AF and HR 1.50 (95% CI: 1.14–1.98) for patients with recurrent AF; mortality: HR 0.98 (95% CI: 0.87–1.10) for patients with transient AF and HR 1.35 (95% CI: 1.23–1.49) for patients with recurrent AF (Figure). We identified that 20.9% for transient AF and 42.2% for recurrent AF were prescribed OAC therapy in the three-month period after one year.

Conclusion

In patients surviving one year after ACS with first-time detected AF, a recurrent AF episode was associated with an increased long-term rate of ischemic stroke and mortality, while transient AF yielded no statistically difference as compared with patients without AF.

Funding Acknowledgement

Type of funding sources: None.

Adherence and discontinuation of optimal heart failure therapies according to age

Background

Guideline-recommended disease-modifying pharmacological therapies for heart failure (HF) with reduced ejection fraction are underutilized, particularly among elderly patients.

Purpose

We examined adherence with and discontinuation of evidence-based HF pharmacotherapy, comprising of angiotensin-converting enzyme inhibitors (ACEi)/angiotensin-II receptor blockers (ARB), beta-blockers (BB) and mineralocorticoid receptor antagonists (MRA), according to age.

Methods

Using Danish nationwide registries, we included patients with a first HF diagnosis between 2011 and 2018. Patients were stratified into three age groups, <65 years (reference group), 65–79 years, and ≥80 years. The average daily drug dose was calculated as median proportions of target doses one year after inclusion. Adherence was estimated by the proportion of days covered (PDC), i.e., the total number of days with the drug available for a patient alive for the whole first year of the follow-up period. Discontinuation was defined as a break of >90 days, and the 5-year risk of discontinuation according to age groups was estimated with the Aalen-Johansen estimator. Multivariable Cox regression models were used to evaluate the treatment discontinuation rate according to age groups.

Results

We included a total of 29,482 patients (<65 9,449 (25.4% female), 65–79 13,746 (33.1%), ≥80 6,287 (46.3%)). Advancing age was associated with lower median proportions of daily target doses (ACEi 100%, 88%, 63%; ARB 75%, 67%, 50%; BB 75%, 56%, 44%), and lower adherence (ACEi/ARB 79.1%, 77.5%, 69.4%; BB 79.1%, 78.6%, 73.8%), in the <65, 65–79 and ≥80 age groups respectively, one year after inclusion. Age ≥80 was associated with a higher 5-year risk of discontinuation; cumulative incidence, ACEi/ARB 41%, 44%, 51%; BB 38%, 35%, 39%, in the same age group order as above (adjusted hazard ratio: ACEi/ARB 1.60 [95% CI, 1.51–1.69]; BB 1.33 [95% CI, 1.25–1.41]). Conversely, the risk of discontinuation of MRAs differed little with age (<65 50%, 65–79 54%, ≥80 56%), although MRA initiation in the most elderly was less frequent (<65 33%, 65–79 33%, ≥80 22%).

Conclusion

Among a nationwide cohort of HF patients, advanced age was associated with lower proportions of daily target doses, lower adherence, and a higher rate of discontinuation of ACEi/ARB and BBs. Focus on treatment adherence and optimal dosages among elderly HF patients could improve outcomes.

Funding Acknowledgement

Type of funding sources: None.

Heart failure hospitalizations and diuretic use before and after first-time pulmonary vein isolation ablation for atrial fibrillation among patients with heart failure

Background

Small randomized clinical trials have found that patients with heart failure (HF) and atrial fibrillation (AF) randomized to an ablation strategy for AF experienced improved cardiovascular outcomes. We examined the relation in routine clinical practice.

Purpose

We aimed to assess if first-time pulmonary vein isolation ablation (PVI) for AF among patients with HF was associated with decrease in HF hospital admissions rates and furosemide dosage in the year after PVI compared with the year before.

Methods

We identified patients with HF and available left ventricular ejection fraction (LVEF) treated with a first-time PVI using the Danish Ablation Registry, and alive at 1-year follow-up. Patient comorbidities and concomitant pharmacotherapy (including furosemide dosage and HF hospital admissions) were identified utilizing Danish nationwide registries. For inclusion, patients were required to have been diagnosed with HF in an in- or outpatient setting <10 years of first-time PVI or have a LVEF at the time of PVI ≤45%. Patients were grouped according to LVEF at time of PVI: ≤35%, 36–45%, and >45%. For comparison of HF hospital admission and furosemide usage before and after PVI, McNemars test were used. Wilcox signed-rank test were used to test difference in furosemide dosage before and after PVI.

