RESUMO
Although randomized studies have shown optimal medical therapy (OMT) to be as efficacious as revascularization in stable coronary heart disease (CHD), the application of OMT in routine practice is suboptimal. We sought to understand the predictors of receiving OMT in stable CHD and its impact on clinical outcomes. All patients with stable CHD based on coronary angiography from October 2008 to September 2011 were identified in Ontario, Canada. OMT was defined as concurrent use of ß blocker, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, and statin. Aspirin use was not part of the OMT definition because of database limitations. Multivariable hierarchical logistic models identified predictors of OMT in the 12 months after angiography. Cox proportional hazard models with time-varying covariates for OMT and revascularization status examined differences in death and nonfatal myocardial infarction (MI). In these models, patients transitioned among 4 mutually exclusive treatment groups: no OMT and no revascularization, no OMT and revascularization, OMT and no revascularization, OMT and revascularization. Our cohort had 20,663 patients. Over a mean period of 2.5 years, 8.7% had died. Only 61% received OMT within 12 months. The strongest predictor of receiving OMT at 12 months was OMT before the angiogram (odds ratio 14.40, 95% confidence interval [CI] 13.17 to 15.75, p <0.001). Relative to no OMT and nonrevascularized patients, patients on OMT and revascularized had the greatest reduction in mortality (hazard ratio 0.52, 95% CI 0.45 to 0.60, p <0.001) and nonfatal MI (hazard ratio 0.74, 95% CI 0.64 to 0.84, p <0.001). In conclusion, our study highlights the low rate of OMT in stable CHD. Patients who received both OMT and revascularization achieved the greatest reduction in mortality and nonfatal MI.
Assuntos
Antagonistas Adrenérgicos beta/uso terapêutico , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Doença da Artéria Coronariana/tratamento farmacológico , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Idoso , Causas de Morte/tendências , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/epidemiologia , Feminino , Seguimentos , Humanos , Incidência , Masculino , Ontário/epidemiologia , Prognóstico , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Hospital readmissions for heart failure (HF) contribute to increased morbidity and resource burden. Predictors of hospitalization and patterns of cardiovascular events over the lifetime of patients with HF have not been elucidated. METHODS AND RESULTS: We examined recurrent hospitalizations, cardiovascular events, and survival among newly discharged (April 1999-March 2001) patients with HF in the Enhanced Feedback For Effective Cardiac Treatment phase 1 study. During 10-year follow-up, we examined all new cardiovascular hospitalizations and selected predictors of readmission. Among 8543 patients (mean age, 77.4±10.5 years; 51.6% women) followed for 22 567 person-years, 60.7% had ischemic etiology, and 67.3% had HF with reduced ejection fraction (left ventricular ejection fraction ≤45% versus >45% [HF with preserved ejection fraction]). Overall, 10-year mortality was 98.8%, with 35 966 hospital readmissions occurring over the lifetime of the cohort. Adjusted hazards ratios (HRs) for first cardiovascular hospitalization were 1.36 for ischemic HF (95% CI, 1.28-1.44; P<0.001), 1.10 for HF with reduced ejection fraction (95% CI; 1.00-1.20; P=0.045), and 1.00 for men (95% CI, 0.94-1.06; P=0.979). On repeated-events time-to-event analysis, ischemic HF was a predictor of cardiovascular (HR, 1.24; 95% CI, 1.18-1.29), HF (HR, 1.20; 95% CI, 1.13-1.27), and coronary heart disease (HR, 2.01; 95% CI, 1.81-2.24) hospitalizations (all P<0.001). Of all recurrent HF hospitalizations, 26.8% occurred in the first and 39.8% in the last deciles of cohort survival duration. Similarly, 29.7% and 52.3% of all cardiovascular readmissions occurred in the first and last deciles of the cohort survival duration, respectively. CONCLUSIONS: Among newly discharged patients with HF, cardiovascular events were clustered at early postdischarge and prefatal time periods, and were increased among those with ischemic etiology.
Assuntos
Insuficiência Cardíaca/mortalidade , Admissão do Paciente/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Distribuição de Qui-Quadrado , Intervalo Livre de Doença , Feminino , Pesquisa sobre Serviços de Saúde , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/fisiopatologia , Insuficiência Cardíaca/terapia , Humanos , Masculino , Isquemia Miocárdica/mortalidade , Ontário/epidemiologia , Prognóstico , Modelos de Riscos Proporcionais , Medição de Risco , Fatores de Risco , Volume Sistólico , Análise de Sobrevida , Fatores de Tempo , Função Ventricular EsquerdaRESUMO
We describe a case of disseminated Sporothrix schenckii infection in a man with underlying hairy cell leukemia. The immunological defects associated with this malignancy, as well as the management of refractory sporotrichosis are reviewed.