Socioeconomic position influences the risk of first-time cardiovascular event in patients with type 2 diabetes in spite of equal access to healthcare – a Danish nationwide cohort study

Background

Social inequality poses a major public health challenge. Low socioeconomic position has been associated with cardiovascular disease in patients without diabetes. Yet, the association between socioeconomic position, type 2 diabetes, and first-time cardiovascular disease has not previously been investigated in a nationwide cohort from a country with equal access to healthcare.

Purpose

To examine the association between socioeconomic position and development of first-time major adverse cardiovascular events (MACE) in a Danish nationwide population of patients with incident type 2 diabetes.

Methods

Using the Danish nationwide registers, we identified all Danish residents with newly diagnosed type 2 diabetes between 2000 and 2017. Patients aged 40–79 years, without a history of ischemic heart disease and/or stroke were included. Income was used as a surrogate for socioeconomic position, and was assessed as quartiles of inflation adjusted, mean five-year income prior to index. Multivariable Cox proportional hazard analyses were used to assess the association between income and the primary composite outcome of ischemic stroke, acute myocardial infarction, and cardiovascular mortality (MACE). We assessed income as a time-dependent variable and adjusted for age, gender, calendar year, baseline comorbidities, and medication.

Results

In total 107,612 patients were included with a median age of 63 (interquartile range [IQR] 55–70) years and a median follow-up time of 6.8 (IQR 3.5–10.6) years. Patients in the lowest income quartile were older (median age 69 vs. 60 years) and more likely to be female (53.3% vs 36.7%) compared with the highest quartile (all P<0.0001). The 10-year risk of MACE decreased with higher income quartile: 30.3% (n=6814) in 1st quartile, 23.4% (n=4760) in 2nd quartile; 19.1% (n=3861) in 3rd quartile; 16.0% (n=3042) in 4th quartile (P<0.0001). In adjusted analysis, using the highest quartile as reference, the relative risk of MACE was inversely proportional to income (P-trend<0.0001): hazard ratio (HR) 1.59 (95% confidence interval [95% CI] 1.52–1.66) in 1st quartile; HR 1.42 (95% CI 1.36–1.49) in 2nd quartile; 1.20 (95% CI 1.14–1.25) in 3rd quartile. We found age specific differences in the risk of MACE between the younger (40–64 years) and the older (65–79 years) patients (P-interaction = 0.007). In stratified adjusted analysis, the youngest age group were associated with higher HR's compared to the oldest age group (Figure). The absolute unadjusted risk of MACE was highest in the elderly with low income.

Conclusions

Despite equal access to healthcare, low socioeconomic position was independently associated with an increased risk of first-time MACE in patients with incident type 2 diabetes. The finding was significant across age groups with the highest relative risks of MACE among younger patients. Our results indicate the importance of prevention strategies targeting patients with low socioeconomic position.

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Zealand University Hospital Roskilde

Prevalence of infective endocarditis in streptococcal bloodstream infections is dependent on streptococcal species

Background

Streptococci frequently cause infective endocarditis (IE), yet the prevalence of IE in patients with bloodstream infections (BSIs) caused by different streptococcal species is unknown.

Purpose

To investigate the prevalence of IE in BSIs with different streptococcal species.

Methods

We included all patients with streptococcal BSIs, from 2008 to 2017, in a population-based setup. Based on microbiological identification of phylogenetic relationship, streptococcal species were classified into eight main groups: Anginosus, Bovis, Mitis, Mutans, Salivarius, Pyogenic, S. pneumoniae, and “other streptococci”. Using nationwide registries, we determined the prevalence of IE at streptococcal group level and at species level. In a multivariable logistic regression analysis, we investigated the risk of IE according to streptococcal species with S. pneumoniae as reference and adjusted for age, sex, ≥3 positive blood culture (BC) bottles, native valve disease, prosthetic valve, previous IE, and cardiac device.

