Publications by authors named "Ahmad Shoaib"

55 Publications

Pakistan and COVID-19: The mystery of the flattened curve.

J Glob Health 2021 Jan 11;11:03013. Epub 2021 Jan 11.

Medical Research Center, Kateb University, Kabul, Afghanistan.

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http://dx.doi.org/10.7189/jogh.11.03013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7898371PMC
January 2021

Effect of primary percutaneous coronary intervention on in-hospital outcomes among active cancer patients presenting with ST-elevation myocardial infarction: a propensity score matching analysis.

Eur Heart J Acute Cardiovasc Care 2021 Feb 4. Epub 2021 Feb 4.

Keele Cardiovascular Research Group, Centre for Prognosis Research, Institutes of Applied Clinical Science and Primary Care and Health Sciences, Keele University, UK.

Aims: Primary percutaneous coronary intervention (pPCI) is the gold standard, guideline-recommended revascularization strategy in patients presenting with ST-elevation myocardial infarction (STEMI). However, there are limited data on its use and effectiveness among patients with active cancer presenting with STEMI.

Methods And Results: All STEMI hospitalizations between 2004 and 2015 from the National Inpatient Sample were retrospectively analysed, stratified by cancer type. Propensity score matching was performed to estimate the average treatment effect of pPCI in each cancer on in-hospital adverse events, including major adverse cardiovascular and cerebrovascular events (MACCE) and its individual components, and compare treatment effect between cancer and non-cancer patients. Out of 1 870 815 patients with STEMI, 38 932 (2.1%) had a current cancer diagnosis [haematological: 11 251 (28.9% of all cancers); breast: 4675 (12.0%); lung: 9538 (24.5%); colon: 3749 (9.6%); prostate: 9719 (25.0%)]. Patients with cancer received pPCI less commonly than those without cancer (from 54.2% for lung cancer to 70.6% for haematological vs. 82.3% in no cancer). Performance of pPCI was strongly associated with lower adjusted probabilities of MACCE and all-cause mortality in the cancer groups compared with the no cancer group. There was no significant difference in estimated average pPCI treatment effect between the cancer groups and non-cancer group.

Conclusion: Primary percutaneous coronary intervention is underutilized in STEMI patients with current cancer despite its significantly lower associated rates of in-hospital all-cause mortality and MACCE that is comparable to patients without cancer. Further work is required to assess the long-term benefit and safety of pPCI in this high-risk group.
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http://dx.doi.org/10.1093/ehjacc/zuaa032DOI Listing
February 2021

A skeleton in the closet: The implications of COVID-19 on XDR strain of typhoid in Pakistan.

Public Health Pract (Oxf) 2021 Nov 23;2:100084. Epub 2021 Jan 23.

Department of Global Health and Development, London School of Hygiene and Tropical Medicine, United Kingdom.

Extensively drug resistant typhoid fever is a major public health concern in Pakistan. During the COVID-19 pandemic, poor sanitation is leading typhoid cases to a surge and obsolete diagnostic methods are paving the way towards ir-rational pharmacotherapy. In particular, the overuse of azithromycin for the treatment of COVID-19 might impair one of the few remaining regimens against XDR. Facing COVID-19 and XDR at the same time can lead to a catastrophy, unless the government, the stakeholders and healthcare workers take joint action to improve sanitation, educate the public, vaccinate vulnerable groups and establish good diagnostic and management practices.
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http://dx.doi.org/10.1016/j.puhip.2021.100084DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7826057PMC
November 2021

An update on developments in medical education in response to the COVID-19 pandemic: A BEME scoping review: BEME Guide No. 64.

Med Teach 2021 Jan 26:1-52. Epub 2021 Jan 26.

University of Michigan Medical School, Ann Arbor, MI, USA.

Background: COVID-19 has fundamentally altered how education is delivered. Gordon et al. previously conducted a review of medical education developments in response to COVID-19; however, the field has rapidly evolved in the ensuing months. This scoping review aims to map the extent, range and nature of subsequent developments, summarizing the expanding evidence base and identifying areas for future research.

Methods: The authors followed the five stages of a scoping review outlined by Arskey and O'Malley. Four online databases and MedEdPublish were searched. Two authors independently screened titles, abstracts and full texts. Included articles described developments in medical education deployed in response to COVID-19 and reported outcomes. Data extraction was completed by two authors and synthesized into a variety of maps and charts.

Results: One hundred twenty-seven articles were included: 104 were from North America, Asia and Europe; 51 were undergraduate, 41 graduate, 22 continuing medical education, and 13 mixed; 35 were implemented by universities, 75 by academic hospitals, and 17 by organizations or collaborations. The focus of developments included pivoting to online learning ( = 58), simulation ( = 24), assessment ( = 11), well-being ( = 8), telehealth ( = 5), clinical service reconfigurations ( = 4), interviews ( = 4), service provision ( = 2), faculty development ( = 2) and other ( = 9). The most common Kirkpatrick outcome reported was Level 1, however, a number of studies reported 2a or 2b. A few described Levels 3, 4a, 4b or other outcomes (e.g. quality improvement).

Conclusions: This scoping review mapped the available literature on developments in medical education in response to COVID-19, summarizing developments and outcomes to serve as a guide for future work. The review highlighted areas of relative strength, as well as several gaps. Numerous articles have been written about remote learning and simulation and these areas are ripe for full systematic reviews. Telehealth, interviews and faculty development were lacking and need urgent attention.
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http://dx.doi.org/10.1080/0142159X.2020.1864310DOI Listing
January 2021

Drug supply shortage in Nigeria during COVID-19: efforts and challenges.

J Pharm Policy Pract 2021 Jan 22;14(1):17. Epub 2021 Jan 22.

Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.

The COVID-19 pandemic has resulted in massive disruptions in global supply chains. Nigeria is particularly vulnerable with respect to pharmaceuticals since there is reduced local production and about 70% of the drug supply is imported creating a huge supply-demand disparity particularly in times like COVID-19. Nigeria is in need of huge quantities of quality-assured health commodities to effectively respond to the pandemic. Significant shortages of other essential medicines and medical products across the country could be imminent. Drug scarcity in Nigeria during the COVID-19 pandemic period is because of several accumulated factors, majorly as a result of global lockdown, decreased manufacturing, unaddressed regulatory affairs, poor access to resources by the population, lack of buffer stocks, security instability, and poor funding of the healthcare system. This situation if left unattended, could cause serious drawbacks to the health of the populace as well as the quality of life of Nigerians amid the COVID-19 Pandemic. Appropriate measures should be directed to ensure ethical processes on drug production, importation, pricing, and distribution to avoid such events during unavoidable scenarios, like the COVID-19 pandemic and other public health emergencies.
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http://dx.doi.org/10.1186/s40545-021-00302-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7820524PMC
January 2021

Outcomes of COVID-19 Positive Acute Coronary Syndrome Patients; a multisource Electronic Healthcare Records Study from England.

