Long-Term Incidence of Ischemic Stroke After Transient Ischemic Attack: A Nationwide Study From 2014 to 2020.

BACKGROUND: The short-term incidence of ischemic stroke after a transient ischemic attack (TIA) is high. However, data on the long-term incidence are not well known but are needed to guide preventive strategies. METHODS: Patients with first-time TIA (index date) in the Danish Stroke Registry (January 2014-December 2020) were included and matched 1:4 with individuals from the background population and 1:1 with patients with a first-time ischemic stroke on the basis of age, sex, and calendar year. The incidences of ischemic stroke and mortality from index date were estimated by Aalen-Johansen and Kaplan-Meier estimators, respectively, and compared between groups using multivariable Cox regression. RESULTS: We included 21 500 patients with TIA, 86 000 patients from the background population, and 21 500 patients with ischemic stroke (median age, 70.8 years [25th-75th percentile, 60.8-78.7]; 53.1% males). Patients with TIA had more comorbidities than the background population, yet less than the control stroke population. The 5-year incidence of ischemic stroke after TIA (6.1% [95% CI, 5.7-6.5]) was higher than the background population (1.5% [95% CI, 1.4-1.6], P<0.01; hazard ratio, 5.14 [95% CI, 4.65-5.69]) but lower than the control stroke population (8.9% [95% CI, 8.4-9.4], P<0.01; hazard ratio, 0.58 [95% CI, 0.53-0.64]). The 5-year mortality for patients with TIA (18.6% [95% CI, 17.9-19.3]) was higher than the background population (14.8% [95% CI, 14.5-15.1], P<0.01; hazard ratio, 1.26 [95% CI, 1.20-1.32]) but lower than the control stroke population (30.1% [95% CI, 29.3-30.9], P<0.01; hazard ratio, 0.41 [95% CI, 0.39-0.44]). CONCLUSIONS: Patients with first-time TIA had an ischemic stroke incidence of 6.1% during the 5-year follow-up period. After adjustment for relevant comorbidities, this incidence was approximately 5-fold higher than what was found for controls in the background population and 40% lower than for patients with recurrent ischemic stroke.

Mortality in patients with chronic obstructive pulmonary disorder undergoing transcatheter aortic valve replacement: The importance of chronic obstructive pulmonary disease exacerbation.

BACKGROUND: Severe chronic obstructive pulmonary disease (COPD) has been associated with futile outcome after transcatheter aortic valve replacement (TAVR). Data on outcomes according to COPD severity are warranted to aid identification of patients who may not benefit from TAVR. We aimed to examine the association between risk of COPD exacerbation and 1-year mortality after TAVR. METHODS: Using Danish nationwide registries we identified patients undergoing first-time TAVR during 2008-2021 by COPD status. COPD severity levels were defined as low or high risk of acute exacerbation of COPD (AE-COPD) and treatment intensity levels (none or short-term, mono/dual, triple therapy, or home oxygen). Kaplan-Meier functions and adjusted Cox regression models were used to assess 1-year mortality comparing COPD severity groups with patients without COPD. RESULTS: We identified 7,047 patients with TAVR of whom 644 had a history of COPD (low risk of AE-COPD: 439, high risk of AE-COPD: 205). The median age of the TAVR cohort was 81.4 years (IQR: 76.8-85.1) and 55.8% were males. One-year mortality for TAVR patients without COPD was 8.5% (95% CI: 7.8-9.2) and 15.4% (95% CI: 12.5-18.2) for those with COPD (adjusted HR: 1.63 [95% CI: 1.28-2.07]). Patients with low or high risk of AE-COPD had 1-year mortality of 13.1% (95% CI: 9.8-16.3) and 20.2% (95% CI: 14.6-25.8) corresponding to adjusted HRs of 1.31 (95% CI: 0.97-1.78) and 2.44 (95% CI: 1.70-3.50) compared with patients without COPD. Patients with high risk of AE-COPD and no/short term therapy or use of home oxygen represented the subgroups of patients with the highest 1-year mortality (31.6% [95% CI: 14.5-48.7] and 30.9% [95% CI: 10.3-51.6]). CONCLUSION: Among patients undergoing TAVR, increasing risk of exacerbation with COPD was associated with increasing 1-year mortality compared with non-COPD patients. Patients with a high risk of exacerbation with COPD not using any guideline recommended COPD medication and those using home oxygen had the highest 1-year mortality.

