Omecamtiv mecarbil evokes diastolic dysfunction and leads to periodic electromechanical alternans.

Omecamtiv mecarbil (OM) is a promising novel drug for improving cardiac contractility. We tested the therapeutic range of OM and identified previously unrecognized side effects. The Ca2+ sensitivity of isometric force production (pCa50) and force at low Ca2+ levels increased with OM concentration in human permeabilized cardiomyocytes. OM (1 µM) slowed the kinetics of contractions and relaxations and evoked an oscillation between normal and reduced intracellular Ca2+ transients, action potential lengths and contractions in isolated canine cardiomyocytes. Echocardiographic studies and left ventricular pressure-volume analyses demonstrated concentration-dependent improvements in cardiac systolic function at OM concentrations of 600-1200 µg/kg in rats. Administration of OM at a concentration of 1200 µg/kg was associated with hypotension, while doses of 600-1200 µg/kg were associated with the following aspects of diastolic dysfunction: decreases in E/A ratio and the maximal rate of diastolic pressure decrement (dP/dtmin) and increases in isovolumic relaxation time, left atrial diameter, the isovolumic relaxation constant Tau, left ventricular end-diastolic pressure and the slope of the end-diastolic pressure-volume relationship. Moreover, OM 1200 µg/kg frequently evoked transient electromechanical alternans in the rat in vivo in which normal systoles were followed by smaller contractions (and T-wave amplitudes) without major differences on the QRS complexes. Besides improving systolic function, OM evoked diastolic dysfunction and pulsus alternans. The narrow therapeutic window for OM may necessitate the monitoring of additional clinical safety parameters in clinical application.

Validation of the Hospital Frailty Risk Score in older surgical patients: A population-based retrospective cohort study.

BACKGROUND: There is a need for standardized and cost-effective identification of frailty risk. The objective was to validate the Hospital Frailty Risk Score which utilizes International Classification Diagnoses in a cohort of older surgical patients, assess the score as an independent risk factor for adverse outcomes and compare discrimination properties of the frailty risk score with other risk stratification scores. METHODS: Data were analysed from all patients ≥65 years undergoing primary surgical procedures from 2006-2018. Patients were categorized based on the frailty risk score. The primary outcomes were 30-day mortality and 180-day risk of readmission. RESULTS: Of 16 793 patients evaluated, 7480 (45%), 7605 (45%) and 1708 (10%) had a low, intermediate and high risk of frailty. There was a higher incidence of 30-day mortality for individuals with intermediate (2.9%) and high (8.3%) compared with low (1.4%) risk of frailty (P < .001 for both comparisons). Similarly, the hazard of readmission within the first 180 days was higher for intermediate (HR 1.25; 95% CI: 1.16-1.34) and high (HR 1.84; 95% CI: 1.66-2.03) compared with low (HR 1.00, P < .001 for both comparisons) risk of frailty. The hazard of long-term mortality was higher for intermediate (HR 1.70; 95% CI: 1.61-1.80) and high (HR 4.16; 95% CI: 3.84-4.49) compared with low (HR 1.00, P < .001 for both comparisons) risk of frailty. Finally, long length of primary hospitalization occurred for 9.3%, 15.0% and 27.3% of individuals with low, intermediate and high frailty risk (P < .001 for all comparisons). A model including age and ASA classification had the best discrimination for 30-day mortality (AUC 0.862; 95% CI: 0.847-0.877). CONCLUSION: Our findings suggest that the Hospital Frailty Risk Score might be used to screen older surgical patients for risk of frailty. While only slightly improving prediction of 30-day mortality using the ASA classification, the Hospital Frailty Risk Score can be used to independently classify older patients for the risk of important outcomes using pre-existing readily available electronic data.

Reoperation for bleeding following coronary artery bypass surgery with special focus on long-term outcomes.