Results

We identified 668/3450 patients with HF treated with first-time PVI for AF between 2010–2017 (median age 62 years [Q1,Q3=56,69 years], 81% male, and median LVEF 45% [Q1,Q3=40,60%]). Of these, 13 patients (2%) died during one-year follow-up. Overall, 36% of patients with HF had one or more HF hospital admissions the year before PVI compared with 7% in the year after PVI (p<0.0001) (Figure 1). Patients with LVEF ≤35% had the highest proportion of HF hospital admissions the year before PVI (53%) and was reduced more than 4-fold (13%) in the year after first-time PVI, with consistent findings in all LVEF groups (Figure 1). At the time of PVI, 36% of patients with HF were treated with furosemide compared with 30% in the year after PVI (p<0.0001) (Figure 2). Moreover, we identified significant reductions in furosemide dose in the year after PVI compared with the year before (median dose 60 mg [Q1,Q3=30,80 mg] and 20 mg [Q1,Q3=0,60 mg], respectively, p=0.001). Here, reductions in furosemide requirements were consistent across LVEF subgroups.

Conclusion

Patients with HF treated with a first-time PVI strategy for AF had a 5-fold decrease in HF hospital admissions in the following year compared with the year before PVI. Among patients treated with furosemide at time of PVI, significant reductions in dose one year after PVI was identified but also significant reductions in proportion of patients requiring any furosemide at all.

Funding Acknowledgement

Type of funding sources: None.

Temporal changes in aortic valve replacement according to age in Denmark: nationwide data from 2008 to 2020

Background

Since the introduction of transcatheter aortic valve implantation (TAVI), the management of symptomatic severe aortic stenosis has changed. Recent published European guidelines (2021) favours TAVI over surgical aortic valve replacements (SAVR) in patients with older age (≥75 years of age) or patients with high surgical risk. The study of nationwide practice patterns for AVR is important and renders the possibility to evaluate whether clinical practice differs from current guidelines.

Purpose

To evaluate temporal changes in use of isolated aortic valve replacement (AVR) procedures according to age in the era of TAVI in Denmark.

Methods

We identified all first-time aortic valve replacement procedures (TAVI or SAVR) from 2008 until the end of 2020 through administrative registries in Denmark. Patients with no prior diagnosis of aortic stenosis at time of AVR were excluded. Patients with prior AVR or valve repair were excluded. SAVR was divided according to type of prostheses: surgical bioprostheses and mechanical prostheses. To evaluate changes according to age the study cohort was divided into two age groups: <75 and ≥75 years of age.

Results

Between 2008 and 2020, 12,313 first-time isolated AVR procedures were performed in Denmark. Volume of isolated AVR increased from 621 to 1256 procedures per year (ptrend <0.001). Isolated SAVR was performed in 6,548 patients (53.2%) and TAVI in 5,765 patients (46.8%). Median age of TAVI patients was 81.4 [76.9–85.2] years of age compared to 73.1 [68.0-≥77.7] in patients receiving surgical bioprostheses and TAVI patients had a higher degree of comorbidity (TAVI: 70% of patients with Charlson comorbidity score ≥1, surgical bioprostheses: 50% of patients with Charlson comorbidty score ≥1). TAVI increased during study period compared to isolated SAVR, where a decreasing trend was observed from 2014 and onwards. In <75-year-old patients, volume of TAVI significantly increased during study period (ptrend<0.001), whereas volume of surgical bioprostheses remained stable. Volume of mechanical prostheses decreased over time (ptrend <0.001) TAVI increased in ≥75-year-old patients (ptrend <0.001) and TAVI accounted for 91.5% of all isolated AVR procedures in 2020. In contrast, volume of isolated SAVR declined driven by a decreasing use of surgical bioprostheses (ptrend=0.001). (Figure 1).

Conclusions

Volume of isolated aortic valve replacement (AVR) doubled from 2008 and 2020. The increase in isolated AVR was driven by transcatheter aortic valve implantation (TAVI). TAVI has become the predominant choice of isolated AVR in management of aortic stenosis and our results suggest that real-world practise patterns are in line with current guideline recommendations.

Funding Acknowledgement

Type of funding sources: None.