Trends in first-time hospitalization, management, and short-term mortality in acute myocardial infarction-related cardiogenic shock from 2005 to 2017: A nationwide cohort study.

BACKGROUND: Cardiogenic shock remains the leading cause of in-hospital death in acute myocardial infarction (AMI). Because of temporary changes in management of cardiogenic shock with widespread implementation of early revascularization along with increasing attention to the use of mechanical circulatory devices, complete and longitudinal data are important in this subject. The objective of this study was to examine temporal trends of first-time hospitalization, management, and short-term mortality for patients with AMI-related cardiogenic shock (AMICS). METHODS: Using nationwide medical registries, we identified patients hospitalized with first-time AMI and cardiogenic shock from January 1, 2005, through December 31, 2017. We calculated annual incidence proportions of AMICS. Thirty-day mortality was estimated with use of Kaplan-Meier estimator comparing AMICS and AMI-only patients. Multivariable Cox regression models were used to assess mortality rate ratios. RESULTS: We included 101,834 AMI patients of whom 7,040 (7%) had AMICS. The median age was 72 (interquartile range: 62-80) for AMICS and 69 (interquartile range: 58-79) for AMI-only patients. The gender composition was similar between AMICS and AMI-only patients (male: 64% vs 63%). The annual incidence proportion of AMICS decreased slightly over time (2005: 7.0% vs 2017: 6.1%, P for trend < .0001). In AMICS, use of coronary angiography increased between 2005 and 2017 from 48% to 71%, as did use of left ventricular assist device (1% vs 10%) and norepinephrine (30% to 70%). In contrast, use of intra-aortic balloon pump (14% vs 1%) and dopamine (34% vs 20%) decreased. Thirty-day mortality for AMICS patients was 60% (95% CI: 59-61) and substantially higher than the 8% (95% CI: 7.8-8.2) for AMI-only patients (mortality rate ratio: 11.4, 95% CI: 10.9-11.8). Over time, the mortality decreased after AMICS (2005: 68% to 2017: 57%, P for temporal change in adjusted analysis < .0001). CONCLUSIONS: We observed a slight decrease in AMICS hospitalization over time with changing practice patterns. Thirty-day mortality was markedly higher for patients with AMICS compared with AMI only, yet our results suggest improved 30-day survival over time after AMICS.

Positive predictive value of International Classification of Diseases, 10th revision, diagnosis codes for cardiogenic, hypovolemic, and septic shock in the Danish National Patient Registry.