Objectives: We studied the incidence and risk factors of reoperation for bleeding following CABG in a nationwide cohort with focus on long-term complications and survival. Design: A retrospective study on 2060 consecutive, isolated CABG patients operated 2001-2016. Outcome of reoperated patients (n = 130) were compared to non-reoperated ones (n = 1930), including major adverse cardiac and cerebrovascular events (MACCE) and overall survival. Risk factors for reoperation were determined using multivariate logistic regression and a Cox proportional hazards model to assess prognostic factors of long-term survival. Median follow-up was 7.6 years. Results: One hundred thirty patients (6.3%) were reoperated with an annual decrease of 4.1% per year over the study period (p=.04). Major complications (18.5 vs. 9.6%) and 30-day mortality (8.5 vs. 1.9%,) were higher in the reoperation group (p<.001). The use of clopidogrel preoperatively (OR 3.62, 95% CI: 1.90-6.57) and reduced left ventricular ejection fraction (OR 2.23, 95% CI: 1.25-3.77) were the strongest predictors of reoperation, whereas off-pump surgery was associated with a lower reoperation risk (OR 0.44, 95% CI: 0.22-0.85). After exluding patients that died within 30 days postoperatively, no difference in long-term survival or freedom from MACCE was found between groups, and reoperation was not an independent risk factor for long-term mortality in multivariate analysis. Conclusions: The reoperation rate in this study was relatively high but decreased significantly over time. Reoperation was associated with twofold increased risk for major complications and fourfold 30-day mortality, but comparable long-term MACCE and survival rates. This implies that if patients survive the first 30 days following reoperation, their long-term outcome is comparable to non-reoperated patients.

New-onset postoperative atrial fibrillation after heart surgery.

BACKGROUND: New-onset postoperative atrial fibrillation (poAF) complicates approximately 20-60% of all cardiac surgical procedures and is associated with an increased periprocedural mortality and morbitity, prolonged hospital stay, increased costs, and worse long-term survival. Unfortunately multiple advances in surgery and perioperative care over the last two decades have not led to a reduction in the incidence of poAF or associated complications in the daily clinical practice. METHODS: A narrative review of the available literature was performed. RESULTS: An extensive review of the pathophysiology of poAF following cardiac surgery, clinical, and procedural risk-factors is provided, as well as prophylactic measures and treatment. CONCLUSION: Multiple strategies to prevent and manage poAF following heart surgery already exist. Our hope is that this review will facilitate more rigorous testing of prevention strategies, implementation of prophylaxis regimens as well as optimal treatment of this common and serious complication.

[Incidence and predictors of prolonged intensive care unit stay after coronary artery bypass in Iceland].

INTRODUCTION: To maximize the use of intensive care unit (ICU) re--sources, it is important to estimate the prevalence and risk factors for prolonged ICU unit stay after coronary artery bypass grafting (CABG) surgery. MATERIAL AND METHODS: This retrospective cohort study included all patients who underwent primary isolated CABG at Landspitali between 2001 and 2018. Patient information was collected from hospital charts and death registries. Patients who stayed in the ICU for the conventional one night postoperatively were compared with those who needed longer stays in the ICU. Survival rate was estimated with the Kaplan-Meier method. Predictors for prolonged ICU stay were calculated with logistic regression and the outcome used to create a calculator that estimates the probability of prolonged ICU stay. RESULTS: Out of 2177 patients, 20% required prolonged ICU stay. Patients with prolonged stay were more frequently female (23% vs 16%, p=0.001), had a higher rate of cardiovascular risk factors and higher EuroSCORE II (4.7 vs. 1.9, p<0.001). They also had a higher rate of impaired renal function before surgery (14% vs. 4%, p<0.001) and emergent surgery (18% vs. 2%, p<0.001). Furthermore, these patients had higher rates of both short-term and long-term complications, and lower long-term survival (85% vs 68% five-year survival rate, p<0.0001). Independent risk factors for prolonged ICU stay were advanced age, female gender, EuroSCORE II, history of heart diseases, impaired renal function and emergent surgery.  Conclusions: Every fifth patient had a prolonged ICU stay after CABG. Several risk factors predicted prolonged ICU stay after CABG, in particular patients' medical condition before surgery, EuroSCORE II and emergent surgery. A better understanding of the risk factors for prolonged ICU stay will hopefully aid in scheduling CABG surgeries at Landspitali.

[The use of Intra Aortic Balloon Pump in Coronary Artery Bypass Graft Surgery].