J Intern Med 2021 Jan 19. Epub 2021 Jan 19.

Keele Cardiovascular Research Group, Institute for Prognosis Research, School of Primary Care, Keele University, Stoke On Trent, United Kingdom of Great Britain and Northern Ireland.

Background: Patients with underlying cardiovascular disease and Coronavirus disease 2019 (COVID-19) infection are at increased risk of morbidity and mortality.

Objectives: This study was designed to characterise the presenting profile and outcomes of patients hospitalized with acute coronary syndrome (ACS) and COVID-19 infection.

Methods: This observational cohort study was conducted using multisource data from all acute NHS hospitals in England. All consecutive patients hospitalized with diagnosis of ACS with or without COVID-19 infection between 1 March- 31 May 2020 were included. The primary outcome was in-hospital and 30-day mortality.

Results: A total of 12,958 patients were hospitalized with ACS during the study period, of which 517 (4.0%) were COVID-19 positive and were more likely to present with non-ST elevation acute myocardial infarction. COVID-19 ACS group were generally older, Black Asian and Minority ethnicity, more comorbid and had unfavourable presenting clinical characteristics such as elevated cardiac troponin, pulmonary oedema, cardiogenic shock and poor left ventricular systolic function compared with non-COVID-19 ACS group. They were less likely to receive an invasive coronary angiography (67.7% vs 81.0%), percutaneous coronary intervention (PCI) (30.2% vs 53.9%) and dual antiplatelet medication (76.3% vs 88.0%). After adjusting for all the baseline differences, patients with COVID-19 ACS had higher in-hospital (adjusted odds ratio (aOR) 3.27 95% confidence interval (CI) 2.41-4.42) and 30-day mortality (aOR 6.53 95%CI 5.1-8.36) compared to the non COVID-19 ACS group.

Conclusion: COVID-19 infection was present in 4% of patients hospitalized with an ACS in England and is associated with lower rates of guideline recommended treatment and significant mortality hazard.
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http://dx.doi.org/10.1111/joim.13246DOI Listing
January 2021

The Hajj and COVID-19: How the Pandemic Shaped the World's Largest Religious Gathering.

Am J Trop Med Hyg 2021 Jan 11. Epub 2021 Jan 11.

Punjab Medical College, Faisalabad, Pakistan.

The Hajj pilgrimage, one of the five pillars of Islam, is held in Saudi Arabia in the second week of Dhu'l-Hijjah, the last month of the Islamic calendar. It is one of the world's largest mass gatherings, constituting more than 2.5 million Muslim pilgrims from more than 180 countries. The COVID-19 pandemic posed a significant public health threat for such mass gatherings. Thus, a health risk assessment for the 2020 Hajj was held by the Saudi Arabia Ministry of Health and the WHO Collaborating Centre for Mass Gatherings Medicine, which concluded that foreign pilgrims should be excluded from the 2020 Hajj and that the number of pilgrims should be significantly reduced. Timely decisions allowed the Saudi government to conduct the Hajj, despite an initial postponement. However, the number of pilgrims was significantly downscaled, and extensive new protocols were set in place because of the pandemic. This article aims to shed light on the challenges faced and efforts made by Saudi Arabia to mitigate the spread of COVID-19 during the religious proceedings of the Hajj.
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http://dx.doi.org/10.4269/ajtmh.20-1563DOI Listing
January 2021

Clinical Characteristics, Management Strategies and Outcomes of Acute Myocardial Infarction Patients With Prior Coronary Artery Bypass Grafting.

Mayo Clin Proc 2021 01;96(1):120-131

Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent, United Kingdom; Department of Medicine (Cardiology), Thomas Jefferson University Hospital, Philadelphia, PA. Electronic address:

Objective: To investigate the management strategies, temporal trends, and clinical outcomes of patients with a history of coronary artery bypass graft (CABG) surgery and presenting with acute myocardial infarction (MI).

Patients And Methods: We undertook a retrospective cohort study using the National Inpatient Sample database from the United States (January 2004-September 2015), identified all inpatient MI admissions (7,250,768 records) and stratified according to history of CABG (group 1, CABG-naive [94%]; group 2, prior CABG [6%]).

Results: Patients in group 2 were older, less likely to be female, had more comorbidities, and were more likely to present with non-ST-elevation myocardial infarction compared with group 1. More patients underwent coronary angiography (68% vs 48%) and percutaneous coronary intervention (PCI) (44% vs 26%) in group 1 compared with group 2. Following multivariable logistic regression analyses, the adjusted odd ratio (OR) of in-hospital major adverse cardiovascular and cerebrovascular events (OR, 0.98; 95% CI, 0.95 to 1.005; P=.11), all-cause mortality (OR, 1; 95% CI, 0.98 to 1.04; P=.6) and major bleeding (OR, 0.99; 95% CI, 0.94 to 1.03; P=.54) were similar to group 1. Lower adjusted odds of in-hospital major adverse cardiovascular and cerebrovascular events (OR, 0.64; 95% CI, 0.57 to 0.72; P<.001), all-cause mortality (OR, 0.45; 95% CI, 0.38 to 0.53; P<.001), and acute ischemic stroke (OR, 0.71; 95% CI, 0.59 to 0.86; P<.001) were observed in group 2 patients who underwent PCI compared with those managed medically without any increased risk of major bleeding (OR, 1.08; 95% CI, 0.94 to 1.23; P=.26).

Conclusions: In this national cohort, MI patients with prior-CABG had a higher risk profile, but similar in-hospital adverse outcomes compared with CABG-naive patients. Prior-CABG patients who received PCI had better in-hospital clinical outcomes compared to those who received medical management.
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http://dx.doi.org/10.1016/j.mayocp.2020.05.047DOI Listing
January 2021

Outcomes Following Percutaneous Coronary Intervention in Renal Transplant Recipients: A Binational Collaborative Analysis.

Mayo Clin Proc 2021 02 25;96(2):363-376. Epub 2020 Dec 25.

Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Keele, UK, and Academic Department of Cardiology, Royal Stoke Hospital, University Hospitals of North Midlands, Stoke-on-Trent, UK; Department of Cardiology, Thomas Jefferson University Hospital, Philadelphia, PA. Electronic address:

Objective: To investigate the clinical and procedural characteristics in patients with a history of renal transplant (RT) and compare the outcomes with patients without RT in 2 national cohorts of patients undergoing percutaneous coronary intervention (PCI).

Patients And Methods: Data from the National Inpatient Sample (NIS) and British Cardiovascular Intervention Society (BCIS) were used to compare the clinical and procedural characteristics and outcomes of patients undergoing PCI who had RT with those who did not have RT. The primary outcome of interest was in-hospital mortality.