BACKGROUND: Large registries are important data sources in epidemiological studies of shock, if these registries are valid. Therefore, we examined the positive predictive value (PPV) of diagnosis codes for shock, the procedure codes for inotropic/vasopressor therapy among patients with a diagnosis of shock, and the combination of a shock diagnosis and a code for inotropic/vasopressor therapy in the Danish National Patient Registry (DNPR). METHODS: We randomly selected 190 inpatients with an International Classification of Diseases, 10th revision (ICD-10) diagnosis of shock at Aarhus University Hospital from 2005-2012 using the DNPR; 50 patients were diagnosed with cardiogenic shock, 40 patients with hypovolemic shock, and 100 patients with septic shock. We used medical charts as the reference standard and calculated the PPV with 95% confidence intervals (CI) for overall shock and for each type of shock separately. We also examined the PPV for inotropic/vasopressor therapy and the PPV for shock when a concurrent code for inotropic/vasopressor therapy was also registered. RESULTS: The PPV was 86.1% (95% CI: 79.7-91.1) for shock overall, 93.5% (95% CI: 82.1-98.6) for cardiogenic shock, 70.6% (95% CI: 52.5-84.9) for hypovolemic shock, and 69.2% (95% CI: 57.7-79.2) for septic shock. The PPV of use of inotropes/vasopressors among shock patients was 88.9% (95% CI: 79.3-95.1). When both a shock code and a procedure code for inotropic/vasopressor therapy were used, the PPV for shock overall was 93.1% (95% CI: 84.5-97.7). ICD-10 codes for subtypes of shock and simultaneously registered use of inotropes/vasopressors provided PPVs of 96.0% (95% CI: 79.6-99.9) for cardiogenic shock, 69.2% (95% CI: 38.6-90.9) for hypovolemic shock, and 82.4% (95% CI: 65.5-93.2) for septic shock. CONCLUSIONS: Overall, we found a moderately high PPV for shock in the DNPR. The PPV was highest for cardiogenic shock but lower for hypovolemic and septic shock. Combination diagnoses of shock with codes for inotropic/vasopressor therapy further increased the PPV of shock overall, and for cardiogenic and septic shock diagnoses.

Acute kidney injury treated with renal replacement therapy and 5-year mortality after myocardial infarction-related cardiogenic shock: a nationwide population-based cohort study.

BACKGROUND: Myocardial infarction-related cardiogenic shock is frequently complicated by acute kidney injury. We examined the influence of acute kidney injury treated with renal replacement therapy (AKI-RRT) on risk of chronic dialysis and mortality, and assessed the role of comorbidity in patients with cardiogenic shock. METHODS: In this Danish cohort study conducted during 2005-2012, we used population-based medical registries to identify patients diagnosed with first-time myocardial infarction-related cardiogenic shock and assessed their AKI-RRT status. We computed the in-hospital mortality risk and adjusted relative risk. For hospital survivors, we computed 5-year cumulative risk of chronic dialysis accounting for competing risk of death. Mortality after discharge was computed with use of Kaplan-Meier methods. We computed 5-year hazard ratios for chronic dialysis and death after discharge, comparing AKI-RRT with non-AKI-RRT patients using a propensity score-adjusted Cox regression model. RESULTS: We identified 5079 patients with cardiogenic shock, among whom 13% had AKI-RRT. The in-hospital mortality was 62% for AKI-RRT patients, and 36% for non-AKI-RRT patients. AKI-RRT remained associated with increased in-hospital mortality after adjustment for confounders (relative risk=1.70, 95% confidence interval (CI): 1.59-1.81). Among the 3059 hospital survivors, the 5-year risk of chronic dialysis was 11% (95% CI: 8-16%) for AKI-RRT patients, and 1% (95% CI: 0.5-1%) for non-AKI-RRT patients (adjusted hazard ratio: 15.9 (95% CI: 8.7-29.3). The 5-year mortality was 43% (95% CI: 37-53%) for AKI-RRT patients compared with 29% (95% CI: 29-31%) for non-AKI-RRT patients. The adjusted 5-year hazard ratio for death was 1.55 (95% CI: 1.22-1.96) for AKI-RRT patients compared with non-AKI-RRT patients. In patients with comorbidity, absolute mortality increased while relative impact of AKI-RRT on mortality decreased. CONCLUSION: AKI-RRT following myocardial infarction-related cardiogenic shock predicted elevated short-term mortality and long-term risk of chronic dialysis and mortality. The impact of AKI-RRT declined with increasing comorbidity suggesting that intensive treatment of AKI-RRT should be accompanied with optimized treatment of comorbidity when possible.

The use of telemedicine in lung diseases with focus on chronic obstructive pulmonary disease.