INTRODUCTION: Intra-aortic balloon pump (IABP) is a mechanical device that increases cardiac output by increasing diastolic blood flow to the coronary arteries and lowers the afterload of the left ventricle in systole. IABP is primarily used in acute heart failure, that includes patients that have to undergo coronary artery bypass grafting (CABG). Its usage, however, in cardiac surgery has been declining with ongoing controversy regarding its benefits. The aim of this study was to assess the use and indications and outcome of IABP related to CABG surgery. MATERIAL AND METHODS: The study was retrospective and included 2177 patients that underwent CABG at Landspítali during 2001-2018. We compared those who received an IABP with controls, using uni- and multivariate analysis. Long term survival and complications (major adverse cardiovascular and cerebral events, MACCE) was estimated with Kaplan-Meier method. RESULTS: A total of 99 (4.5%) patients received an IABP. The incidence was highest in 2006 (8.9%) and lowest in 2001 (1.7%), but the incidence did not change during the study period (p=0.90). Most patients received the pump before (58.6%) or during (34.3%) CABG, but only 6.1% after surgery. Complication rate was 14.1%, with bleeding from the insertion site in the groin being the most common complication. Thirty day mortality was higher in the IABP group compared with controls (22.2% vs 1.3%, p<0.001) and both 5-year survival (56.4% vs 91.5%, 95% CI: 0.47-0.67) and 5-year MACCE-free survival (46.9% vs 83.0%, 95% CI: 0.38-0.58) were inferior. CONCLUSIONS: Less than 5% of patients received IABP in relation to CABG in Iceland and the rate hasn't changed much for the last 18 years. Both the complication rate and 30-day mortality was higher in patients in IABP group and both the long term and MACCE-free survival was much worse, probably mostly related to worse overall clinical condition of the patient that received IABP.

Postoperative Acute Kidney Injury: Focus on Renal Recovery Definitions, Kidney Disease Progression and Survival.

BACKGROUND: The aim of this study was to examine different definitions of renal recovery following postoperative acute kidney injury (AKI) and how these definitions associate with survival and the development and progression of chronic kidney disease (CKD). METHODS: This was a retrospective study of all patients who underwent abdominal, cardiothoracic, vascular, or orthopedic surgery at a single university hospital between 1998 and 2015. Recovery of renal function following postoperative AKI was assessed comparing 4 different definitions: serum creatinine (SCr) (i) < 1.1 × baseline, (ii) 1.1-1.25 × baseline, (iii) 1.25-1.5 × baseline, and (iv) > 1.5 × baseline. One-year survival and the development or progression of CKD within 5 years was compared with a propensity score-matched control groups. RESULTS: In total, 2,520 AKI patients were evaluated for renal recovery. Risk of incident and progressive CKD within 5 years was significantly increased if patients did not achieve a reduction in SCr to < 1.5 × baseline (hazard ratio [HR] 1.50; 95% CI 1.29-1.75) and if renal recovery was limited to a fall in SCr to 1.25-1.5 × baseline (HR 1.32; 95% CI 1.12-1.57) within 30 days. The definition of renal recovery that best predicted survival was a reduction in SCr to < 1.5 × baseline within 30 days. One-year survival of patients whose SCr decreased to < 1.5 × baseline within 30 days was significantly better than that of a propensity score-matched control group that did not achieve renal recovery (85 vs. 71%, p < 0.001). CONCLUSIONS: These findings should be considered when a consensus definition of renal recovery after AKI is established.

[No significant association between obesity and long-term outcome of coronary artery bypass grafting].

OBJECTIVES:  Our objective was to investigate long-term outcomes of obese patients undergoing coronary artery bypass grafting (CABG) in Iceland. MATERIALS AND METHODS:  A retrospective analysis on 1698 patients that underwent isolated CABG in Iceland between 2001-2013. Patients were divided into four groups according to body mass index (BMI); Normal=18.5-24.9kg/m2 (n=393), ii) overweight=25-29.9 kg/m2 (n=811), iii) obese=30-34.9 kg/m2 (n=388) and iv) severely obese ≥35kg/m2 (n=113). Thirty-day mortality and short-term complications were documented as well as long-term complications that were pooled into major adverse cardiac and cerebrovascular events (MACCE) and included myocardial infarction, stroke, repeated CABG, percutaneous coronary intervention with or without stenting, and death. After pooling the study groups, survival and freedom from MACCE plots (Kaplan- Meier) were generated and Cox regression analysis used to identify predictive factors of survival. Average follow-up time was 5.6 years. RESULTS:  Severely obese and obese patients were significantly younger than those with a normal BMI, more often males with identifiable risk factors of coronary artery disease (CAD) and a lower EuroSCORE II (1.6 vs. 2.7, p=0.002). The incidence of major early complications, 30-day mortality (2%), long-term survival (90% at 5 years, log-rank test p=0.088) and MACCE-free survival (81% at 5 years, log-rank test p=0.7) was similar for obese and non-obese patients. BMI was neither an independent predictor for long-term (OR: 0.98 95%-CI: 0.95-1.01) nor MACCE-free survival (OR: 1.0 95%-CI: 0.98-1.02).  Conclusions: Obese patients that undergo CABG in Iceland are younger and have an increased number of risk factors for coronary disease when compared to non-obese patients. However, BMI neither predicted long-term survival or long-term complications. The outcomes following CABG in obese patients are good in Iceland.