Results: Of the PCI procedures performed in 2004-2014 (NIS) and 2007-2014 (BCIS), 12,529 of 6,601,526 (0.2%) and 1521 of 512,356 (0.3%), respectively, were undertaken in patients with a history of RT. Patients with RT were younger and had a higher prevalence of congestive cardiac failure, hypertension, and diabetes but similar use of drug-eluting stents, intracoronary imaging, and pressure wire studies compared with patients who did not have RT. In the adjusted analysis, patients with RT had increased odds of in-hospital mortality (NIS: odds ratio [OR], 1.90; 95% CI, 1.41-2.57; BCIS: OR, 1.60; 95% CI, 1.05-2.46) compared with patients who did not have RT but no difference in vascular or bleeding events. Meta-analysis of the 2 data sets suggested an increase in in-hospital mortality (OR, 1.79; 95% CI, 1.40-2.29) but no difference in vascular (OR, 1.24; 95% CI, 0.77-2.00) or bleeding (OR, 1.21; 95% CI, 0.86-1.68) events.

Conclusion: This large collaborative analysis of 2 national databases revealed that patients with RT undergoing PCI are younger, have more comorbidities, and have increased mortality risk compared with the general population undergoing PCI.
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http://dx.doi.org/10.1016/j.mayocp.2020.04.045DOI Listing
February 2021

In-Hospital and 30-Day Mortality After Percutaneous Coronary Intervention in England in the Pre-COVID and COVID Eras.

J Invasive Cardiol 2021 03 22;33(3):E206-E219. Epub 2020 Dec 22.

Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, UK.

Background: Public reporting of percutaneous coronary intervention (PCI) outcomes is a performance metric and a requirement in many healthcare systems. There are inconsistent data on the causes of death after PCI, and the proportion of these deaths that are attributable to cardiac causes.

Methods: All patients undergoing PCI in England between January 1, 2017 and May 10, 2020 (n = 273,141) were retrospectively analyzed according to their outcome from the date of PCI: no death, in-hospital death, postdischarge death, and total 30-day death. The present study examined short-term primary causes of death after PCI in a national cohort before and during COVID-19.

Results: The overall rates of in-hospital and 30-day death were 1.9% and 2.8%, respectively. The rate of 30-day death declined between 2017 (2.9%) and February 2020 (2.5%), mainly due to lower in-hospital death (2.1% vs 1.5%), before rising again from March 1, 2020 (3.2%) due to higher rates of postdischarge mortality. Only 59.6% of 30-day deaths were due to cardiac causes, with the most common causes being acute coronary syndrome, cardiogenic shock, and heart failure, and this persisted throughout the study period. In the 30-day death group, 10.4% after March 1, 2020 were due to confirmed COVID-19.

Conclusions: In this nationwide study, we show that 40% of 30-day deaths are due to non-cardiac causes. Non-cardiac deaths have increased even more from the start of the COVID-19 pandemic, with 1 in 10 deaths from March 2020 being COVID-19 related. These findings raise a question of whether public reporting of PCI outcomes should be cause specific.
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March 2021

Polio Amidst COVID-19 in Pakistan: What are the Efforts Being Made and Challenges at Hand?

Am J Trop Med Hyg 2020 Dec 2. Epub 2020 Dec 2.

Faculty of Management and Development Studies, University of the Philippines (Open University), Los Baños, Laguna, Philippines.

Poliomyelitis, a crippling viral disease, has been affecting many children in Pakistan despite the numerous efforts that have been taken to curb its spread. The COVID-19 pandemic has halted mass polio vaccination campaigns globally, including Pakistan, resulting in a resurgence of new cases. Pakistan managed to flatten the COVID-19 curve from July to October that made three immunization drives possible, but the COVID-19 cases are on the rise again which can again complicate the polio situation in the country if left unmonitored. The efforts of Pakistan have been effective with no significant rise in polio cases in 2020 as compared with 2019. We discuss the numerous challenges faced by the polio eradication program in Pakistan. To help eliminate polio, Pakistan needs to enhance its efforts in the struggle against polio with the same zeal and stringency used to flatten the curve of COVID-19 in these challenging times.
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http://dx.doi.org/10.4269/ajtmh.20-1438DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7866369PMC
December 2020

Impact of Coronavirus Disease 2019 Pandemic on the Incidence and Management of Out-of-Hospital Cardiac Arrest in Patients Presenting With Acute Myocardial Infarction in England.

J Am Heart Assoc 2020 11 7;9(22):e018379. Epub 2020 Oct 7.

Keele Cardiovascular Research Group Institute for Prognosis Research School of Primary Care Keele University Newcastle UK.

Background Studies have reported significant reduction in acute myocardial infarction-related hospitalizations during the coronavirus disease 2019 (COVID-19) pandemic. However, whether these trends are associated with increased incidence of out-of-hospital cardiac arrest (OHCA) in this population is unknown. Methods and Results Acute myocardial infarction hospitalizations with OHCA during the COVID-19 period (February 1-May 14, 2020) from the Myocardial Ischaemia National Audit Project and British Cardiovascular Intervention Society data sets were analyzed. Temporal trends were assessed using Poisson models with equivalent pre-COVID-19 period (February 1-May 14, 2019) as reference. Acute myocardial infarction hospitalizations during COVID-19 period were reduced by >50% (n=20 310 versus n=9325). OHCA was more prevalent during the COVID-19 period compared with the pre-COVID-19 period (5.6% versus 3.6%), with a 56% increase in the incidence of OHCA (incidence rate ratio, 1.56; 95% CI, 1.39-1.74). Patients experiencing OHCA during COVID-19 period were likely to be older, likely to be women, likely to be of Asian ethnicity, and more likely to present with ST-segment-elevation myocardial infarction. The overall rates of invasive coronary angiography (58.4% versus 71.6%; <0.001) were significantly lower among the OHCA group during COVID-19 period with increased time to reperfusion (mean, 2.1 versus 1.1 hours; =0.05) in those with ST-segment-elevation myocardial infarction. The adjusted in-hospital mortality probability increased from 27.7% in February 2020 to 35.8% in May 2020 in the COVID-19 group (<.001). Conclusions In this national cohort of hospitalized patients with acute myocardial infarction, we observed a significant increase in incidence of OHCA during COVID-19 period paralleled with reduced access to guideline-recommended care and increased in-hospital mortality.
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http://dx.doi.org/10.1161/JAHA.120.018379DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7763705PMC
November 2020

Trends of repeat revascularization choice in patients with prior coronary artery bypass surgery.

Catheter Cardiovasc Interv 2020 Sep 5. Epub 2020 Sep 5.

Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Keele, UK.

Objective: To examine rates and predictors repeat revascularization strategies (percutaneous coronary intervention [PCI] and coronary artery bypass grafting [CABG]) in patients with prior CABG.

