Usefulness of Heart Failure Categories Based on Left Ventricular Ejection Fraction.

BACKGROUND: Heart failure guidelines have recently introduced a narrow category with mildly reduced left ventricular ejection fraction (LVEF) (heart failure with mildly reduced ejection fraction; LVEF 41%-49%) between the previous categories of reduced (heart failure with reduced ejection fraction; LVEF ≤40%) and preserved (heart failure with preserved ejection fraction; LVEF ≥50%) ejection fraction. Grouping of continuous measurements into narrow categories can be questioned if their variability is high. METHODS AND RESULTS: We constructed a cohort of all 9716 new cases of chronic heart failure with an available LVEF in Stockholm, Sweden, from January 1, 2015, until December 31, 2020. All values of LVEF were collected over time, and patients were followed up until death, moving out of Stockholm, or end of study. Mixed models were used to quantify within-person variance in LVEF, and multistate Markov models, with death as an absorbing state, to quantify the stability of LVEF categories. LVEF values followed a normal distribution. The SD of the within-person variance in LVEF over time was 7.4%. The mean time spent in any LVEF category before transition to another category was on average <1 year for heart failure with mildly reduced ejection fraction. Probabilities of transitioning between categories during the first year were substantial; patients with heart failure with mildly reduced ejection fraction had a probability of <25% of remaining in that category 1 year later. CONCLUSIONS: LVEF follows a normal distribution and has considerable variability over time, which may impose a risk for underuse of efficient treatment. The heart failure with mildly reduced ejection fraction category is especially inconstant. Assumptions of a patient's current LVEF should take this variability and the normal distribution of LVEF into account.

Mechanisms of adhesive small bowel obstruction and outcome of surgery; a population-based study.

BACKGROUND: This study aims to describe the mechanisms of adhesive small bowel obstruction (SBO) and its morbidity, mortality and recurrence after surgery for SBO in a defined population. METHOD: Retrospective study of 402 patients (240 women, median age 70 years, range 18-97) who underwent surgery for SBO in the Uppsala and Gävleborg regions in 2007-2012. Patients were followed to last note in medical records or death. RESULT: The cause of obstruction was a fibrous band in 56% and diffuse adhesions in 44%. Early overall postoperative morbidity was 48 and 10% required a re-operation. Complications, intensive care and early mortality (n = 21, 5.2%) were related to age (p < 0.05) and American Society of Anesthesiologist's class (p < 0.01). At a median follow-up of 66 months (0-122), 72 patients (18%) had been re-admitted because of SBO; 26 of them underwent a re-operation. Previous laparotomies (p = 0.013), diffuse adhesions (p = 0.050), and difficult surgery (bowel injury, operation time and bleeding, p = 0.034-0.003) related to recurrent SBO. The cohort spent 6735 days in hospital due to SBO; 772 of these days were due to recurrent SBO. In all, 61% of the cohort was alive at last follow-up. Late mortality was related to malignancies, cardiovascular disease, and other chronic diseases. CONCLUSIONS: About half of patients with SBO are elderly with co-morbidities which predispose to postoperative complications and mortality. Diffuse adhesions, which make surgery difficult, were common and related to future SBO. Overall, nearly one-fifth of patients needed re-admission for recurrent SBO. Continued research for preventing SBO is desirable. TRIAL REGISTRATION: The study was registered at ClinicalTrials.gov (NCT03534596, retrospectively registered, 2018-05-24).