[Early outcome of surgical aortic valve replacement for aortic stenosis in Icelandic females].

INTRODUCTION: Aortic valve replacement (AVR) for aortic stenosis (AS) is the second most common open-heart procedure performed in Iceland. The aim of this study was to analyze the early outcome of AVR among females in Iceland. MATERIALS AND METHODS: This was a retrospective study including 428 patients who underwent surgical AVR due to AS in Iceland from 2002-2013. Information was gathered from medical records, including pre- and postoperative results of echocardiography and complications. Overall survival was estimated (Kaplan-Meier) and logistic regression used to identify predictors of operative mortality. The median follow-up time was 8.8 years (0-16.5 years). RESULTS: Of the 428 patients, 151 were female (35.3%), that were on average 2 years older than men (72.6 ± 9.4 vs. 70.4 ± 9.8 yrs., p=0.020). Preoperative symptoms were similar, but women had significantly higher EurosSCORE II than men (5.2 ± 8.8 vs. 3.2 ± 4.6, p=0.002). Maximal pressure-gradient across the aortic valve was higher for women (74.4 ± 29.3 mmHg vs. 68.0 ± 23.4 mmHg, p=0,013) but postoperative complications, operative mortality (8.6% vs. 4.0%, p=0.068) and 5-year survival (78.6% vs. 83.1%, p=0.245) were comparable for women and men. Logistic regression analysis showed that female gender was not an independent predictor of 30-day mortality (OR 1.54, 95% CI 0.63-3.77). CONCLUSIONS: Females constitute one third of patients that undergo AVR for AS in Iceland. At the time of surgery females are two years older than men and appear to have a more significant aortic stenosis at the time of surgery. However, complication rates, operative mortality and long-term survival were comparable for both genders.

Favourable long-term outcome after coronary artery bypass grafting in a nationwide cohort.

OBJECTIVES: In a nationwide cohort, we analyzed long-term outcome following coronary artery bypass grafting, using the combined strategy of left internal mammary artery to the left anterior descending artery and saphenous vein as secondary graft to other coronary targets. METHODS: 1,507 consecutive patients that underwent myocardial revascularization during 2001-2012 in Iceland. Mean follow-up was 6.8 years. Major adverse cardiac and cerebrovascular events were depicted using the Kaplan-Meier method. Cox-regression was used to define risk factors. Relative survival was estimated by comparing overall survival to the survival of Icelanders of the same age and gender. RESULTS: Mean age was 66 years, 83% were males, mean EuroSCOREst was 4.5, and 23% of the procedures were performed off-pump. At 5 years, 19.7% had suffered a major adverse cardiac or cerebrovascular event, 4.5% a stroke, 2.2% myocardial infarction, and 6.2% needed repeat revascularization. Overall 5-year survival was 89.9%, with a relative survival of 0.990. Independent predictors of major adverse cardiac and cerebrovascular events were left ventricular ejection fraction ≤30%, a previous history of percutaneous coronary intervention, chronic obstructive lung disease, chronic kidney disease, diabetes, and old age. The same variables and an earlier year of operation were predictors of long-term mortality. CONCLUSIONS: The long-term outcome following myocardial revascularization, using the left internal mammary artery and the great saphenous vein as conduits, is favourable and improving. This is reflected by the 5-year survival of 89.9%, deviating minimally from the survival rate of the general Icelandic population, together with a freedom from major adverse cardiac and cerebrovascular events of 80.3%.

Acute Kidney Injury After Abdominal Surgery: Incidence, Risk Factors, and Outcome.

