Treatment Restrictions and the Risk of Death in Patients With Ischemic Stroke or Intracerebral Hemorrhage

Background and Purpose: Do-not-resuscitate (DNR) orders in the first 24 hours after intracerebral hemorrhage have been associated with an increased risk of early death. This relationship is less certain for ischemic stroke. We assessed the relation between treatment restrictions and mortality in patients with ischemic stroke and in patients with intracerebral hemorrhage. We focused on the timing of treatment restrictions after admission and the type of treatment restriction (DNR order versus more restrictive care). Methods: We retrospectively assessed demographic and clinical data, timing and type of treatment restrictions, and vital status at 3 months for 622 consecutive stroke patients primarily admitted to a Dutch university hospital. We used a Cox regression model, with adjustment for age, sex, comorbidities, and stroke type and severity. Results: Treatment restrictions were installed in 226 (36%) patients, more frequently after intracerebral hemorrhage (51%) than after ischemic stroke (32%). In 187 patients (83%), these were installed in the first 24 hours. Treatment restrictions installed within the first 24 hours after hospital admission and those installed later were independently associated with death at 90 days (adjusted hazard ratios, 5.41 [95% CI, 3.17–9.22] and 5.36 [95% CI, 2.20–13.05], respectively). Statistically significant associations were also found in patients with ischemic stroke and in patients with just an early DNR order. In those who died, the median time between a DNR order and death was 520 hours (interquartile range, 53–737). Conclusions: The strong relation between treatment restrictions (including DNR orders) and death and the long median time between a DNR order and death suggest that this relation may, in part, be causal, possibly due to an overall lack of aggressive care.

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Higher Long-term Visit-to-Visit Glycemic Variability Predicts New-Onset Atrial Fibrillation in Patients with Diabetes Mellitus

10.21203/rs.3.rs-588082/v1 ◽

2021 ◽

Author(s):

Jung-Chi Hsu ◽

Yen-Yun Yang ◽

Shu-Lin Chuang ◽

Chih-Chieh Yu ◽

Lian-Yu Lin

Keyword(s):

Diabetes Mellitus ◽

Atrial Fibrillation ◽

Ischemic Stroke ◽

Cox Regression ◽

Total Mortality ◽

Glycemic Variability ◽

University Hospital ◽

Cardiac Mortality ◽

Increased Risk ◽

New Onset

Abstract BackgroundAtrial fibrillation (AF) is prevalent in patients with type 2 diabetes mellitus (T2DM). Glycemic variability (GV) is associated with risk of micro- and macrovascular diseases. However, whether the GV can increase the risk of AF remains unknown.MethodsThe cohort study used a database from National Taiwan University Hospital, a tertiary medical center in Taiwan. Between 2014 and 2019, a total of 27246 adult patients with T2DM were enrolled for analysis. Each individual was assessed to determine the coefficients of variability of fasting glucose (FGCV) and HbA1c variability score (HVS). The GV parameters were categorized into quartiles. Multivariate Cox regression models were employed to estimate the relationship between the GV parameters and the risk of AF, transient ischemic accident (TIA)/ischemic stroke and mortality in patients with T2DM.ResultsThe incidence rates of AF and TIA/ischemic stroke were 21.31 and 13.71 per 1000 person-year respectively. The medium follow-up period was 70.7 months. In Cox regression model with full adjustment, the highest quartiles of FGCV was not associated with increased risk of AF (Hazard ratio (HR): 1.11, 95% confidence interval (CI): 0.96-1.29, p=0.165) or TIA/ischemic stroke (HR: 1.03, 95% CI: 0.82-1.29, p=0.821), but was associated with increased risk of total mortality (HR: 1.34, 95% CI: 1.13-1.60, p<0.001) and non-cardiac mortality (HR: 1.42, 95% CI: 1.17-1.72, p<0.001). The highest HVS was significantly associated with increased risk of AF (HR: 1.29, 95% CI: 1.12-1.48, p<0.001), total mortality (HR: 2.44, 95% CI: 2.04-2.91, p<0.001), cardiac mortality (HR: 1.48, 95% CI: 1.04-2.10, p=0.028) and non-cardiac mortality (HR: 2.83, 95% CI: 2.31-3.14, p<0.001) but was not associated with TIA/ischemic stroke (HR: 1.00, 95% CI: 0.79-1.26, p=0.989). The Kaplan-Meier analysis showed significantly higher risk of AF, cardiac and non-cardiac mortality according to the magnitude of GV(log-rank<0.001). ConclusionsHigher GV is independently associated with the development of new-onset AF in patients with T2DM. Reducing GV may be a potential new therapeutic target to prevent AF.