Results

In 6,506 cases with streptococcal BSIs (mean age 68.1 years (SD 16.2), 52.8% men), the IE prevalence was 7.1% (95% CI: 6.5–7.8%). For the most common streptococcal species (>5% of BSIs), the IE prevalence was: S. pneumoniae 1.2% (95% CI: 0.8–1.6%), S. dysgalactiae 6.4% (95% CI: 4.9–8.2%), S. pyogenes 1.9% (95% CI: 0.9–3.3%), S. agalactiae 9.1% (95% CI: 6.6–12.1%), S. anginosus 4.8% (95% CI: 3.0–7.3%), and S. mitis/oralis 19.4% (95% CI: 15.6–23.5%) (Figure 1). For moderately common streptococcal species (1–5% of BSIs), the IE prevalence was: S. gallolyticus 30.2% (95% CI: 24.3–36.7%), S. salivarius 5.8% (95% CI: 2.9–10.1%), S. sanguinis 34.6% (95% CI: 26.6–43.3%), S. parasanguinis 10.3% (95% CI: 5.2–17.7), and S. gordonii 44.2% (95% CI: 34.0–54.8%). For uncommon streptococcal species (0.1–1% of BSIs), the highest IE prevalence was in S. mutans with 47.9% (95% CI: 33.3–62.8%). In a multivariable adjusted analysis using S. pneumoniae as a reference, we identified that all species except S. pyogenes were associated with a significantly higher IE risk (Figure 1). The highest associated IE risk was found in S. mutans (OR 81.3, 95% CI: 37.6–176), S. gordonii (OR 80.8, 95% CI: 43.9–149), S. sanguinis (OR 59.1, 95% CI: 32.6–107), S. gallolyticus (OR 31.0, 95% CI: 18.8–51.1), and S. mitis/oralis (OR 31.6, 95% CI: 19.8–50.5) (Figure 1).

Conclusion

The prevalence of IE in streptococcal BSIs is highly species dependent with the lowest IE prevalence observed in S. pneumoniae and S. pyogenes BSIs, whereas S. mutans, S. gordonii, S. sanguinis, S. gallolyticus and S. mitis/oralis had the highest IE prevalence and the highest associated IE risk after adjusting for IE risk factors.

Figure 1. Risk of IE in streptococcal BSIs

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Herlev-Gentofte University Hospital

Surgical treatment for infective endocarditis over three decades: a nationwide study

Background

An increasing number of patients with infective endocarditis (IE) are treated surgically over time. It is important to know how this affects patient outcome. Current studies are mainly from tertiary centres which may bias estimations of outcomes. We have therefore conducted a nationwide study of surgical outcomes during admission for IE over three decades.

Purpose

We set out to examine temporal trends in use of valve surgery for IE and these patients' characteristics and related outcomes in Denmark in the period 1998–2017.

Methods

Using Danish nationwide registries, we included patients with first-time IE (1998–2017). The study population was categorized into four groups of five-year intervals (1998–2002, 2003–2007, 2008–2012, 2012–2017). Annual number of patients with IE and the proportion who underwent valve surgery during admission were reported. Kaplan-Meier estimates and multivariable logistic regression analyses were used to compare the associated 30-day mortality risk between calendar periods. Kaplan-Meier estimates and multivariable adjusted Cox proportional hazard analyses were used compare the associated 1-year mortality risk between calendar periods.

Results

A total of 8,455 patients with first-time IE were identified in the period of 1998–2017 of which 1,906 (22.5%) underwent valve surgery (1998–2002; N=320, 2003–2007; N=468, 2008–2012; N=528, 2013–2017; N=595). The proportion of patients who underwent surgery was 21.5% in 1998 and 19.4% in 2017 (P=0.02 for trend). See figure.

For patients undergoing surgery, the median age and proportion of males increased from 58.3 years (P25-P75: 48.2–67.4) and 69.1% to 66.7 years (P25-P75: 55.2–73.0) and 73.1% in 1998–2002 and 2013–2017, respectively. Patients had an increasing burden of comorbidities including diabetes (10.3% to 14.3%), hypertension (16.9% to 37.5%) and renal disease (9.1% to 9.6%) across calendar periods. The 30-day mortality risk for patients with IE who underwent valve surgery was 10.0% (1998–2002), 10.8% (2003–2007), 6.4% (2008–2012) and 8.5% (2013–2017), respectively (P=0.09). One-year mortality risk for patients with IE who underwent valve surgery was 16.7% (1998–2002), 21.2% (2003–2007), 15.2% (2008–2012) and 16.6% (2013–2017), respectively (P=0.08). The declining 30-day and 1-year mortality was statistically significant over time when adjusting for patient characteristics (P=0.01 and P≤0.0001, respectively).

Conclusion

From a nationwide, unselected cohort of patients with first-time IE, around 1/5 undergo surgery during admission. Surgical IE-cases are older and sicker now compared to 10–20 years ago. In spite of this, there was a trend towards a decreased associated 30-day and 1-year mortality over time. Our data show a lower rate of surgery in IE than in most prior studies and we believe that this is due to the nationwide, unselected nature of our study.