Rehospitalizations, repeated aortic surgery, and death in initial survivors of surgery for Stanford type A aortic dissection and the significance of age – a nationwide registry-based cohort study

Background

All patients with type A aortic dissections, regardless of age, are recommended urgent aortic surgery. However, studies exploring long term outcomes in survivors are sparse, and especially, the significance of age on long-term outcomes remain unclear.

Purpose

We described and compared incidences across age groups of post-discharge readmission, repeated aortic surgery, and death in patients who survived surgery and hospitalization for type A aortic dissection.

Methods

Using data from Danish nationwide registries, we identified patients hospitalized with Stanford type A aortic dissections from 2006–2018. Survivors of hospitalization and surgery on the ascending aorta and/or aortic arch comprised the study population (Figure 1). Using cumulative incidence plots taking death into account as a competing risk and Cox regression analysis, we described long-term outcomes (rehospitalizations, repeated aortic surgery, and death) and compared different age groups. The diagnosis of type A aortic dissection in the registries used, was validated from 191 clinical records to have a positive predictive value of 94.8%.

Results

Of 606 initial survivors of surgery and hospitalization with type A aortic dissection, 236 (38.9%) were <60 years old (group I), 194 (32.0%) were 60–69 years old (group II), and 176 (29.1%) were >69 years old (group III). Figure 2 shows cumulative incidences of outcomes according to age. During the first year, 62.5% were re-hospitalized (median number of days hospitalized was 2 days (IQR 1–8 days) and 1.4% underwent repeated aortic surgery with no significant differences across age groups (P=0.68 and P=0.39, respectively). Further, 5.9% died (group I: 3.0%, group II: 8.3%, group III: 7.4%, P=0.04). After 10 years of follow up, 8.0% had undergone repeated aortic surgery (group I: 11.5%, group II: 8.5%, group III: 1.6%, P=0.04) and 10.2% (group I), 17.0% (group II), and 22.2% (group III) had died (P=0.01). In adjusted analyses, no age differences were found in one-year outcomes, while age >69 years (group III) compared with age <60 years (group I) was associated with a lower rate of repeated aortic surgery (hazard ratio 0.17, 95% confidence interval 0.04–0.78) and a higher rate of all-cause mortality (hazard ratio 2.44, 95% confidence interval 1.37–4.34) in the 10-years analysis.

Conclusion

Among survivors of type A aortic dissections, rehospitalizations the first year after discharge were common among all age groups, but survival was high. Repeated aortic surgery was rare, and significantly more common among younger than older patients. Evaluations of quality of life in survivors of type A aortic dissections are needed.

Funding Acknowledgement

Type of funding sources: None.

Long-term cardiovascular outcomes in five-year cancer survivors: a nationwide cohort study

Background

Patients with cancer have higher short-term rates of cardiovascular events than the general population. However, little is known about rates of long-term cardiovascular outcomes in 5-year cancer survivors, especially in older patients.

Objective

We investigated the long-term rates of cardiovascular outcomes, including heart failure, atrial fibrillation, venous thromboembolism, ischemic stroke and myocardial infarction in five-year cancer survivors, overall and according to age.

Methods

Using Danish nationwide registries, five-year survivors of 20 of the most common cancers (diagnosed between 1994 and 2013; 15 years of age or older at the time of the diagnosis) were matched with four non-cancer controls from the background population by age and sex. Study participants with a history of any the outcomes of interest prior to index date were excluded. Rates of outcomes in the cancer and non-cancer group were compared with Cox regression models, overall and according to age (i.e., 15–39, 40–59, and >60 years).

Results

In total, 167,215 five-year cancer survivors were age- and sex-matched with 668,860 non-cancer controls (median age 66 years; 34.4% men, median follow-up of 6.8 years). Five-year survivors had higher associated rates of cardiovascular outcomes, irrespective of age, and the incidence rates per 1,000 person-years of cardiovascular outcomes for cancer survivors and non-cancer controls were: HF: 6.2 (95% CI: 6.1–6.4) and 5.2 (5.1–5.3), respectively; atrial fibrillation: 11.1 (10.9–11.3) and 9.3 (9.3–9.4), respectively; venous thromboembolism: 5.1 (5.0–5.2) and 2.8 (2.8–2.9), respectively; ischemic stroke: 5.8 (5.6–5.9) and 5.4 (5.4–5.5), respectively; and myocardial infarction: 3.6 (3.5–3.7) and 3.4 (3.3–3.4), respectively. The absolute rates of cardiovascular outcomes were highest in the oldest group, whereas the relative rates were more pronounced in the youngest cancer group compared with matched controls (Figure 1).