Telemedicine is emerging and has both clinical, scientific, and political interest. In this review, we present the present literature on implementation and describe the economic considerations when implementing telemedicine in chronic obstructive pulmonary disease (COPD). The use of telemedicine in COPD is well-received by patients, but there is little evidence to suggest its superiority to standard outpatient care or to support better outcomes for patients. Thus, local settings and cost effectiveness should be considered during the implementational process.

Five-year risk of heart failure and death following myocardial infarction with cardiogenic shock: a nationwide cohort study.

AIMS: More patients survive myocardial infarction (MI) with cardiogenic shock (CS), but long-term outcome data are sparse. We aimed to examine rates of heart failure hospitalization and mortality in MI hospital survivors. METHODS AND RESULTS: First-time MI patients with and without CS alive until discharge were identified using Danish nationwide registries between 2005 and 2017. One-, 5-, and 1- to 5-year rates of heart failure hospitalization and mortality were compared using landmark cumulative incidence curves and Cox regression models. We identified 85 865 MI patients of whom 2865 had CS (3%). Cardiogenic shock patients were of similar age as patients without CS (median age years: 68 vs. 67), and more were men (70% vs. 65%). Cardiogenic shock was associated with a higher 5-year rate of heart failure hospitalization compared with patients without CS [40% vs. 20%, adjusted hazard ratio (HR) 2.90 (95% confidence interval (CI) 2.67-3.12)]. The increased rate of heart failure hospitalization was evident after 1 year and in the 1- to 5-year landmark analysis among 1-year survivors. All-cause mortality was higher at 1 year among CS patients compared with patients without CS [18% vs. 8%, adjusted HR 3.23 (95% CI 2.95-3.54)]. However, beyond the first year, the mortality for CS was not markedly different compared with patients without CS [12% vs. 13%, adjusted HR 1.15 (95% CI 1.00-1.33)]. CONCLUSION: Among MI hospital survivors, CS was associated with a markedly higher rate of heart failure hospitalization and 1-year mortality compared with patients without CS. However, among 1-year survivors, the remaining 5-year mortality was similar for MI patients with and without CS.

Temporal trends in patient characteristics, presumed causes, and outcomes following cardiogenic shock between 2005 and 2017: a Danish registry-based cohort study.

AIMS: Most cardiogenic shock (CS) studies focus on acute coronary syndrome (ACS). Contemporary data on temporal trends in patient characteristics, presumed causes, treatments, and outcomes of ACS- and in particular non-ACS-related CS patients are sparse. METHODS AND RESULTS: Using nationwide medical registries, we identified patients with first-time CS between 2005 and 2017. Cochrane-Armitage trend tests were used to examine temporal changes in presumed causes of CS, treatments, and outcomes. Among 14 363 CS patients, characteristics remained largely stable over time. As presumed causes of CS, ACS (37.1% in 2005 to 21.4% in 2017), heart failure (16.3% in 2005 to 12.0% in 2017), and arrhythmias (13.0% in 2005 to 10.9% in 2017) decreased significantly over time; cardiac arrest increased significantly (11.3% in 2005 to 24.5% in 2017); and changes in valvular heart disease were insignificant (11.5% in 2005 and 11.6% in 2017). Temporary left ventricular assist device, non-invasive ventilation, and extracorporeal membrane oxygenation use increased significantly over time; intra-aortic balloon pump and mechanical ventilation use decreased significantly. Over time, 30-day and 1-year mortality were relatively stable. Significant decreases in 30-day and 1-year mortality for patients presenting with ACS and arrhythmias and a significant increase in 1-year mortality in patients presenting with heart failure were seen. CONCLUSION: Between 2005 and 2017, we observed significant temporal decreases in ACS, heart failure, and arrhythmias as presumed causes of first-time CS, whereas cardiac arrest significantly increased. Although overall 30-day and 1-year mortality were stable, significant decreases in mortality for ACS and arrhythmias as presumed causes of CS were seen.