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Abstract P439: Mortality After an Arterial Ischemic Event Among Intracerebral Hemorrhage Survivors

Stroke ◽

10.1161/str.52.suppl_1.p439 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Melvin Parasram ◽

Neal S Parikh ◽

Alexander E Merkler ◽

Guido J Falcone ◽

Kevin N Sheth ◽

...

Keyword(s):

Ischemic Stroke ◽

Confidence Interval ◽

Intracerebral Hemorrhage ◽

Medicare Beneficiaries ◽

Ischemic Event ◽

Risk Of Death ◽

Diagnosis Codes ◽

Increased Risk ◽

Secondary Analyses ◽

Ischemic Events

Background and Purpose: Emerging data suggest an increased risk of arterial ischemic events after intracerebral hemorrhage (ICH), but their impact on ICH outcomes is unclear. This study aimed to evaluate the risk of death among ICH survivors with and without an incident arterial ischemic event. Methods: We performed a retrospective cohort study using claims data from Medicare beneficiaries with a non-traumatic ICH from January 2008 to October 2015. Our exposure was an arterial ischemic event, defined as a composite of acute ischemic stroke or myocardial infarction (MI), identified using validated ICD-9-CM diagnosis codes. The outcome was death. After excluding ischemic events and deaths in the first 30 days after ICH discharge to prevent carryover of diagnosis codes from the initial hospitalization, we used marginal structural models to analyze the risk of death among ICH patients with and without an arterial ischemic event, after adjusting for demographics and vascular comorbidities as time-varying covariates. In secondary analyses, we studied the mortality risk separately after an ischemic stroke and MI. Results: Among 8,222 Medicare beneficiaries with an ICH, 2,371 (28.8%) had an arterial ischemic event. During a median follow up time of 2.0 years (interquartile range, 0.8-3.8), the cumulative mortality rate was 7.0% (95% confidence interval [CI], 6.5-7.5%) in patients with an arterial ischemic event and 4.0% (95% CI, 3.8-4.2%) in patients without an arterial ischemic event. In the marginal structural model, the occurrence of an arterial ischemic event was associated with an increased risk of death (hazard ratio [HR], 1.6; 95% confidence interval [CI], 1.5- 1.7). In secondary analyses, the mortality risk was elevated after both an ischemic stroke (HR, 1.5; 95% CI, 1.4-1.6), and a MI (HR, 2.6; 95% CI, 2.1-3.2). Conclusions: In a large population-based cohort, we found that elderly patients who survived an ICH had an increased risk of death after a subsequent ischemic stroke or MI. Careful exploration of secondary cardiovascular and stroke prevention strategies may be warranted in these patients.

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Treatment of intracerebral hemorrhage: From specific interventions to bundles of care

International Journal of Stroke ◽

10.1177/1747493020964663 ◽

2020 ◽

Vol 15 (9) ◽

pp. 945-953

Author(s):

Adrian R Parry-Jones ◽

Tom J Moullaali ◽

Wendy C Ziai

Keyword(s):

