Rehospitalisations, 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.

AIMS: Describe and compare incidences across age groups of rehospitalization, repeated aortic surgery, and death in patients who survived surgery and hospitalization for type A aortic dissection. METHODS AND RESULTS: From Danish nationwide registries, we identified patients hospitalized with Stanford type A aortic dissections (2006-2018). Survivors of hospitalization and surgery on the ascending aorta and/or aortic arch comprised the study population (n = 606, 36 (38.9%) <60 years old (group I), 194 (32.0%) 60-69 years old (group II), and 176 (29.1%) >69 years old (group III)). During the first year, 62.5% were re-hospitalized 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, 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). Using multivariable Cox regression analysis, we described long-term outcomes comparing age groups. No age differences were found in one-year outcomes, while age > 69 years compared with age < 60 years was associated with a lower rate of repeated aortic surgery [hazard ratio 0.17, 95% confidence interval (CI) 0.04-0.78] and a higher rate of all-cause mortality (hazard ratio 2.44, 95% CI 1.37-4.34) in the 10-year analyses. CONCLUSION: Rehospitalisations in the first year after discharge were common in all age groups, but survival was high. Repeated aortic surgery was significantly more common among younger than older patients.

Partial Oral versus Intravenous Antibiotic Treatment of Endocarditis.

BACKGROUND: Patients with infective endocarditis on the left side of the heart are typically treated with intravenous antibiotic agents for up to 6 weeks. Whether a shift from intravenous to oral antibiotics once the patient is in stable condition would result in efficacy and safety similar to those with continued intravenous treatment is unknown. METHODS: In a randomized, noninferiority, multicenter trial, we assigned 400 adults in stable condition who had endocarditis on the left side of the heart caused by streptococcus, Enterococcus faecalis, Staphylococcus aureus, or coagulase-negative staphylococci and who were being treated with intravenous antibiotics to continue intravenous treatment (199 patients) or to switch to oral antibiotic treatment (201 patients). In all patients, antibiotic treatment was administered intravenously for at least 10 days. If feasible, patients in the orally treated group were discharged to outpatient treatment. The primary outcome was a composite of all-cause mortality, unplanned cardiac surgery, embolic events, or relapse of bacteremia with the primary pathogen, from the time of randomization until 6 months after antibiotic treatment was completed. RESULTS: After randomization, antibiotic treatment was completed after a median of 19 days (interquartile range, 14 to 25) in the intravenously treated group and 17 days (interquartile range, 14 to 25) in the orally treated group (P=0.48). The primary composite outcome occurred in 24 patients (12.1%) in the intravenously treated group and in 18 (9.0%) in the orally treated group (between-group difference, 3.1 percentage points; 95% confidence interval, -3.4 to 9.6; P=0.40), which met noninferiority criteria. CONCLUSIONS: In patients with endocarditis on the left side of the heart who were in stable condition, changing to oral antibiotic treatment was noninferior to continued intravenous antibiotic treatment. (Funded by the Danish Heart Foundation and others; POET ClinicalTrials.gov number, NCT01375257 .).

Microvascular dysfunction is associated with plasma osteoprotegerin levels in patients with acute myocardial infarction.

OBJECTIVE: Osteoprotegerin (OPG) is a glycoprotein that inhibits nuclear factor-κB's regulatory effects on inflammation, skeletal, and vascular systems, and is a potential biomarker of atherosclerosis and seems to be involved in vascular calcifications. The objective of this study was to assess the relationship between OPG, left ventricular function, and microvascular function in patients with acute myocardial infarction (AMI). PATIENTS AND METHODS: After successful revascularization, noninvasive assessment of coronary flow reserve (CFR) was performed in the distal part of the left anterior descending artery in 183 patients with first AMI. We performed low-dose dobutamine stress echocardiography to assess viability and finally we assessed the ventriculoarterial coupling (VAC). Plasma OPG was determined by ELISA. RESULTS: Plasma OPG concentrations were higher in patients with impaired microcirculation (CFR<2) than in patients without [median (first; third quartile), 1.939 (1.366; 2.724) vs. 1.451 (0.925; 2.164) ng/l; P=0.001]. OPG was associated with CFR both in linear regression single-variable analysis (P=0.001) and in multivariable analysis adjusting for possible confounders (P=0.024).Eighty-seven patients had resting wall motion abnormalities and 28 patients fulfilled the criteria for viability. In the group with low OPG 20 patients had viability, and in patients with high OPG only eight patients had viability (P=0.03).Both the E/A ratio (1.22±0.65 vs. 1.06±0.39; P=0.04) and the E/e' ratio (10.4±3.1 vs. 12.2±4.6; P=0.002) indicated worse diastolic function in patients with increased levels of OPG.Overall, an increase in the VAC point was observed in the population (1.11±0.6). The VAC point was higher in patients with increased OPG compared with low OPG (1.01±0.51 vs. 1.2±0.67; P=0.03). CONCLUSION: This is the first study to show an association between OPG levels and CFR, decreased diastolic function, and increased VAC in the setting of AMI. Our results indicate a relationship between OPG and the degree of microvascular dysfunction.

Influence of abnormal glucose metabolism on coronary microvascular function after a recent myocardial infarction.

OBJECTIVES: This study sought to assess the association between abnormal glucose metabolism and abnormal coronary flow reserve (CFR) in patients with a recent acute myocardial infarction (AMI). BACKGROUND: Mortality and morbidity after AMI is high among patients with abnormal glucose metabolism, which may be related to abnormal microcirculation. METHODS: We studied 183 patients with a first AMI. In 161 patients with no history of diabetes mellitus (DM), an oral glucose tolerance test was performed, and patients were categorized according to World Health Organization criteria for whole blood glucose into 3 groups. After coronary angiography and revascularization, a comprehensive transthoracic echocardiogram and noninvasive assessment of CFR was performed in the distal part of left descending artery, as an indicator of microvascular function. Adenosine was administered by intravenous infusion (140 microg/kg/min) to obtain the hyperemic flow profiles. The CFR was defined as the ratio of hyperemic to baseline peak diastolic coronary flow velocities. RESULTS: Median CFR was 1.9 (interquartile range [IQR] 1.4 to 2.4], and 109 (60%) patients had a CFR