Conclusions

Compared with the general population, five-year cancer survivors had higher associated rates of cardiovascular outcomes across the spectrum of age. The increased rates of cardiovascular outcomes were more pronounced in the youngest group. These data underline the importance of risk assessment and prevention of cardiovascular diseases in five-year cancer survivors.

Funding Acknowledgement

Type of funding sources: None.

Diuretic use before and after transcatheter aortic valve implantation: a nationwide study

Background

Transcatheter aortic valve implantation (TAVI) is the new standard of care in patients of older age with symptomatic severe aortic stenosis, and these patients often depend upon diuretics for symptom relief. Randomized clinical trials suggest that approximately one third of patients undergoing TAVI do not achieve symptom relief. Furthermore, some patients have more symptoms after intervention, but “real-life” data are lacking.

Purpose

We examined use of diuretic therapy before and one year after TAVI in order to identify the proportion of patients who had intensification of diuretic treatment after intervention as a proxy for more symptoms. We also examined baseline factors associated with an intensification event.

Methods

Using Danish nationwide registries, we identified all Danish citizens who underwent TAVI from January 1, 2008 to December 31, 2019 and were alive one year after the intervention. Diuretic use pre-TAVI and 1-year post-TAVI (based on prescription fillings) was divided into the following groups: 1) no use; 2) low diuretic use: 1–40 mg of furosemide (or equivalent bumetanide); 3) intermediate diuretic use: 41–120 mg of furosemide; and 4) high diuretic use: >120 mg furosemide. Diuretic intensification was defined as a change from one pre-TAVI diuretic group to a higher post-TAVI diuretic group. Factors associated with intensified diuretic treatment was examined with logistic regression. In this analysis of intensification, only patients who could potentially have an intensification event were included (i.e., no diuretic use, low diuretic use, or intermediate diuretic use groups).

Results

A total of 3,978 patients (median age 81 [interquartile range 77–85]; 54% men) undergoing TAVI were identified. Pre-TAVI, 1,279 (32%) had no diuretic use, 1,818 (46%) had low diuretic use and 881 (22%) had intermediate diuretic use. Overall, patients with pre-TAVI intermediate diuretic use had a greater burden of cardiovascular and non-cardiovascular comorbidities (higher prevalence of heart failure, atrial fibrillation, chronic kidney disease and diabetes) compared with those with no or low diuretic use. The distribution of age and sex was similar between diuretic groups. One year post-TAVI, 1,406 (35.3%) had no diuretic use, 1,635 (41.1%) had low diuretic use, 654 (16.4%) had intermediate diuretic use and 283 (7.1%) had high diuretic use (Figure 1). Overall, 1,077 (27%) patients had intensification of diuretic treatment one year after undergoing TAVI. Ischemic heart disease and chronic renal failure were associated with an intensification event (odds ratio 1.23 [95% CI 1.05–1.23] and 1.46 [95% CI 1.10–1.94], respectively).

Conclusion

Among patients undergoing TAVI not treated with high-dose diuretics at time of intervention, approximately 1 out of 4 patients had intensification of diuretic treatment one year after intervention. Ischemic heart disease and chronic renal failure were associated with intensification.

Funding Acknowledgement

Type of funding sources: None.

Temporal trends in the incidence of endocarditis among patients with a prosthetic heart valve: a nationwide study

Background

The incidence of infective endocarditis (IE) is increasing in the adult population, as is the insertion of prosthetic heart valves. Patients with prosthetic heart valves are considered at high risk of IE – a complication with a high mortality. However, data on temporal changes in the incidence of IE among patients with prosthetic heart valves from unselected cohorts are sparse

Purpose

We aimed to examine nationwide temporal trends in the incidence of IE in patients with an implanted prosthetic heart valve in Denmark from 1999 to 2018.

Methods

Using Danish nationwide health-care registries we identified all patients, who underwent heart valve implantation between 1996–2018. Crude annual incidence rates per 1,000 person years (PY) of IE were computed and presented in two year intervals. Analyses were stratified by sex and age groups (<50, 50–59, 60–69, 70–79, >80 years).