Intracerebral Hemorrhage ◽

Vitamin K ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Phase Iii ◽

Hematoma Expansion ◽

Care Bundle ◽

Do Not Resuscitate ◽

Risk Of Death ◽

Increased Risk

Intracerebral hemorrhage (ICH) represents a major, global, unmet health need with few treatments. A significant minority of ICH patients present taking an anticoagulant; both vitamin-K antagonists and increasingly direct oral anticoagulants. Anticoagulants are associated with an increased risk of hematoma expansion, and rapid reversal reduces this risk and may improve outcome. Vitamin-K antagonists are reversed with prothrombin complex concentrate, dabigatran with idarucizumab, and anti-Xa agents with PCC or andexanet alfa, where available. Blood pressure lowering may reduce hematoma growth and improve clinical outcomes and careful (avoiding reductions ≥60 mm Hg within 1 h), targeted (as low as 120–130 mm Hg), and sustained (minimizing variability) treatment during the first 24 h may be optimal for achieving better functional outcomes in mild-to-moderate severity acute ICH. Surgery for ICH may include hematoma evacuation and external ventricular drainage to treat hydrocephalus. No large, well-conducted phase III trial of surgery in ICH has so far shown overall benefit, but meta-analyses report an increased likelihood of good functional outcome and lower risk of death with surgery, compared to medical treatment only. Expert supportive care on a stroke unit or critical care unit improves outcomes. Early prognostication is difficult, and early do-not-resuscitate orders or withdrawal of active care should be used judiciously in the first 24–48 h of care. Implementation of acute ICH care can be challenging, and using a care bundle approach, with regular monitoring of data and improvement of care processes can ensure consistent and optimal care for all patients.

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Risk of Mortality After an Arterial Ischemic Event Among Intracerebral Hemorrhage Survivors

The Neurohospitalist ◽

10.1177/19418744211026709 ◽

2021 ◽

pp. 194187442110267

Author(s):

Melvin Parasram ◽

Neal S. Parikh ◽

Alexander E. Merkler ◽

Guido J. Falcone ◽

Kevin N. Sheth ◽

...

Keyword(s):

Ischemic Stroke ◽

Confidence Interval ◽

Intracerebral Hemorrhage ◽

Structural Model ◽

Medicare Beneficiaries ◽

Ischemic Event ◽

Risk Of Death ◽

Increased Risk ◽

The Impact ◽

Time Varying Covariates

Background and Purpose: The impact of arterial ischemic events after intracerebral hemorrhage (ICH) on outcomes is unclear. This study aimed to evaluate the risk of death among ICH survivors with and without an incident arterial ischemic event. Methods: We performed a retrospective cohort study using claims data from Medicare beneficiaries with a non-traumatic ICH from January 2008 to October 2015. Our exposure was an arterial ischemic event, a composite of acute ischemic stroke or myocardial infarction (MI), identified using validated ICD-9-CM diagnosis codes. The outcome was mortality. We used marginal structural models to analyze the risk of death among ICH patients with and without an arterial ischemic event, after adjusting for confounders as time-varying covariates. Results: Among 8,804 Medicare beneficiaries with ICH, 2,371 (26.9%) had an arterial ischemic event. During a median follow-up time of 1.9 years (interquartile range, 0.7-3.9), ICH patients with an arterial ischemic event had a mortality rate of 21.7 (95% confidence interval [CI], 20.4-23.0) per 100 person-years compared to a rate of 15.0 (95% CI, 14.4-15.6) per 100 person-years in those without. In the marginal structural model, an arterial ischemic event was associated with an increased risk of death (hazard ratio [HR], 1.8; 95% confidence interval [CI], 1.6-1.9). In secondary analyses, the mortality risk was elevated after an ischemic stroke (HR, 1.7; 95% CI, 1.5-1.8), and MI (HR, 3.0; 95% CI, 2.4-3.8). Conclusions: We found that elderly patients who survived an ICH had an increased risk of death after a subsequent ischemic stroke or MI.

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Differences in risk factors for 3 types of stroke

Neurology ◽

10.1212/wnl.0000000000004856 ◽

2018 ◽

Vol 90 (4) ◽

pp. e298-e306 ◽

Cited By ~ 18

Author(s):

Alison J. Price ◽

F. Lucy Wright ◽

Jane Green ◽

Angela Balkwill ◽

Sau Wan Kan ◽

...