BACKGROUND: Acute kidney injury (AKI) is a serious complication after major surgical procedures. We examined the incidence, risk factors, and mortality of patients who sustained AKI after abdominal surgery in a large population-based cohort. METHODS: All patients who underwent open and laparoscopic abdominal surgery (excluding genitourinary and abdominal vascular procedures), between 2007 and 2014 at the University Hospital in Reykjavik were identified and their perioperative serum creatinine (SCr) measurements used to identify AKI after surgery employing the Kidney Disease: Improving Global Outcome (KDIGO) criteria. Risk factors were evaluated using multivariate logistic regression analysis and 30-day mortality compared with a propensity score-matched control group. RESULTS: During the 8-year period, a total of 11,552 abdominal surgeries were performed on 10,022 patients. Both pre- and postoperative SCr measurements were available for 3902 (33.8%) of the surgical cases. Of these, 264 (6.8%) were complicated by AKI; 172 (4.4%), 49 (1.3%), and 43 (1.1%) were classified as KDIGO stages 1, 2 and 3, respectively. The overall incidence of AKI for patients with available SCr values was 67.7 (99% confidence interval [CI], 57.7-78.6) per 1000 surgeries. In logistic regression analysis, independent risk factors for AKI were female sex (odds ratio [OR] = 0.68; 99% CI, 0.47-0.98), hypertension (OR = 1.75; 99% CI, 1.10-2.74), preoperative chronic kidney disease (OR= 1.68; 99% CI, 1.12-2.50), ASA physical status classification of IV (OR = 9.48; 99% CI, 3.66-29.2) or V (OR = 21.4; 99% CI, 5.28-93.6), and reoperation (OR = 4.30; 99% CI, 2.36-7.70). Patients with AKI had greater 30-day mortality (18.2% vs 5.3%; P < 0.001) compared with propensity score-matched controls. CONCLUSIONS: AKI is an important complication of abdominal surgery. In addition to sex, hypertension, and chronic kidney disease, ASA physical status classification is an independent predictor of AKI. Individuals who develop AKI have substantially worse short-term outcomes, including higher 30-day mortality, even after correcting for multiple patient- and procedure-related risk factors.

Lower mortality following coronary arterial revascularization in patients taking statins.

OBJECTIVES: Numerous studies have suggested that statins have beneficial non-lipid-lowering effects, including reduction of systemic inflammatory response following surgery. We wanted to evaluate the effect of preoperative statin treatment on complications and operative mortality after coronary arterial revascularization. DESIGN: We performed a retrospective study of 720 consecutive patients who underwent on-pump coronary artery bypass grafting (CABG) (n = 513) or off-pump (OPCAB) (n = 207) in Iceland from 2002-2006. Patients taking statins preoperatively (n = 529) were compared with those not taking statins (n = 191). Predictors of complications and operative mortality were evaluated by univariate and multivariate analysis. RESULTS: Cardiovascular risk profiles were similar. However, hypertension was more common in the statin group but EuroSCORE was slightly lower. Operative mortality was significantly lower in patients taking statins (1.7% vs. 5.8%, p < 0.001). There were no significant differences in the incidence of major complications. Multivariate analysis showed that preoperative statin treatment was an independent predictor of lower operative mortality (OR = 0.33, p = 0.043), even after adjusting for EuroSCORE, acute operations, advanced age, or other medications. CONCLUSIONS: In this non- randomized study, patients taking statins had lower operative mortality than the controls after adjusting for multiple confounders. The reason for this might be linked to pleiotropic effects of statins.

Mild Stage 1 post-operative acute kidney injury: association with chronic kidney disease and long-term survival.

BACKGROUND: Mild cases of acute kidney injury (AKI) are identified by a small rise in serum creatinine (SCr) according to the KDIGO AKI definition. The aim of this study was to examine the long-term outcomes of individuals with mild AKI.Methods. This was a retrospective cohort study of all adult patients who underwent abdominal, cardiothoracic, vascular or orthopaedic surgery at Landspitali-The National University Hospital of Iceland in 1998-2015. Incident chronic kidney disease (CKD), progression of pre-existing CKD and long-term survival were compared between patients with mild Stage 1 AKI (defined as a rise in SCr of ≥26.5 µmol/L within 48 h post-operatively without reaching 1.5× baseline SCr within 7 days), and a propensity score-matched control group without AKI stratified by the presence of CKD. RESULTS: Pre- and post-operative SCr values were available for 47 333 (42%) surgeries. Of those, 1161 (2.4%) had mild Stage 1 AKI and 2355 (5%) more severe forms of AKI. Mild Stage 1 AKI was associated with both incident CKD and progression of pre-existing CKD (P < 0.001). After exclusion of post-operative deaths within 30 days, mild Stage 1 AKI was not associated with worse 1-year survival in patients with preserved kidney function (94% versus 94%, P = 0.660), and same was true for patients with pre-operative CKD (83% versus 82%, P = 0.870) compared with their matched individuals. Conclusions. Mild Stage 1 AKI is associated with development and progression of CKD, but not with inferior 1-year survival. These findings support the inclusion of a small absolute increase in SCr in the definition of AKI.

Acute Kidney Injury After Acute Repair of Type A Aortic Dissection.