Infective endocarditis and surgery

Funding Acknowledgement

Type of funding source: None

The prognostic value of myocardial deformational patterns is reduced in patients with heart failure

Background

Early systolic lengthening (ESL) and postsystolic shortening are considered highly specific for myocardial ischemia. We aimed to investigate the prognostic potential of both deformational patterns in patients with heart failure (HF) and to determine if a history of ischemic heart disease modified this relationship.

Method

A total of 884 patients with systolic HF (66±12 years, male 73%, mean ejection fraction 28±9%) underwent speckle tracking echocardiography. Of these, 61% suffered from ischemic cardiomyopathy (ICM). Patients were followed for all-cause mortality. We assessed the ESL index: [−100x (peak positive strain/maximal strain)] and the postsystolic index (PSI): [100x (postsystolic strain/maximal strain)]. Both parameters were averaged across 18 myocardial segments.

Results

During a median follow-up of 3.4 years [interquartile range 1.9 to 4.8], 132 patients (15%) died. In multivariable survival analyses adjusted for potential confounders (age, sex, BMI, mean arterial pressure, cholesterol, heart rate, CABG/PCI, left ventricular ejection fraction and mass index, left atrial volume index, tricuspid annular plane systolic excursion, E-wave, E/e', deceleration time, and global longitudinal strain) neither the ESL index (HR 1.02 per 1% increase [0.97 to 1.08], P=0.40) nor PSI (HR 1.00 per 1% increase [0.98 to 1.01], P=0.69) were associated with all-cause mortality. ICM modified the relationship (P interaction unadjusted/adjusted=0.001/0.008; Figure) such that per 1% increase in ESL index in patients with ICM was significantly associated with all-cause mortality (unadjusted: HR 1.09 [1.04 to 1.15], P<0.001 and adjusted: HR 1.06 [1.00 to 1.13], P=0.045) but not in those without (unadjusted: HR 1.02 [1.01 to 1.03], P=0.002 and adjusted: HR 0.99 [0.90 to 1.09], P=0.086). ICM did not modify the relationship between PSI and all-cause mortality (P interaction unadjusted/adjusted=0.15/0.13).

Conclusion

Our results indicate that in this cohort of undifferentiated HF patients with reduced ejection fraction the prognostic value of deformational patterns was reduced. However, the ESL index may provide some information on prognosis in patients with ICM.

ESL and interaction with ICM

Funding Acknowledgement

Type of funding source: None

Prognosis of short- and long-term dialysis in patients with infective endocarditis: a nationwide study

Background

Infective endocarditis (IE) may be complicated by acute kidney injury, yet data on the use of dialysis and subsequent reversibility are sparse. We set out to examine the prognosis of short- and long-term dialysis in patients with IE.

Methods

Using Danish nationwide registries we identified patients with first-time IE from 2000 to 2017. Dialysis naïve patients were grouped into: those who were treated with dialysis during admission with IE and those who were not. The cumulative incidence of continuous use of dialysis was examined one year post-discharge Multivariable adjusted Cox proportional hazard analysis was used to examine one-year mortality for patients surviving IE based on use of dialysis.

Results

We included 7,307 patients with IE; 416 patients (5.7%) initiated dialysis treatment during admission with IE and these were younger, had more comorbidities and more often underwent cardiac valve surgery during admission with IE compared with non-dialysis patients (47.4% vs. 20.9%). In patients with both surgical intervention and dialysis treatment, 153 (77.7%) initiated dialysis on- or after the date of surgery. The in-hospital mortality was 40.4% and 19.0% for patients with and without dialysis, respectively (p<0.0001). Of those who started dialysis and survived hospitalisation, 78.4% became dialysis-free within one year after discharge. Among those who survived one week subsequent to IE discharge, we identified 5,520 who never had dialysis, 204 patients without continued use of dialysis, and 40 patients with a continued use of dialysis. The corresponding mortality risk at one year was 15.2%, 13.5%, and 41.6% (Figure), respectively. Compared with patients not treated with dialysis, those who became dialysis-free at discharge showed no increased risk of one year mortality in adjusted analysis (HR=1.45, 95% CI: 0.97–2.20), while patients who continued dialysis had an increased associated risk of mortality (HR=2.00, 95% CI: 1.20–3.33).