Keyword(s):

Risk Factors ◽

Ischemic Stroke ◽

Subarachnoid Hemorrhage ◽

Intracerebral Hemorrhage ◽

Cox Regression ◽

Related Factors ◽

Stroke Incidence ◽

Relative Risks ◽

Increased Risk ◽

Meta Analyses

ObjectiveTo compare associations of behavioral and related factors for incident subarachnoid hemorrhage and intracerebral hemorrhage and ischemic stroke.MethodsA total of 712,433 Million Women Study participants without prior stroke, heart disease, or cancer reported behavioral and related factors at baseline (1999–2007) and were followed up by record linkage to national hospital admission and death databases. Cox regression yielded adjusted relative risks (RRs) by type of stroke. Heterogeneity was assessed with χ2 tests. When appropriate, meta-analyses were done of published prospective studies.ResultsAfter 12.9 (SD 2.6) years of follow-up, 8,128 women had an incident ischemic stroke, 2,032 had intracerebral hemorrhage, and 1,536 had subarachnoid hemorrhage. In women with diabetes mellitus, the risk of ischemic stroke was substantially increased (RR 2.01, 95% confidence interval [CI] 1.84–2.20), risk of intracerebral hemorrhage was increased slightly (RR 1.31, 95% CI 1.04–1.65), but risk of subarachnoid hemorrhage was reduced (RR 0.43, 95% CI 0.26–0.69) (heterogeneity by stroke type, p < 0.0001). Stroke incidence was greater in women who rated their health as poor/fair compared to those who rated their health as excellent/good (RR 1.36, 95% CI 1.30–1.42). Among 565,850 women who rated their heath as excellent/good, current smokers were at an increased risk of all 3 stroke types, (although greater for subarachnoid hemorrhage [≥15 cigarettes/d vs never smoker, RR 4.75, 95% CI 4.12–5.47] than for intracerebral hemorrhage [RR 2.30, 95% CI 1.94–2.72] or ischemic stroke [RR 2.50, 95% CI 2.29–2.72]; heterogeneity p < 0.0001). Obesity was associated with an increased risk of ischemic stroke and a decreased risk of hemorrhagic stroke (heterogeneity p < 0.0001). Meta-analyses confirmed the associations and the heterogeneity across the 3 types of stroke.ConclusionClassic risk factors for stroke have considerably different effects on the 3 main pathologic types of stroke.

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Triglyceride-glucose index and the risk of stroke and its subtypes in the general population: an 11-year follow-up

Cardiovascular Diabetology ◽

10.1186/s12933-021-01238-1 ◽

2021 ◽

Vol 20 (1) ◽

Author(s):

Anxin Wang ◽

Guangyao Wang ◽

Qian Liu ◽

Yingting Zuo ◽

Shuohua Chen ◽

...

Keyword(s):

Ischemic Stroke ◽

Subarachnoid Hemorrhage ◽

General Population ◽

Intracerebral Hemorrhage ◽

Cox Regression ◽

Surrogate Marker ◽

Tyg Index ◽

Increased Risk

Abstract Background Triglyceride-glucose (TyG) index was recently suggested to be a reliable surrogate marker of insulin resistance. We aim to investigate the associations between baseline and long-term TyG index with subsequent stroke and its subtypes in a community-based cohort. Methods A total of 97,653 participants free of history of stroke in the Kailuan Study were included. TyG index was calculated as ln (fasting triglyceride [mg/dL] × fasting glucose [mg/dL]/2). Baseline TyG index was measured during 2006–2007. Updated cumulative average TyG index used all available TyG index from baseline to the outcome events of interest or the end of follow up. The outcome was the first occurrence of stroke, including ischemic stroke, intracerebral hemorrhage and subarachnoid hemorrhage. The associations of TyG index with outcomes were explored with Cox regression. Results During a median of 11.02 years of follow-up, 5122 participants developed stroke of whom 4277 were ischemic stroke, 880 intracerebral hemorrhage, and 144 subarachnoid hemorrhage. After adjusting for confounding variables, compared with participants in the lowest quartile of baseline TyG index, those in the third and fourth quartile were associated with an increased risk of stroke (adjusted hazard ratio [HR] 1.22, 95% confidence interval [CI] 1.12–1.33, and adjusted HR 1.32, 95% CI 1.21–1.44, respectively, P for trend < 0.001). We also found a linear association between baseline TyG index with stroke. Similar results were found for ischemic stroke. However, no significant associations were observed between baseline TyG index and risk of intracranial hemorrhage. Parallel results were observed for the associations of updated cumulative average TyG index with outcomes. Conclusions Elevated levels of both baseline and long-term updated cumulative average TyG index can independently predict stroke and ischemic stroke but not intracerebral hemorrhage in the general population during an 11-year follow-up.