Methods: Using the National Inpatient Sample, patients with a history of CABG hospitalized for revascularization by PCI or CABG from January 2004 to September 2015 were included. Regression analyses were performed to examine predictors of receipt of either revascularization strategy as well as in-hospital outcomes.

Results: The rate of redo CABG doubled between 2004 (5.3%) and 2015 (10.3%). Patients who underwent redo CABG were more comorbid and experienced significantly worse major adverse cardiovascular and cerebrovascular events (odds ratio [OR]: 5.36 95% CI 5.11-5.61), mortality (OR 2.84 95% CI 2.60,-3.11), bleeding (OR 5.97 95% CI 5.44-6.55) and stroke (OR 2.15 95% CI 1.92-2.41), but there was no difference in cardiac complications between groups. Thoracic complications were high in patients undergoing redo CABG (8%), especially in females. Factors favoring receipt of redo CABG compared to PCI included male sex, age < 80 years, and absence of diabetes and renal failure.

Conclusion: Reoperation in patients with prior CABG has doubled in the United States over a 12-year period. Patients undergoing redo CABG are more complex and associated with worse clinical outcomes than those receiving PCI.
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http://dx.doi.org/10.1002/ccd.29234DOI Listing
September 2020

Clinical Characteristics and Outcomes From Percutaneous Coronary Intervention of Last Remaining Coronary Artery: An Analysis From the British Cardiovascular Intervention Society Database.

Circ Cardiovasc Interv 2020 09 2;13(9):e009049. Epub 2020 Sep 2.

Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, United Kingdom (A.S., M.R., E.F.F., J.N., K.R., A.A., M. Mohamed, M.A.M.).

Background: Patients with complex high-risk coronary anatomy, such as those with a last remaining patent vessel (LRPV), are increasingly revascularized with percutaneous coronary intervention (PCI) in contemporary practice. There are limited data on the outcomes of these high-risk procedures.

Methods: We analyzed a large longitudinal PCI cohort (2007-2014, n=501 841) from the British Cardiovascular Intervention Society database. Clinical, demographic, procedural, and outcome data were analyzed by dividing patients into 2 groups; LRPV group (n=2432) and all other PCI groups (n=506 691).

Results: Patients in the LRPV PCI group were older, had more comorbidities, and higher prevalence of moderate-severe left ventricular systolic dysfunction. Mortality was higher in the LRPV PCI group during hospital admission (12 % versus 1.5 %, <0.001), at 30 days (15% versus 2%, <0.001), and at one-year (24% versus 5%, <0.001). In a propensity score matching analysis the adjusted risk of mortality during index admission (odds ratio, 2.05 [95% CI, 1.65-2.44], <0.001), at 30 days (odds ratio, 2.13 [95% CI, 1.78-2.5], <0.001), at 1 year (odds ratio, 1.81 [95% CI, 1.59-2.03], <0.001), and in-hospital major adverse cardiovascular events (odds ratio, 1.8 [95% CI, 1.42-2.19], <0.001) were higher in LRPV PCI group as compared to control group. In sensitivity analyses, similar clinical outcomes were observed irrespective of which major epicardial coronary artery was treated.

Conclusions: In this contemporary cohort, patients who had PCI to their LRPV had a higher-risk profile and more adverse clinical outcomes, irrespective of the vessel treated.
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http://dx.doi.org/10.1161/CIRCINTERVENTIONS.120.009049DOI Listing
September 2020

Clinical Outcomes of Percutaneous Coronary Intervention for Chronic Total Occlusion in Native Coronary Arteries vs Saphenous Vein Grafts.

J Invasive Cardiol 2020 Sep 10;32(9):350-357. Epub 2020 Aug 10.

Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent, United Kingdom.

Background: There are limited data comparing outcomes of patients with previous coronary artery bypass grafting (CABG) presenting with stable angina who undergo percutaneous coronary intervention (PCI) to either a saphenous vein grafts (SVG) or a chronic total occlusion (CTO) in the native coronary arteries. We compared clinical characteristics and outcomes of these two groups in a national cohort.

Methods And Results: We formed a longitudinal cohort (2007-2014; n = 11,132) of patients who underwent SVG-PCI (group 1; n = 8619) or CTO-PCI in native arteries (group 2; n = 2513) in the British Cardiovascular Intervention Society (BCIS) database. Median age was 68 years in both groups, but patients in group 2 were less likely to be female, had a higher prevalence of diabetes mellitus, hypertension, hypercholesterolemia, and previous myocardial infarction, as well as worsened angina and breathlessness, but history of prior stroke, renal diseases, and the presence of left ventricular systolic dysfunction were similar to group 1. Following multivariable analysis, no significant difference in mortality was observed during index hospital admission (odds ratio [OR], 1.70; 95% confidence interval [CI], 0.63-4.58; P=.29), at 30 days (OR, 1.81; 95% CI, 0.99-3.3; P=.05), and 1 year (OR, 1.11; 95% CI, 0.85-1.44; P=.43), nor was a significant difference found in in-hospital MACE rates (OR, 1.36; 95% CI, 0.85-2.19; P=.19). However, CTO-PCI was associated with more procedural complications (OR, 2.88; 95% CI, 2.38-3.47; P<.01) and vessel perforation (OR, 4.82; 95% CI, 2.80-8.28; P<.01) as compared with the SVG-PCI group. Risk of target-vessel revascularization at 1 year was similar (SVG-PCI 5.6% vs CTO-PCI 6.9%; P=.08).

Conclusion: In this national cohort, CTO-PCI was performed in higher-risk patients, and was associated with more procedural complications but similar short-term or long-term mortality and in-hospital MACE.
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September 2020

Adoption of same day discharge following elective left main stem percutaneous coronary intervention.

Int J Cardiol 2020 Dec 30;321:38-47. Epub 2020 Jul 30.

Centre for Biostatistics, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK; Keele Cardiovascular Research Group, Institute of Primary Care and Health Sciences, University of Keele and Academic Department of Cardiology, Royal Stoke Hospital, Stoke-on-Trent, UK. Electronic address:

Background: This study sought to investigate the safety and feasibility of same day discharge (SDD) practice and compare clinical outcomes to patients admitted for overnight stay (ON) undergoing elective left main stem (LMS) percutaneous coronary intervention (PCI). ON observation is still widely practiced in highly complex PCI as the standard of care, with no previous data comparing clinical outcomes in patients undergoing LMS PCI.

Methods: We analysed 6452 patients undergoing elective LMS PCI between 2007 and 2014 in England and Wales. Multiple logistic regressions and the BCIS risk model were used to study association between SDD and 30 day mortality.