Conclusion

In dialysis-naïve patients with IE, more than 1 in 20 patients initiated dialysis treatment during admission. Dialysis identified a high-risk group with an in-hospital mortality of 40%–twice as high as their counterparts. In dialysis patients surviving admission with IE, almost 80% became dialysis-free and showed better long-term survival than those who continued dialysis after discharge.

Figure 1

Funding Acknowledgement

Type of funding source: None

Recommendations on echocardiography following surgical aortic valve replacement (SAVR): time for revision?

Background

ESC guidelines recommend annual echocardiographic evaluation following biological surgical aortic valve replacement (SAVR), and 5 years following mechanical SAVR. Conversely, increased life expectancy result in increasing demand on health care resources.

Purpose

To assess aortic reintervention rates at 1-year, 3-year and 5-year following biological and mechanical SAVR in relation to estimated echocardiographic controls.

Methods

From the nationwide Danish Register of Surgical Procedures, we identified all patients ≥40 years with isolated biological or mechanical SAVR +/− concomitant coronary artery bypass graft surgery (CABG) during 2000–2016. In 90-day reintervention-free survivors we assessed aortic valve reintervention rates at 1-year, 3-years and 5-years until December 31st, 2017. We further assessed cumulative risk of reintervention by age (<60, 60–69, 70–79, ≥80 years at SAVR) accounting for the competing risk of death during the study period.

Results

The population of 90-day reintervention-free survivors included 10,526 patients with biological SAVR (CABG 39.7%) and 3,677 patients with mechanical SAVR (CABG 23.8%). Reintervention rates at 1-year, 3-years and 5-years were comparable across type of SAVR, and generally low (Figure). Accounting for the competing risk of death, reintervention rates at 5-years were 1.4% (95% CI 1.1–1.6) for biological SAVR and 1.5% (95% CI 1.1–1.9) for mechanical SAVR, respectively. In age-stratified competing risk analyses, we observed the highest rates in patients aged 40–59 years (4% [95% CI 1.8–6] at 5 years for biological SAVR, and 2% [95% CI 1.3–3] for mechanical SAVR). Following biological SAVR, annual echocardiographic controls would yield a total of 34,516 scans in our population in the first 5 years following surgery. This contrasts to a total of 66 reinterventions following biological SAVR in our population between years 1–5 of which the majority was preceded by a hospital admission with a primary diagnosis of endocarditis within the last 90 days prior to the reintervention; which are unlikely to have been diagnosed at the annual assessment scan.

Conclusion(s)

In this nationwide study, reintervention rates following biological or mechanical SAVR were very low within the first five years after surgery suggesting a discrepancy between ESC recommendations on echocardiographic controls following SAVR, the benefit for patients, and the associated resource burden on the health care system.

Figure 1

Funding Acknowledgement

Type of funding source: None

Right ventricular speckle tracking in patients with heart failure – a comparison of right ventricular measures

Background

RV dysfunction is associated with increased mortality and morbidity in patients with heart failure. Due to the complex shape and position of the RV, assessing RV function from echocardiographic images remains a challenge.

Purpose

We have previously found that global longitudinal strain from 2DSTE is superior to left ventricular ejection fraction (LVEF) in identifying HFrEF patients with high risk of mortality. In this study we wanted to examine RV 2DSTE in patients with HFrEF and compare its prognostic value to conventional RV measures.

Methods and results

Echocardiographic examinations were retrieved from 701 patients with HFrEF. RV estimates were analysed offline, and end point was all-cause mortality. During follow-up (median 39 months) 118 patients (16.8%) died. RV GLS and RV FWS remained associated with mortality after multivariable adjustment, independent of TAPSE (RV GLS: HR 1.07, 95% CI 1.02–1.13, p=0.010, per 1% decrease) (RV FWS: HR 1.05, 95% CI 1.01–1.09, p=0.010, per 1% decrease). This seemed to be caused by significant associations in men as TAPSE remained as the only independent prognosticator in women. All RV estimates provided prognostic information incremental to established risk factors and significantly increased C-statistics (TAPSE: 0.74 to 0.75; RVFAC: 0.74 to 0.75; RVFWS: 0.74 to 0.77; RVGLS: 0.74 to 0.77).

Conclusions

RV strain from 2DSTE was associated with mortality in patients with HFrEF, independent of TAPSE and established risk factors. Our results indicate that RV strain is particularly valuable in male patients, whereas in women TAPSE remains a stronger prognosticator.