Results

We identified 26,604 patients with first time prosthetic valve implantation with a median age of 72.7 years at the time of implantation, 63.1% were men with a median follow-up of 6.5 years. We found 1,442 cases of first time IE. The IE incidence rate ranged from 5.4 /1,000 PY (95% CI 3.9–7.4) in calendar period 2001–2002 to 10.0/1,000 PY (95% 8.84–11.11) in calendar period 2017–2018 with an unadjusted increasing trend during the study period (ptrend<0.0001), (Figure 1). Overall, men had a higher crude incidence rate compared with women, however no significant temporal changes were seen in the incidence rate during the study period. For age groups, a trend of stepwise increase in the incidence rate of IE was observed for increasing age groups, however no temporal changes were observed (Figure 2).

Conclusion

The incidence of IE following prosthetic heart valve implantation has increased slightly over the last 20 years in Denmark.

Funding Acknowledgement

Type of funding sources: None.

Readmission after transcatheter aortic valve implantation according to frailty

Background

Readmissions and time spent hospitalized following transcatheter aortic valve implantation (TAVI) are important parameters of patient autonomy, particularly for frail patients with limited life-expectancy. Yet, such data remain scarce.

Purpose

To investigate actual time spent hospitalized the first year after TAVI. Secondly, to investigate time spent hospitalized according to frailty risk.

Methods

Through Danish, nationwide registries, we included all patients undergoing TAVI and alive at discharge between January 2008 and June 2020. From discharge, patients were followed until death, emigration, end of study period, or one year of follow-up, whichever came first. During follow-up, all in-patient hospital admissions were identified according to ICD-10 diagnosis codes. Length of stay was calculated, and cumulative numbers of days hospitalized was presented. Further, the proportion of patients dying within one year of follow-up was calculated.

Using The Hospital Frailty Risk Score, a validated frailty risk assessment tool, patients were categorized as low, intermediate, and high frailty risk. We then evaluated the time spent hospitalized stratified by frailty risk group.

Results

The study population comprised 5,464 patients undergoing first-time TAVI with a median age of 81 years among whom 55.2% were males. After one year, 445 (8.1%) patients had died. In total, 2,452 (44.9%) of TAVI patients survived one year and were never admitted, whereas 3,012 (55.1%) patients were admitted at least once or died within one year of TAVI. Of these, 1,200 (21.9%) patients were admitted for more than two weeks or died within one year of TAVI (Figure 1).

Regarding frailty, 3,296 (60.3%), 1,965 (36.0%), and 203 (3.7%) patients were classified as low, intermediate, and high frailty risk, respectively. In the low frailty risk group, 6.2% of patients died within one year and 50.4% survived one year without a hospital admission. By contrast, 16.7% of patients in the high frailty risk group died within one year and only 24.6% survived one year without a hospital admission. Further, 17.1% of patients in the low frailty risk group were admitted for more than two weeks or died within one year of TAVI compared with 47.3% in the high frailty risk group (Figure 2).

Conclusion

Readmissions in the first year after transcatheter aortic valve implantation were common and time spent hospitalized after transcatheter aortic valve implantation was significant. Our results were clearly related to frailty, which should be considered for future prevention strategies.

Funding Acknowledgement

Type of funding sources: None.

Risk of infective endocarditis in patients with Staphylococcus aureus blood stream infection and declining kidney function

Background

Worldwide, Staphylococcus aureus (S.aureus) is one the most common causes of infective endocarditis (IE), particularly in dialysis patients. However, the association between mildly and moderately decreased kidney function and IE in patients with S.aureus blood stream infection (SAB) has not been examined.

Purpose

In a retrospective nation-wide study, to evaluate the association between IE and declining kidney function in SAB patients.

Methods

All patients with first-time SAB between January 1st, 1996 to December 31st, 2018 were identified from a national database including >90% of all patients with SAB. By cross-linking with other nationwide databases, co-morbidities were recorded. The population was divided into 4 groups according to eGFR: group 1 (eGFR ≥90), group 2 (eGFR 30–89), group 3 (eGFR <30) and group 4 (Renal Replacement Therapy dependent). Patients were followed until the outcome of IE. Changes in co-morbidities across the eGFR groups were tested with the Cochran-Armitage test. In a multivariable logistic regression analysis, the odds ratio (OR) of IE was calculated for each eGFR group while adjusting for age, sex, hypertension, diabetes, native valve disease (NVD), prosthetic valve, and cardiac implantable electronic device (CIED).