Results: SDD rates almost doubled from 19.9% in 2007 to 39.8% in 2014 for all LMS procedures and increased from 20.7% to 41.4% for unprotected LMS cases during the same study period. There was a significant increase in procedural complexity with higher use of rotational atherectomy, longer stents and multivessel PCI. SDD was not associated with increased 30 day mortality (OR 0.70 95%CI 0.30-1.65) in the overall LMS PCI cohort and the results were similar in unprotected LMS (OR 0.48 95%CI 0.17-1.41) and those requiring ON stay (OR 0.58 95%CI 0.25-1.34).

Conclusions: We did not find evidence that SDD is not safe or feasible in highly complex LMS PCI procedures despite increasing procedural complexity with no significant increase in 30 day mortality rates.
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http://dx.doi.org/10.1016/j.ijcard.2020.07.038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7392050PMC
December 2020

Low-dose fractionated radiation with induction docetaxel and cisplatin followed by concurrent cisplatin and radiation therapy in locally advanced nasopharyngeal cancer: A randomized phase II-III trial.

Hematol Oncol Stem Cell Ther 2020 May 21. Epub 2020 May 21.

King Faisal Hospital and Research Centre, Riyadh, Saudi Arabia.

Objective/background: To evaluate the efficacy and outcome of adding low-dose fractionated radiotherapy (LDFRT) to induction chemotherapy plus concurrent chemoradiation in locally advanced nasopharyngeal carcinoma (LANPC).

Methods: A single-institute, phase II-III, prospectively controlled randomized clinical trial was performed at King Faisal Specialist Hospital and Research Centre. Patients aged 18-70 years with WHO type II and III, stage III-IVB nasopharyngeal carcinoma, Eastern Cooperative Oncology Group performance score of 0-2, with adequate hematological, renal, and hepatic function were eligible. In total, 108 patients were enrolled in this trial. All patients received two cycles of induction docetaxel and cisplatin (75 mg/m each) chemotherapy on Days 1 and 22, followed by concurrent chemoradiation therapy. Radiation therapy consisted of 70 Gy in 33 fractions, with concurrent cisplatin 25 mg/m for 4 days on Days 43 and 64. Patients were randomly assigned to either adding LDFRT (0.5 Gy twice daily 6 hours apart for 2 days) to induction chemotherapy in the experimental arm (54 patients) or induction chemotherapy alone in the control arm (54 patients).

Results: There was no significant difference in the post-induction response rates (RRs) or in toxicity between the two treatment arms. The 3-year overall survival (OS), locoregional control (LRC), and distant metastases-free survival (DMFS) rates for experimental arm and control arm were 94% versus 93% (p = .8), 84.8% versus 87.5% (p = .58), and 84.1% versus 91.6% (p = .25), respectively.

Conclusion: The results showed no benefit from adding LDFRT to induction chemotherapy in terms of RR, OS, LRC, and DMFS.
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http://dx.doi.org/10.1016/j.hemonc.2020.05.005DOI Listing
May 2020

Prosthesis-Patient Mismatch Increases Early and Late Mortality in Low Risk Aortic Valve Replacement.

Semin Thorac Cardiovasc Surg 2021 Spring;33(1):23-30. Epub 2020 May 18.

Royal Papworth Hospital, Cardiac Surgery Department, Cambridge Biomedical Campus, Cambridge, UK.

The concept of prosthesis-patient mismatch (PPM) has gained much attention since first described 40 years ago. Previous studies have shown conflicting evidence regarding increased early and late morbidity and mortality with PPM after aortic valve replacement (AVR). The aim of this study was to evaluate the effects of PPM on short- and long-term mortality in low-risk patients after isolated AVR. A retrospective, single-center study involving 1707 consecutive patients ≤80 years of age with preserved left ventricular systolic function who underwent elective, primary isolated AVR operations from 2008 to 2018. Patients were stratified into 2 groups according to the presence of PPM (n = 96), defined as effective orifice area index <0.85 cm/m body surface area, and no-PPM (n = 1611). The effect of PPM on mortality was evaluated with univariate and multivariate analyses. 30-day mortality was 0.8% (4.2% in PPM group vs 0.6 in no-PPM group; P = 0.005). PPM occurred more in female gender, obese and older patients. PPM was highly associated with long-term all-cause mortality (median 4 years [Q1-Q3 2-7]; HR: 1.79, 95% CI: 1.27-2.55, P = 0.002), and remained strongly and independently associated after adjustment for other risk factors (HR: 1.60, 95% CI: 1.10-2.34, P = 0.014). In propensity score-matched analysis, the adjusted mortality risk was higher in PPM group (HR: 2.03, 95% CI: 1.22-3.39, P = 0.006) compared to no-PPM group. In a single-centre observational study, PPM increased early mortality and was independently associated with long-term all-cause mortality after low-risk, primary isolated AVR operations. Strategies to avoid PPM should be explored and implemented.
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http://dx.doi.org/10.1053/j.semtcvs.2020.05.006DOI Listing
May 2020

Flax L.): A Potential Candidate for Phytoremediation? Biological and Economical Points of View.

Plants (Basel) 2020 Apr 13;9(4). Epub 2020 Apr 13.

Department of Zoology, College of Science, King Saud University, Riyadh 11451, Saudi Arabia.

Flax ( L.) is an important oil seed crop that is mostly cultivated in temperate climates. In addition to many commercial applications, flax is also used as a fibrous species or for livestock feed (animal fodder). For the last 40 years, flax has been used as a phytoremediation tool for the remediation of different heavy metals, particularly for phytoextraction when cultivated on metal contaminated soils. Among different fibrous crops (hemp, jute, ramie, and kenaf), flax represents the most economically important species and the majority of studies on metal contaminated soil for the phytoextraction of heavy metals have been conducted using flax. Therefore, a comprehensive review is needed for a better understanding of the phytoremediation potential of flax when grown in metal contaminated soil. This review describes the existing studies related to the phytoremediation potential of flax in different mediums such as soil and water. After phytoremediation, flax has the potential to be used for additional purposes such as linseed oil, fiber, and important livestock feed. This review also describes the phytoremediation potential of flax when grown in metal contaminated soil. Furthermore, techniques and methods to increase plant growth and biomass are also discussed in this work. However, future research is needed for a better understanding of the physiology, biochemistry, anatomy, and molecular biology of flax for increasing its pollutant removal efficiency.
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http://dx.doi.org/10.3390/plants9040496DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7238412PMC
April 2020

Contributors to the Growth of Same Day Discharge After Elective Percutaneous Coronary Intervention.

Circ Cardiovasc Interv 2020 03 10;13(3):e008458. Epub 2020 Mar 10.

Keele Cardiovascular Research Group, Institute of Primary Care and Health Sciences, University of Keele (T.K., A.S., M.R., M.A.M.).

Background: Financial pressures for reducing hospitalization costs have driven to a move toward same day discharge (SDD) following uncomplicated percutaneous coronary intervention. The UK healthcare system has transitioned to predominantly SDD for elective percutaneous coronary intervention. This study aimed to examine patient's clinical, procedural, and institutional characteristics that are associated with the increased adoption of SDD adoption over time in the United Kingdom and determine whether these vary by region.