RV GLS and the risk of mortality

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): PGJ reports receiving lecture fee from Novo Nordisk.

Prognostic value of global longitudinal layer specific strain for patients with heart failure with reduced ejection fraction

Background

Novel echocardiographic software allows for layer-specific evaluation of myocardial deformation by 2-dimensional speckle tracking echocardiography. Endocardial, epicardial- and whole wall global longitudinal strain (GLS) may be superior to conventional echocardiographic parameters in predicting all-cause mortality in patients with heart failure with reduced ejection fraction (HFrEF).

Purpose

The purpose of this study was to investigate the prognostic value of endocardial-, epicardial- and whole wall GLS in patients with HFrEF in relation to all-cause mortality.

Methods

We included and analyzed transthoracic echocardiographic examinations from 1,015 patients with HFrEF. The echocardiographic images were analyzed, and conventional and novel echocardiographic parameters were obtained. A p value in a 2-sided test <0.05 was considered statistically significant. Cox proportional hazards regression models were constructed, and both univariable and multivariable hazard ratios (HRs) were calculated.

Results

During a median follow-up time of 40 months, 171 patients (16.8%) died. A lower endocardial (HR 1.17; 95% CI (1.11–1.23), per 1% decrease, p<0.001), epicardial (HR 1.20; 95% CI (1.13–1.27), per 1% decrease, p<0.001), and whole wall (HR 1.20; 95% CI (1.14–1.27), per 1% decrease, p<0.001) GLS were all associated with higher risk of death (Figure 1). Both endocardial (HR 1.12; 95% CI (1.01–1.23), p=0.027), epicardial (HR 1.13; 95% CI (1.01–1.26), p=0.040) and whole wall (HR 1.13; 95% CI (1.01–1.27), p=0.030) GLS remained independent predictors of mortality in the multivariable models after adjusting for significant clinical parameters (age, sex, total cholesterol, mean arterial pressure, heart rate, ischemic cardiomyopathy, percutaneous transluminal coronary angioplasty and diabetes) and conventional echocardiographic parameters (left ventricular (LV) ejection fraction, LV mass index, left atrial volume index, deceleration time, E/e', E-velocity, E/A ratio and tricuspid annular plane systolic excursion). No other echocardiographic parameters remained an independent predictors after adjusting. Furthermore, endocardial, epicardial and whole wall GLS had the highest C-statistics of all the echocardiographic parameters.

Conclusion

Endocardial, epicardial and whole wall GLS are independent predictors of all-cause mortality in patients with HFrEF. Furthermore, endocardial, epicardial and whole wall GLS were superior prognosticators of all-cause mortality compared with all other echocardiographic parameters.

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Herlev and Gentofte Hospital

Hemoglobin level at stabilization is associated with long-term all-cause mortality in patients with left-sided endocarditis, a POET substudy

Background

Left-sided infectious endocarditis (IE) has a high 1-year mortality. Anemia is a common finding in patients with IE, yet little is known about frequency, severity, and associated outcomes in this setting.

Purpose

To examine the relationship between Hemoglobin (Hgb) level measured at IE stabilization (time of randomization) in the Partial Oral versus intravenous Antibiotic Treatment of Endocarditis (POET) trial - and long-term all-cause mortality.

Methods

In the POET trial, 400 patients with left-sided IE were randomized, after medical and/or surgical stabilization, to conventional antibiotic treatment or partial oral treatment. Only non-surgically treated patients were considered in this study. Patients were divided by quartiles into four groups based on Hgb level at randomization.

Results

We examined 248 patients with non-surgically treated IE. Median time from diagnosis of IE to randomization was 14 days (IQ 12–19). At long-term follow-up (median 3.2 years, IQ 2.18–4.60), 71 patients had died (28.6%). Patients in the lowest quantile (Hgb ≤6.0 mmol) had a HR of 4.17 (95% CI 1.81–9.61, p<0.001) for death compared to patients in the highest quantile (Hgb >7.5 mmol/L). This association remained significant after multivariable adjustment for age, sex, renal disease, C-Reactive Protein, and Prosthetic heart valve (HR 2.69, 95% CI 1.11–6.50); p=0.028).

Conclusion

Low Hemoglobin level at stabilization in patients with IE was associated with an increased risk of long-term mortality. Whether intensified treatment of anemia in patients with IE could improve long-term outcome requires investigation.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): The Danish Heart Foundation, The Capital Regions Research Council