Results

Among 17,759 SAB patients, 1,098 were diagnosed with IE. The male population accounted for 60–70% of the IE patients in each eGFR group (Table 1). The overall median age of S.aureus IE patients was 61.5 [48–72] with the highest median age in group 2 (67 [57–76]). Across the eGFR groups, there was a significant increase in the prevalence of diabetes (12.6% in group 1 to 47.0% in group 4), hypertension (18.9% in group 1 to 80% in group 4) and native valve disease (18.7% in group 1 to 36.4% in group 4), p<0.0001. In a multivariate analysis with group 1 as reference, the adjusted OR of S.aureus IE increased significantly with OR 1.16 [95% CI 1.01–1.34] in group 2 to OR 1.42 [95% CI 1.07–1.87] in group 3. The increase was not significant in group 4, OR 1.63 [95% CI 0.95–2.53]. The OR of S.aureus IE decreased with increasing age groups and OR was 0.55 [95% CI 0.43–0.71] among patients >80 years as compared to the reference age group, 18–39 years. A significantly increased OR of S.aureus IE was found among patients with NVD (OR 3.25 [95% CI 2.22–4.76]), prosthetic valve (OR 6.31 [95% CI 5.10–7.79] and CIED (OR 2.88 [95% CI 2.35–3.53]). The overall in-hospital mortality was 16.4% (n=181), with the highest mortality in group 3 (n=11, 22.3%). Overall, the one-year mortality was 26.6% (n=292), and the highest mortality was found in group 4 (n=29, 34.1%). When adjusting for age and sex, mortality did not differ significantly with declining eGFR.

Conclusion

In this study, we found a significant increase in the odds ratio of IE in patients with SAB when kidney function decreased. Both in-hospital and one-year mortality were high, but did not differ significantly across the eGFR groups.

Funding Acknowledgement

Type of funding sources: None.

P3798High levels of C-reactive protein after coronary artery bypass graft surgery is associated with postoperative atrial fibrillation

Background

Postoperative atrial fibrillation (POAF), a common complication following coronary artery bypass graft (CABG) surgery, is associated with increased morbidity and mortality. Inflammation seems to be an important pathogenic factor and elevated preoperative levels of C-reactive protein (CRP) are associated with POAF. However, the association between postoperative CRP and POAF is less established.

Purpose

To examine the association between postoperative levels of CRP and POAF after CABG.

Methods

Patients undergoing first-time isolated CABG (Jan 01, 2000 to Dec 31, 2016) were identified using Danish nationwide administrative registries. Patients with CRP measurements from the fourth postoperative day and no history of atrial fibrillation were included. POAF was defined as a postoperative atrial fibrillation rhythm that required medical therapy or cardioversion, with patients being followed for POAF until discharge. The study population was divided into quartiles based on CRP levels. A Cochran-Armitage trend test was used to examine the trend of increased levels of CRP and the associated risk of POAF. The association between CRP levels and POAF was investigated using a multivariable logistic regression analysis adjusted for other patient characteristics.

Results

The study included 6,711 patients with mean CRP values from the lowest to the highest CRP groups being 66, 109, 150 and 228 mg/L, respectively. Patients in the highest CRP group were older and more likely to be male compared with the lowest CRP group (median age 67 years [P25-P75: 61–73] and 84.7% men vs. median age 64 years [P25-P75: 56–70] and 77.9% men). In the highest CRP group, 35% of patients developed POAF vs. 25% in the lowest CRP group. A dose-response relationship was seen between increasing levels of CRP and the associated risk of POAF (p<0.0001 for trend). An adjusted analysis showed a statistically significant association between the highest CPR group and POAF (OR: 1.44; 95% CI: 1.24–1.69) compared with the lowest CRP group (figure 1).

Conclusion

High postoperative CRP levels after CABG were associated with POAF development. Future studies may examine whether CRP also predicts worse outcomes and whether these factors could be modified in the development of POAF.

Acknowledgement/Funding

Internal grant from Copenhagen University Hospital

P4792Dabigatran versus vitamin K antagonists in patients with atrial fibrillation and valvular heart disease

Background

Atrial fibrillation (AF) and valvular heart disease (VHD) are both associated with an increased risk of stroke. Outside post-hoc analyses of randomized controlled trials, knowledge on the effectiveness and safety of dabigatran in patients with AF and VHD is scarce.

Objectives

To compare the risk of all-cause mortality, stroke, and bleeding in patients with AF and VHD treated with dabigatran or a vitamin K antagonist (VKA).