Methods: The data were derived from the British Cardiovascular Intervention Society including all the elective percutaneous coronary intervention from 2007 to 2014 in the United Kingdom. We structured 8 meaningful groups of variables, and their relative importance was obtained by decomposing the R in each study year.

Results: The relative importance of Strategic Health Authorities was substantially higher than all other factors every year, with some reduction over time, from 49.2% (95% CI, 45.4%-52.4%) in 2007 to 43.4% (95% CI, 39.9%-46.6%) in 2014. Center volume followed with 8.95% (95% CI, 7.0%-10.9%) to 19.8% (95% CI, 16.7%-22.4%). Between patients' clinical and procedural characteristics, pharmacology and access site had the highest relative importance values, from 14.3% (95% CI, 12.1%-16.4%) to 7.1% (95% CI, 5.5%-8.8%) and from 3.6% (95% CI, 2.3%-5.1%) to 11.8% (95% CI, 9.4%-14.3%), respectively. Relative importance of different groups varied differently across Strategic Health Authorities.

Conclusions: Growth of SDD was mainly associated with regional characteristics, while subcontributors varied substantially between different regions. Standardized guidelines would provide more homogenous adoption of SDD nationally. This analysis might be of wider interest in healthcare systems slower in SDD adoption.
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http://dx.doi.org/10.1161/CIRCINTERVENTIONS.119.008458DOI Listing
March 2020

Association Between Hospital Cardiac Catheter Laboratory Status, Use of an Invasive Strategy, and Outcomes After NSTEMI.

Can J Cardiol 2020 06 16;36(6):868-877. Epub 2019 Oct 16.

Keele Cardiovascular Research Group, Centre of Prognosis Research, Institute of Primary Care Sciences, Keele University, Stoke on Trent, United Kingdom; Department of Cardiology, University Hospital of North Midlands, Stoke on Trent, United Kingdom; Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, United Kingdom.

Background: Increased use of invasive coronary strategies in patients admitted to hospitals with on-site cardiac catheter laboratory (CCL) facilities has been reported, but the utilisation of invasive coronary strategies according to types of CCL facilities at the first admitting hospital and clinical outcomes is unknown.

Methods: We included 452,216 patients admitted with a diagnosis of non-ST-segment-elevation myocardial infarction (NSTEMI) in England and Wales from 2007 to 2015. The admitting hospitals were categorized into no-laboratory, diagnostic, and PCI hospitals according to CCL facilities. Multilevel logistic regression models were used to study associations between CCL facilities and in-hospital outcomes.

Results: A total of 97,777 (21.6%) of the patients were admitted to no-laboratory hospitals, and 134,381 (29.7%) and 220,058 (48.7%) were admitted to diagnostic and PCI hospitals, respectively. Use of coronary angiography was significantly higher in PCI hospitals (77.3%) than in diagnostic (63.2%) and no-laboratory (61.4%) hospitals. The adjusted odds of in-hospital mortality were similar for diagnostic (odds ratio [OR] 0.93, 95% confidence interval [CI] 0.83-1.04) and PCI hospitals (OR 1.09, 95% CI 0.96-1.24) compared with no-laboratory hospitals. However, in high-risk NSTEMI subgroup (defined as Global Registry of Acute Coronary Events score > 140), an admission to diagnostic hospitals was associated with significantly increased in-hospital mortality (OR 1.36, 95% CI 1.06-1.75) compared with no-laboratory and PCI hospitals.

Conclusions: This study highlights important differences in both the utilisation of invasive coronary strategies and subsequent management and outcomes of NSTEMI patients according to admitting hospital CCL facilities. High-risk NSTEMI patients admitted to diagnostic hospitals had greater in-hospital mortality, possibly because of reduced PCI use, which needs to be addressed.
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http://dx.doi.org/10.1016/j.cjca.2019.10.010DOI Listing
June 2020

Multiple unplanned readmissions after discharge for an admission with percutaneous coronary intervention.

Catheter Cardiovasc Interv 2021 Feb 28;97(3):395-408. Epub 2020 Feb 28.

Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, UK.

Objective: This study aims to describe temporal trends, characteristics, and clinical outcomes of patients with more than one unplanned readmission within 30 and 180 days after admission with percutaneous coronary intervention (PCI).

Background: There is limited understanding of multiple readmissions after PCI.

Methods: Patients undergoing PCI between 2010 and 2014 in the U.S. Nationwide Readmission Database were evaluated for unplanned readmissions at 30 and 180 days after discharge. Trends in multiple readmissions, characteristics of patients, and causes of first readmissions are described.

Results: A total of 2,324,194 patients were included in the analysis of 30-day unplanned readmissions and 1,327,799 patients in the analysis of 180-day unplanned readmission. The proportions of patients with a single readmission and multiple readmissions within 30 days were 8.5 and 1.0% and at 180 days were 15.4 and 9.1%, respectively. Common reasons for first readmission among patients with multiple readmissions were coronary artery disease, including angina, heart failure, and acute myocardial infarction. Factors associated with multiple readmissions were discharge against medical advice, discharge to care home, renal failure, and liver failure. The total cost of multiple readmissions is significant, with an increase from ~$20,000 for no readmission to over $60,000 at 30-day follow up and $86,000 at 180-day follow up.

Conclusions: Multiple readmissions are rare within 30 days after PCI but increase to nearly 1 in 10 patients at 180 days, and 20-25% of patients who have multiple readmissions are readmitted for the same cause as for the first and second readmissions.
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http://dx.doi.org/10.1002/ccd.28797DOI Listing
February 2021

Rates, predictors and the impact of cannabis misuse on in-hospital outcomes among patients undergoing percutaneous coronary intervention (from the National Inpatient Sample).

Int J Clin Pract 2020 May 31;74(5):e13477. Epub 2020 Jan 31.

Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, UK.

Background: Whether cannabis use worsens outcomes in coronary heart disease is unknown and no previous study has evaluated the outcomes for patients who undergo percutaneous coronary intervention (PCI) according to cannabis use.

Methods: We analysed patients in the National Inpatient Sample between 2004 and 2014 who underwent PCI and evaluated rates, predictors and outcomes of patients according to cannabis misuse defined by cannabis abuse or dependence.

Results: A total of 7 306 012 patients were included and 32 765 cannabis misusers (0.4%). Cannabis misusers were younger (49.5 vs 64.6 years, P < .001) and were more likely to be male (82.7% vs 66.3%, P < .001). There was also a greater proportion of patients who were of black ethnicity in the cannabis misuse group (27.7% vs 7.9%, P < .001) and fewer elective admissions (7.8% vs 27.6%, P < .001). There was no difference in in-hospital mortality (OR 1.06 95% CI 0.80-1.40, P = .67), bleeding (OR 0.94 95% CI 0.77-1.15, P = .55) and stroke/transient ischaemic attack (OR 1.19 95% CI 0.98-1.45, P = .084) compared with non-cannabis misusers. Cannabis misusers had significantly lower odds of in-hospital vascular complications (OR 0.73 95% CI 0.58-0.90, P = .004).