BACKGROUND: The aim of this study was to examine the incidence, risk factors, and outcomes of patients with acute kidney injury (AKI) after surgery for acute type A aortic dissection (ATAAD) using the Nordic Consortium for Acute Type A Aortic Dissection registry. METHODS: Patients who underwent ATAAD surgery at 8 Nordic centers from 2005 to 2014 were analyzed for AKI according to the RIFLE criteria. Patients who died intraoperatively, those who had missing baseline or postoperative serum creatinine, and patients on preoperative renal replacement therapy were excluded. RESULTS: AKI occurred in 382 of 941 patients (40.6%), and postoperative dialysis was required for 105 patients (11.0%). Renal malperfusion was present preoperatively in 42 patients (5.1%), of whom 69.0% developed postoperative AKI. In multivariable analysis patient-related predictors of AKI included age (per 10 years; odds ratio [OR], 1.30; 95% confidence interval [CI], 1.15-1.48), body mass index >30 kg/m2 (OR, 2.16; 95% CI, 1.51-3.09), renal malperfusion (OR, 4.39; 95% CI, 2.23-9.07), and other malperfusion (OR, 2.10; 95% CI, 1.55-2.86). Perioperative predictors were cardiopulmonary bypass time (per 10 minutes; OR, 1.04; 95% CI, 1.02-1.07) and red blood cell transfusion (OR per transfused unit, 1.08; 95% CI, 1.06-1.10). Rates of 30-day mortality were 17.0% in the AKI group compared with 6.6% in the non-AKI group (P < .001). In 30-day survivors AKI was an independent predictor of long-term mortality (hazard ratio, 1.86; 95% CI; 1.24-2.79). CONCLUSIONS: AKI is a common complication after surgery for ATAAD and independently predicts adverse long-term outcome. Of note one-third of patients presenting with renal malperfusion did not develop postoperative AKI, possibly because of restoration of renal blood flow with surgical repair. Mortality risk persists beyond the perioperative period, indicating that close clinical follow-up of these patients is required.

Use of serotonin reuptake inhibitors is not associated with increased bleeding after CABG.

OBJECTIVES: Selective serotonin reuptake inhibitors (SSRIs) and serotonin noradrenaline reuptake inhibitors (SNRIs) are the most commonly prescribed antidepressants worldwide. Studies suggest that SSRI/SNRIs can increase bleeding following different surgical procedures, including open heart surgery, but results are conflicting. The objective of this study was to analyse their effects on bleeding after coronary artery bypass grafting (CABG). METHODS: Of 1237 patients that underwent CABG in Iceland in 2007-2016, 97 (7.8%) used SSRIs/SNRIs preoperatively and were compared to a reference group (n = 1140). Bleeding was assessed using 24-h chest-tube output, number of RBC units transfused and reoperation for bleeding. Thirty-day mortality rates and incidence of complications were also compared. RESULTS: The two groups were comparable with respect to preoperative and operative variables, with the exception of BMI being significantly higher in the SSRI/SNRI group (30.2 vs. 28.3 kg/m2, p < 0.001). No significant differences were observed between groups in 24-h chest-tube output [815 (SSRI/SNRI) vs. 877 ml (reference), p = 0.26], number of RBC units transfused (2.2 vs. 2.2, p = 0.99) or the rate of reoperation for bleeding (4.1% vs. 6.0%, p = 0.61). The incidences of complications and 30-day mortality rate were also similar. CONCLUSIONS: Using three different criteria, preoperative use of SSRIs/SNRIs was not shown to increase bleeding after CABG. Furthermore, short-term complications as well as 30-day mortality rates did not differ from those of controls. Thus, temporary cessation of SSRI/SNRI treatment prior to CABG to decrease the risk of bleeding is unwarranted.

Long-term outcomes after coronary artery bypass surgery in patients with diabetes.