Methods

All Danish residents are provided a unique personal identification number enabling cross-linking of data from Danish nationwide registries. We identified all patients with AF and VHD initiating treatment with dabigatran or VKA between the 22nd of August 2011 and the 31st of December 2014. We defined VHD as aortic stenosis/regurgitation, mitral regurgitation, bioprosthetic heart valves, mitral-, and aortic valve repair. Outcomes were all-cause mortality, stroke, and bleeding. 2-year standardized absolute risks were calculated from cause-specific Cox regression models with death as competing risk.

Results

In total, 599 (27.3%) and 1,596 (72.7%) patients initiated treatment with dabigatran and VKA. The 2-year standardized absolute risk of all-cause mortality (95% CI) for VKA was 27.6% (25.1% to 30.1%) and 25.4% (21.8% to 29.0%) for dabigatran with a corresponding absolute risk difference of −2.2% (−6.3% to 1.9%) (Figure 1). The 2-year standardized absolute risk of stroke for VKA was 3.4% (2.3% to 4.5%) and 3.9% (2.2% to 5.5%) for dabigatran with a corresponding absolute risk difference of 0.5% (−1.6% to 2.5%). Lastly, the 2-year standardized absolute risk of bleeding for VKA was 8.2% (6.6% to 9.7%) and 7.6% (5.1% to 10.1%) for dabigatran with a corresponding absolute risk difference of −0.5% (−3.4% to 2.4%).

Figure 1

Conclusions

In this nationwide cohort study, we found no significant difference in the risk of all-cause mortality, stroke, or bleeding in patients with AF and VHD when comparing VKA to dabigatran.

P1953Risk of upper gastrointestinal bleeding following myocardial infarction: a novel prediction model for assessing appropriateness of proton pump inhibition therapy

Background

Upper gastrointestinal bleeding following myocardial infarction continues to be a severe complication associated with increased mortality; however, bleeding events might be avoided by appropriate therapy with proton pump inhibitors.

Purpose

To develop and validate a prediction model aimed at identifying patients at increased risk of upper gastrointestinal bleeding following myocardial infarction.

Methods

Based on multiple nationwide Danish registers, all patients initiating dual antiplatelet or anticoagulant therapy in combination with antiplatelet following myocardial infarction between 2003 and 2016 were identified. Primary outcome of interest was one-year risk of upper gastrointestinal bleeding. A derivation cohort including all patients between 2003 and 2013 was selected, whereas patients identified between 2014 and 2016 was employed for internal validation. Multiple logistic regression was used to predict person specific risks based on age, history of gastrointestinal bleeding or peptic ulcer, anaemia or gastrointestinal cancer, use of nonsteroidal anti-inflammatory drugs, oral anticoagulants, selective serotonin reuptake inhibitors or loop diuretics. We compared our model with the European Society of Cardiology (ESC) guideline recommendation on gastrointestinal bleeding risk assessment.

Results

A total of 61 543 patients with myocardial infarction were identified for the study. In the total cohort, the median age was 68 years (IQR: 58–77), 85.0% (52 334) underwent coronary angiography, 2.6% (1 608) had a history of gastrointestinal bleeding and 7.1% (4 354) used oral anticoagulants. The average one-year risk of upper gastrointestinal bleeding was 1.04% (95% CI: 0.95–1.14%), and mean predicted risk of the model was 1.04% (IQR: 0.64–1.26%). The discriminative ability of the model evaluated by area under the curve was 74.2% (95% CI: 66.9–78.6%) in the validation cohort. The proposed risk model demonstrated improved sensitivity and specificity at the specific threshold of the ESC risk schemes (Figure 1). Results remain principally unchanged regardless of inclusion or exclusion of patients initiating proton pump inhibitors at baseline. Furthermore, using cross-validation for the model evaluation produced similar discrimination results.

Figure 1

Conclusion

Based on nationwide registers a novel prediction model aimed at identifying patients at increased risk of upper gastrointestinal bleeding was developed and validated; the model observed moderate discrimination in the validation cohort providing possible benefit for clinicians in terms of communicating absolute risk to the patients and determining the appropriateness of initiating preventive therapy.

Acknowledgement/Funding

The Danish Heart Foundation

P2754Streptococcal infective endocarditis: distribution of species and their prognosis

Background

Infective endocarditis (IE) is frequently caused by streptococcal species. However, there is limited knowledge about the relationship between different streptococcal species and IE, and their associated outcomes.

Purpose

To examine the prevalence of streptococci at species level in IE, and to relate these different species to outcomes.