Conclusions: Our results suggest that cannabis misusers are more likely to be male, of black ethnicity and from the lowest quartile of income, but there was no evidence that cannabis misuse is associated with worse periprocedural outcomes following PCI when controlling for key proxies of health status.
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http://dx.doi.org/10.1111/ijcp.13477DOI Listing
May 2020

Baseline risk, timing of invasive strategy and guideline compliance in NSTEMI: Nationwide analysis from MINAP.

Int J Cardiol 2020 02 28;301:7-13. Epub 2019 Nov 28.

Keele Cardiovascular Research group, Centre of Prognosis Research, Institute of Primary Care Sciences, Keele University, Stoke on Trent, UK; Department of Cardiology, University Hospital of North Midlands, Stoke on Trent, UK.

Background: International guidelines recommend that for NSTEMI, the timing of invasive strategy (IS) is a function of patient's baseline risk. The extent to which this is delivered across and within healthcare systems is unknown.

Methods: Data were derived from 137,265 patients admitted with an NSTEMI diagnosis between 2010 and 2015 in England and Wales. Patients were stratified into low, intermediate and high-risk in keeping with international guidelines. Time to IS was categorised into early (24 h), intermediate (25-72 h) and late (>72 h). Multivariable logistic regression models were used to identify independent predictors of guidelines recommended receipt of IS.

Results: There were 3608 (2.6%) low, 5037 (3.7%) intermediate and 128,621 (93.7%) high-risk patients. Guidelines recommended use of IS was significantly lower in high-risk (16.4%) compared to intermediate (64.7%) and low-risk (62.5%) groups. Both men and women in the low-risk category were almost twice as likely to receive early IS compared to high-risk men (28.9% vs 17%, p < 0.001) and women (26.9% vs 15%, p < 0.001). Women (OR 0.91 95%CI 0.88-0.94), troponin elevation (OR 0.39 95%CI 0.36-0.43) and acute heart failure on admission (OR 0.65 95%CI 0.61-0.70) were strong negative predictors of receiving IS within recommended time in the high-risk group.

Conclusion: Our study shows that IS for management of NSTEMI is not delivered according to international guidelines recommendations. Specifically, the disconnect between baseline risk and utility of IS increases with increasing risk and women achieve slower access than men to IS.
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http://dx.doi.org/10.1016/j.ijcard.2019.11.146DOI Listing
February 2020

Outcomes Following Percutaneous Coronary Intervention in Saphenous Vein Grafts With and Without Embolic Protection Devices.

JACC Cardiovasc Interv 2019 11;12(22):2286-2295

Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom. Electronic address:

Objectives: The aim of this study was to describe the early (inpatient and 30-day) and late (1-year) outcomes of percutaneous coronary intervention (PCI) in saphenous vein grafts (SVGs), with and without the use of embolic protection devices (EPD), in a large, contemporary, unselected national cohort from the database of the British Cardiovascular Intervention Society.

Background: There are limited, and discrepant, data on the clinical benefits of the adjunctive use of EPDs during PCI to SVGs in the contemporary era.

Methods: A longitudinal cohort of patients (2007 to 2014, n = 20,642) who underwent PCI to SVGs in the British Cardiovascular Intervention Society database was formed. Clinical, demographic, procedural, and outcome data were analyzed by dividing into 2 groups: no EPD (PCI to SVGs without EPDs, n = 17,730) and EPD (PCI to SVGs with EPDs, n = 2,912).

Results: Patients in the EPD group were older, had more comorbidities, and had a higher prevalence of moderate to severe left ventricular systolic dysfunction. Mortality was lower in the EPD group during hospital admission (0.70% vs. 1.29%; p = 0.008) and at 30 days (1.44% vs. 2.01%; p = 0.04) but similar at 1 year (6.22% vs. 6.01%; p = 0.67). Following multivariate analyses, no significant difference in mortality was observed during index admission (odds ratio [OR]: 0.71; 95% confidence interval [CI]: 0.42 to 1.19; p = 0.19), at 30 days (OR: 0.87; 95% CI: 0.60 to 1.25; p = 0.45), and at 1 year (OR: 0.92; 95% CI: 0.77 to 1.11; p = 0.41), along with similar rates of in-hospital major adverse cardiovascular events (OR: 1.16; 95% CI: 0.83 to 1.62; p = 0.39) and stroke (OR: 0.68; 95% CI: 0.20 to 2.35; p = 0.54). In propensity score-matched analyses, lower inpatient mortality was observed in the EPD group (OR: 0.46; 95% CI: 0.13 to 0.80; p = 0.002), although the adjusted risk for the periprocedural no-reflow or slow-flow phenomenon was higher in patients in whom EPDs were used (OR: 2.16; 95% CI: 1.71 to 2.73; p < 0.001).

Conclusions: In this contemporary cohort, EPDs were used more commonly in higher risk patients but were associated with similar clinical outcomes in multivariate analyses. Lower inpatient mortality was observed in the EPD group in univariate and propensity score-matched analyses.
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http://dx.doi.org/10.1016/j.jcin.2019.08.037DOI Listing
November 2019

Acute Myocardial Infarction in Severe Mental Illness: Prevalence, Clinical Outcomes, and Process of Care in U.S. Hospitalizations.

Can J Cardiol 2019 07 2;35(7):821-830. Epub 2019 May 2.

Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute of Applied Clinical Science and Primary Care and Health Sciences, Keele University, Keele, United Kingdom. Electronic address:

Background: Severe mental illness (SMI) is associated with increased cardiovascular mortality. We sought to examine the prevalence, clinical outcomes, and management strategy of patients with SMI presenting with acute myocardial infarction (AMI).

Methods: All AMI hospitalizations from the National Inpatient Sample were included, stratified by mental health status into 5 groups: no SMI, schizophrenia, other non-organic psychoses (ONOP), bipolar disorder, and major depression. Regression analyses were performed to assess the association (adjusted odds ratios [ORs], P ≤ 0.001 for all outcomes) between SMI subtypes and clinical outcomes.