OBJECTIVES: Our aim was to investigate the outcome of patients with diabetes undergoing coronary artery bypass grafting (CABG) surgery in a whole population with main focus on long-term mortality and complications. METHODS: This was a nationwide retrospective analysis of all patients who underwent isolated primary CABG in Iceland between 2001 and 2016. Overall survival together with the composite end point of major adverse cardiac and cerebrovascular events was compared between patients with diabetes and patients without diabetes during a median follow-up of 8.5 years. Multivariable regression analyses were used to evaluate the impact of diabetes on both short- and long-term outcomes. RESULTS: Of a total of 2060 patients, 356 (17%) patients had diabetes. Patients with diabetes had a higher body mass index (29.9 vs 27.9 kg/m2) and more often had hypertension (83% vs 62%) and chronic kidney disease (estimated glomerular filtration rate ≤60 ml/min/1.73 m2, 21% vs 14%). Patients with diabetes had an increased risk of operative mortality [odds ratio 2.52, 95% confidence interval (CI) 1.27-4.80] when adjusted for confounders. 5-Year overall survival (85% vs 91%, P < 0.001) and 5-year freedom from major adverse cardiac and cerebrovascular events were also inferior for patients with diabetes (77% vs 82%, P < 0.001). Cox regression analysis adjusting for potential confounders showed that the diagnosis of diabetes significantly predicted all-cause mortality [hazard ratio (HR) 1.87, 95% CI 1.53-2.29] and increased risk of major adverse cardiac and cerebrovascular events (HR 1.47, 95% CI 1.23-1.75). CONCLUSIONS: Patients with diabetes have significantly lower survival after CABG, both within 30 days and during long-term follow-up.

Association Between Preoperative Opioid and Benzodiazepine Prescription Patterns and Mortality After Noncardiac Surgery.

Importance: The number of patients prescribed long-term opioids and benzodiazepines and complications from their long-term use have increased. Information regarding the perioperative outcomes of patients prescribed these medications before surgery is limited. Objective: To determine whether patients prescribed opioids and/or benzodiazepines within 6 months preoperatively would have greater short- and long-term mortality and increased opioid consumption postoperatively. Design, Setting, and Participants: This retrospective, single-center, population-based cohort study included all patients 18 years or older, undergoing noncardiac surgical procedures at a national hospital in Iceland from December 12, 2005, to December 31, 2015, with follow-up through May 20, 2016. A propensity score-matched control cohort was generated using individuals from the group that received prescriptions for neither medication class within 6 months preoperatively. Data analysis was performed from April 10, 2018, to March 9, 2019. Exposures: Patients who filled prescriptions for opioids only, benzodiazepines only, both opioids and benzodiazepines, or neither medication within 6 months preoperatively. Main Outcomes and Measures: Long-term survival compared with propensity score-matched controls. Secondary outcomes were 30-day survival and persistent postoperative opioid consumption, defined as a prescription filled more than 3 months postoperatively. Results: Among 41 170 noncardiac surgical cases in 27 787 individuals (16 004 women [57.6%]; mean [SD] age, 56.3 [18.8] years), a preoperative prescription for opioids only was filled for 7460 cases (17.7%), benzodiazepines only for 3121 (7.4%), and both for 2633 (6.2%). Patients who filled preoperative prescriptions for either medication class had a greater comorbidity burden compared with patients receiving neither medication class (Elixhauser comorbidity index >0 for 16% of patients filling prescriptions for opioids only, 22% for benzodiazepines only, and 21% for both medications compared with 14% for patients filling neither). There was no difference in 30-day (opioids only: 1.3% vs 1.0%; P = .23; benzodiazepines only: 1.9% vs 1.5%; P = .32) or long-term (opioids only: hazard ratio [HR], 1.12 [95% CI, 1.01-1.24]; P = .03; benzodiazepines only: HR, 1.11 [95% CI, 0.98-1.26]; P = .11) survival among the patients receiving opioids or benzodiazepines only compared with controls. However, patients prescribed both opioids and benzodiazepines had greater 30-day mortality (3.2% vs 1.8%; P = .004) and a greater hazard of long-term mortality (HR, 1.41; 95% CI, 1.22-1.64; P < .001). The rate of persistent postoperative opioid consumption was higher for patients filling prescriptions for opioids only (43%), benzodiazepines only (23%), or both (66%) compared with patients filling neither (12%) (P < .001 for all). Conclusions and Relevance: The findings suggest that opioid and benzodiazepine prescription fills in the 6 months before surgery are associated with increased short-and long-term mortality and an increased rate of persistent postoperative opioid consumption. These patients should be considered for early referral to preoperative clinic and medication optimization to improve surgical outcomes.

[Outcome of coronary artery bypass grafting in women in Iceland].