Methods

From 2002–2012 we prospectively collected consecutive patients with IE admitted to two tertiary heart centres covering a catchment area of 2.4 million people. The registry comprises 915 IE patients, 366 (40%) with streptococcal IE. Based on phylogenetic relationship, streptococcal species were classified into seven main groups: Mitis, Bovis, Mutans, Anginosus, Salivarius, Pyogenic and Nutritionally Variant Streptococcus (NVS). Classification at species level was not possible in 51 patients, who were excluded. Complications and prognosis of streptococcal IE were compared between the subgroups, and at species level.

Results

We included 315 patients with streptococcal IE. Mean age was 63 (IQR 52–76) years, and most were men (67%). A total of 115 patients (37%) had a previous heart valve disease, 58 (18%) had a prosthetic valve, 22 (7%) had previously had IE and 29 (9%) had a cardiac electronic device. With 148 episodes (47%) the Mitis group was the most common cause of IE. Other frequent groups were the Pyogenic group and the Bovis group, accounting for 66 (21%) and 51 (16%) of the cases, respectively. Surgery was carried out in 55% (n=173) of all cases. Patients infected with S. pneumoniae or S. agalactiae had a significantly higher rate of surgery, 72.2% (n=13) and 71.9% (n=23) respectively, whereas the Bovis group had a significantly lower rate, 35.5% (n=18) (p=0.048). The aortic valve was infected in 137 patients (43.5%), mitral valve in 105 patients (33.3%) and both valves were infected in 53 patients (16.8%). Twenty patients (6.3%) had right-sided IE, including pacemaker lead IE. There was no significant difference between the species subgroups regarding type of infected valve. Embolization and osteitis were observed in 76 (24.1%) and 30 (9.5%) patients, respectively. There was no significant difference between the species groups, as was the case with mortality: 23 patients (7.3%) died in-hospital and the one-year mortality was 16% (n=50).

Distribution of streptococcal IE

Conclusion

Species of the Mitis group were the most frequent Streptococci causing IE. Patients infected with S. pneumonia or S. agalactiae had significantly higher rate of surgery, and patients infected with S. bovis group had lower rate of surgery. There was no significant difference in rate of complications such as abscesses, embolization, osteitis or mortality between the streptococcal species.

Acknowledgement/Funding

Supported by grants from Herlev-Gentofte University Hospital Research Foundation

1350Outcome after diagnosis with hypertrophic cardiomyopathy: a nationwide study

Background

Patients with hypertrophic cardiomyopathy (HCM) are generally considered to have an increased morbidity and mortality due to symptomatic heart failure, atrial fibrillation, stroke and sudden cardiac death. Data reporting the mortality compared with background populations are however conflicting and primarily based on small cohorts from tertiary centers.

Purpose

We aimed to investigate whether a nationwide cohort of patients with HCM had an increased risk of death compared with a matched cohort derived from the general Danish population.

Methods

Using nationwide registries, we identified all patients with a first-time HCM diagnosis in Denmark between 2007 and 2016. Patients were matched 1:5 on age, sex and HCM diagnosis date to controls using risk set sampling. The study population was followed until death, emigration, or end of study period Jan. 1, 2017–whichever came first. Mortality was compared using Kaplan Meier plots and multivariable adjusted Cox proportional hazard analysis.

Results

We identified 3010 patients diagnosed with HCM (53.8% male) per registry codes. Men were on average 8.5 years younger at diagnosis than women (62.6 years [p25-p75: 49.8–73.9] vs. 71.1 years [p25-p75: 59.7–80.6]). Patients with HCM had more comorbidities than matched controls. The median time of follow-up was 4.4 years (p25-p75: 2.3, 6.7). For HCM patients and matched controls, 1-year, 5-year and 10-year probabilities of death were 10% (95% CI 9–12%), 28% (95% CI 26–30%) and 47% (95% CI 42–51%) and 2% (95% CI 1–3%), 13% (95% CI 12–14%) and 24% (95% CI 23–25%) respectively (Figure 1). After adjusting for comorbidities and medications a diagnosis of HCM was associated to a 107% increased risk of death (hazard ratio 2.07 [95% confidence interval 1.60, 2.68], p<0.0001).

Figure 1

Conclusion

In a Danish nationwide cohort, HCM was associated with a significantly higher risk of death compared with the background population. This study emphasizes the importance of continued, life-long follow-up of patients with HCM with the aim to anticipate and treat preventable adverse events. Furthermore, the findings stress the need to develop effective disease-modifying treatment strategies.