Results: Of 6,968,777 AMI hospitalizations between 2004 and 2014, 439,544 patients (6.5%) had an SMI diagnosis. Although patients with schizophrenia and ONOP experienced higher crude rates of in-hospital mortality and stroke compared with those without SMI, only schizophrenic patients were at increased odds of mortality (OR, 1.10; 95% confidence interval [CI], 1.04-1.16), whereas ONOP was the only group at increased odds of stroke (OR, 1.53; 95% CI, 1.42-1.65) after multivariate adjustment. Patients with ONOP were the only group associated with increased odds of in-hospital bleeding compared with those without SMI (OR, 1.11; 95% CI, 1.04-1.17). All those with SMI subtypes were less likely to receive coronary angiography and percutaneous coronary intervention, with the schizophrenia group being at least odds of either procedure (OR, 0.46; 95% CI, 0.45-0.48 and OR, 0.57; 95% CI, 0.55-0.59, respectively).

Conclusion: Schizophrenia and ONOP are the only SMI subtypes associated with adverse clinical outcomes after AMI. However, all patients with SMI were less likely to receive invasive management for AMI, with female gender and schizophrenia diagnosis being the strongest predictors of conservative management. A multidisciplinary approach between psychiatrists and cardiologists could improve the outcomes of this high-risk population.
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http://dx.doi.org/10.1016/j.cjca.2019.04.021DOI Listing
July 2019

Does rhythm matter in acute heart failure? An insight from the British Society for Heart Failure National Audit.

Clin Res Cardiol 2019 Nov 8;108(11):1276-1286. Epub 2019 Apr 8.

Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, University of Keele and Royal Stoke Hospital, Stoke-on-Trent, UK.

Background: Atrial fibrillation (AF) is the most common sustained arrhythmia in patients with acute heart failure (AHF). The presence of AF is associated with adverse prognosis in patients with chronic heart failure (CHF) but little is known about its impact in AHF.

Methods: Data were collected between April 2007 and March 2013 across 185 (> 95%) hospitals in England and Wales from patients with a primary death or a discharge diagnosis of AHF. We investigated the association between the presence of AF and all-cause mortality during the index hospital admission, at 30 days and 1 year post-discharge.

Results: Of 96,593 patients admitted with AHF, 44,642 (46%) were in sinus rhythm (SR) and 51,951 (54%) in AF. Patients with AF were older (mean age 79.8 (79.7-80) versus 74.7 (74.5-74.7) years; p < 0.001), than those in SR. In a multivariable analysis, AF was independently associated with mortality at all time points, in hospital (HR 1.15, 95% CI 1.09-1.21, p < 0.0001), 30 days (HR 1.13, 95% CI 1.08-1.19, p < 0.0001), and 1 year (HR 1.09, 95% CI 1.05-1.12, p < 0.0001). In subgroup analyses, AF was independently associated with worse 30-day outcome irrespective of sex, ventricular phenotype and in all age groups except in those aged between 55 and 74 years.

Conclusion: AF is independently associated with adverse prognosis in AHF during admission and up to 1 year post-discharge. As the clinical burden of concomitant AF and AHF increases, further refinement in the detection, treatment and prevention of AF-related complications may have a role in improving patient outcomes.
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http://dx.doi.org/10.1007/s00392-019-01463-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6805810PMC
November 2019

Characteristics and outcome of acute heart failure patients according to the severity of peripheral oedema.

Int J Cardiol 2019 06 15;285:40-46. Epub 2019 Mar 15.

Department of Academic Cardiology, University of Hull, Kingston upon Hull, UK; Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, Scotland, UK; National Heart and Lung Institute, Imperial College, London, UK.

Background: Most trials of patients hospitalized for heart failure focus on breathlessness (alveolar pulmonary oedema) but worsening peripheral oedema is also an important presentation. We investigated the relationship between the severity of peripheral oedema on admission and outcome amongst patients with a primary discharge death or diagnosis of heart failure.

Objectives: We tested the hypothesis that severity of peripheral oedema is associated with length of hospital stay and mortality.

Methods: Patient variables reported to the National Heart Failure Audit for England & Wales between April 2008 and March 2013 were included in this analysis. Peripheral oedema was classified as 'none', 'mild', 'moderate' or 'severe'. Length of stay, mortality during the index admission and for up to three years after discharge are reported.

Results: Of 121,214 patients, peripheral oedema on admission was absent in 24%, mild in 24%, moderate in 33% and severe in 18%. Median length of stay was, respectively, 6, 7, 9 and 12 days (P- < 0.001), index admission mortality was 7%, 8%, 10% and 16% (P- < 0.001) and mortality at a median follow-up of 344 (IQR 94-766) days was 39%, 46%, 52% and 59%. In an adjusted multi-variable Cox model, the hazard ratio for death was 1.51 for severe (P- < 0.001, CI 1.50-1.53), 1.21 for moderate (P- < 0.001, CI 1.20-1.22) and 1.04 (P- < 0.001, CI 1.02-1.05) for mild peripheral oedema compared to patients without peripheral oedema at presentation.

Conclusion: Length of hospital stay and mortality during index admission and after discharge increased progressively with increasing severity of peripheral oedema at admission.
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http://dx.doi.org/10.1016/j.ijcard.2019.03.020DOI Listing
June 2019

Temporal trends and inequalities in coronary angiography utilization in the management of non-ST-Elevation acute coronary syndromes in the U.S.

Sci Rep 2019 01 18;9(1):240. Epub 2019 Jan 18.

Keele Cardiovascular Research Group, Centre for Prognosis Research, Institutes of Applied Clinical Science and Primary Care and Health Sciences, Keele University, Stoke-on-Trent, UK.

Coronary angiography (CA) is the basis of an invasive management strategy in non-ST elevation acute coronary syndromes (NSTEACS). There are limited contemporary data on national temporal trends in utilization of CA in different patient subgroups. We sought to investigate temporal trends, predictors and clinical outcomes associated with the use of CA in the US. Using the Nationwide Inpatient Sample (NIS) from 2004-2014, we identified all inpatient admissions, age ≥18, with a primary diagnosis of NSTEACS. Descriptive statistics and multivariable logistic regression models were used to investigate temporal trends, predictors and clinical outcomes associated with CA. From a total of 4,380,827 patients, 57.5% received CA during the study period and were more likely to be male, younger and less comorbid as defined per Charlson comorbidity index. The proportion of patients receiving CA increased from 48.5% to 68.5%, however, higher proportional increase was observed in males (53.9% to 69.4% P < 0.001) and those age ≤60 years (59.0% to 77.9% P < 0.001). Prior history of CABG (OR 0.33 95%CI 0.35-0.36), previous PCI (OR 0.84 95%CI 0.83-0.86) and previous AMI (OR 0.65 95%CI 0.64-0.67) were inversely related with receipt of CA. Receipt of CA was strongly associated with decreased odds of in-hospital mortality (OR 0.38 95%CI 0.36-0.40). In this national analysis, we observed a temporal increase in utilization of CA albeit slower adoption was noted in older, women and more comorbid patients. The risk-treatment paradox wherein patients who are most likely to benefit were less likely to receive CA persists even in contemporary practice.
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http://dx.doi.org/10.1038/s41598-018-36504-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6338770PMC
January 2019