Introduction The aim of this study was to evaluate the outcome of coronary artery bypass grafting (CABG) in women compared to men, with focus on short-term and long-term complications, 30 day mortality and survival. Materials and methods This was a retrospective study on all CABG patients operated in Iceland between 2001 and 2013. Clinical information was gathered from hospital charts and survival data was obtained from the National Statistics in Iceland. Overall survival was estimated with the Kaplan- Meier method. Logistic and Cox regression analysis were used to identify predictors of operative mortality and long-term survival. Mean follow-up was 6.8 years. Results Of 1755 patients 318 were women (18%). Women were on average four years older than men at the time of operation (69 vs. 65 yrs, p<0.001). Female patients had a higher incidence of hypertension (72 vs. 64%, p=0.009) and their EuroSCOREst was higher (6.1 vs. 4.3, p<0.001). The prevalence of diabetes, dyslipidemia and the extent of coronary artery disease was comparable between groups. The rate of short-term complications, both minor (53% vs. 48%, p=0.07) and major (27% vs. 32%, p=0.2), was similar and operative mortality for women was not statistically different from males (4% vs. 2%, p=0.08). Female gender was neither found to be a predictor of 30-day mortality (OR 0.99; 95%-CI: 0.98-1.01) nor survival (HR 1,08; 95%-ÖB: 0,82-1,42). Conclusions The number of women that undergo CABG is low and they are four years older than men when operated on. As is the case with men, outcome following CABG in Iceland is very good for women, their overall five-year survival being 87%.

Acute kidney injury following coronary angiography: a nationwide study of incidence, risk factors and long-term outcomes.

BACKGROUND: We studied the incidence and risk factors of acute kidney injury (AKI) following coronary angiography (CA) and examined short- and long-term outcomes of patients who developed AKI, including progression of chronic kidney disease (CKD). METHODS: This was a retrospective study of all patients undergoing CA in Iceland from 2008 to 2015, with or without percutaneous coronary intervention. All procedures were performed with iso-osmolar contrast. AKI was defined according to the SCr component of the KDIGO criteria. Patients without post-procedural SCr were assumed to be free of AKI. Incident CKD was defined as 90-day sustained estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2, and progression of CKD as worsening at least one stage sustained over 90 days. RESULTS: AKI was detected in 231 of 13,561 cases (1.7%). There was an interaction between contrast dose and preexisting kidney function, where the risk for AKI was only significant at a dose > 150 mL in patients with baseline eGFR < 45 mL/min/1.73 m2 (OR 5.3, 95% CI 2.1-14.2). The AKI patients had worse short-and long-term survival, as well as elevated hazard of both new-onset CKD (HR 3.7, 95% CI 2.7-5.0) and progression of preexisting CKD (HR 2.0, 95% CI 1.5-2.6) over a median follow-up of 3.3 years (range 0.1-8.4 years), compared to a propensity score-matched control group. CONCLUSIONS: For iso-osmolar contrast, the risk of AKI related to contrast dose was evident for higher amount of contrast in patients with baseline eGFR < 45 mL/min/1.73 m2. In addition to association with adverse short- and long-term survival AKI had a strong association with new-onset or progression of CKD when patients were followed longitudinally.

Acute kidney injury and outcome following aortic valve replacement for aortic stenosis.

OBJECTIVES: Most studies on acute kidney injury (AKI) following open-heart surgery have focused on short-term outcome following coronary artery bypass grafting. We reviewed the incidence, risk factors and outcome, including long-term survival, of AKI after aortic valve replacement (AVR) in a population-based cohort. METHODS: A retrospective review of 365 patients who underwent AVR for aortic stenosis during 2002-2011 was made. AKI was defined according to the RIFLE criteria. All patients requiring dialysis were followed up in a centralized registry. Risk factors for AKI were analysed with univariable and multivariable analysis, and survival was graphically presented with the Kaplan-Meier method. RESULTS: The rate of AKI was 82/365 (22.5%); 40, 28 and 14 patients belonging to the Risk, Injury and Failure groups, respectively. Preoperatively, 37 (45.1%) AKI patients had reduced kidney function. Transfusion of red blood cells, obesity and prolonged cardiopulmonary bypass time were independent risk factors for AKI. Acute postoperative dialysis was required in 15 patients (4.1%), and 1 patient developed dialysis-dependent end-stage renal disease. Major postoperative complications were more common in the AKI group (65 vs 22%, P < 0.001). The 30-day mortality rate in the AKI group was 18%, as opposed to 2% in the non-AKI group (P < 0.001), with a 5-year survival rate of 66 vs 87%, respectively (P < 0.001). In multivariable analysis AKI was an independent predictor of operative mortality [odds ratio = 5.89, 95% confidence interval (CI) = 1.99-18.91] but not of long-term survival (hazard ratio = 1.44, 95% CI = 0.86-2.42). CONCLUSIONS: More than 1 in 5 patients (22.5%) who underwent AVR developed AKI postoperatively. AKI was associated with higher morbidity and was an independent predictor of operative mortality. However, AKI was not a determinant of long-term survival.