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Diffusion-Weighted Imaging Lesions After Intracerebral Hemorrhage and Risk of Stroke

Stroke ◽

10.1161/strokeaha.120.031628 ◽

2021 ◽

Vol 52 (2) ◽

pp. 595-602

Author(s):

Santosh B. Murthy ◽

Cenai Zhang ◽

Ajay Gupta ◽

Sung-Min Cho ◽

Lucia Rivera-Lara ◽

...

Keyword(s):

Magnetic Resonance Imaging ◽

Ischemic Stroke ◽

Magnetic Resonance ◽

Intracerebral Hemorrhage ◽

Diffusion Weighted Imaging ◽

Cox Regression ◽

Hazard Ratio ◽

Resonance Imaging ◽

Diffusion Weighted ◽

Increased Risk

Background and Purpose: Punctate ischemic lesions noted on diffusion-weighted imaging (DWI) are associated with poor functional outcomes after intracerebral hemorrhage (ICH). Whether these lesions increase long-term risk of stroke is poorly understood. Methods: We pooled individual patient data from the ATACH-2 trial (Antihypertensive Treatment of Acute Cerebral Hemorrhage) and the MISTIE III trial (Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation Phase 3). We included subjects with a magnetic resonance imaging scan. The exposure was a DWI lesion. The primary outcome was any stroke, defined as a composite of ischemic stroke or recurrent ICH, whereas secondary outcomes were incident ischemic stroke and recurrent ICH. Using multivariate Cox regression analysis, we evaluated the risk of stroke. Results: Of 505 patients with ICH with magnetic resonance imaging, 466 were included. DWI lesions were noted in 214 (45.9%) subjects, and 34 incident strokes (20 ischemic stroke and 14 recurrent ICH) were observed during a median follow-up of 324 days (interquartile range, 91–374). Presence of a DWI lesion was associated with a 6.9% (95% CI, 2.2–11.6) absolute increase in risk of all stroke (hazard ratio, 2.6 [95% CI, 1.2–5.7]). Covariate adjustment with Cox regression models also demonstrated this increased risk. In the secondary analyses, there was an increased risk of ischemic stroke (hazard ratio, 3.5 [95% CI, 1.1–11.0]) but not recurrent ICH (hazard ratio, 1.7 [95% CI, 0.6–5.1]). Conclusions: In a heterogeneous cohort of patients with ICH, presence of a DWI lesion was associated with a 2.5-fold heightened risk of stroke among ICH survivors. This elevated risk persisted for ischemic stroke but not for recurrent ICH.

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Individuals with familial hypercholesterolemia have increased risk of re-hospitalization after acute myocardial infarction compared with controls

European Heart Journal ◽

10.1093/ehjci/ehaa946.2962 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

K Svendsen ◽

H.W Krogh ◽

J Igland ◽

G.S Tell ◽

L.J Mundal ◽

...

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Familial Hypercholesterolemia ◽

Cox Regression ◽

Public Institution ◽

University Hospital ◽

Funding Source ◽

Hazard Ratios ◽

Increased Risk ◽

University Of Oslo

Abstract Background and aim We have previously reported that individuals with familial hypercholesterolemia (FH) have a two-fold increased risk of acute myocardial infarction (AMI) compared with the general population. The consequences of having an AMI on re-hospitalization and mortality are however less known. The aim of the present study was to compare the risk of re-hospitalization with AMI and CHD and risk of mortality after incident (first) AMI-hospitalization between persons with and without FH (controls). Methods The original study population comprised 5691 persons diagnosed with FH during 1992–2014 and 119511 age and sex matched controls randomly selected from the general Norwegian population. We identified 221 individuals with FH and 1947 controls with an incident AMI registered in the Norwegian Patient Registry (NPR) or the Cardiovascular Disease in Norway Project during 2001–2017. Persons with incident AMI were followed until December 31st 2017 for re-hospitalization with AMI or coronary heart disease (CHD) registered in the NPR, and for mortality through linkage to the Norwegian Cause of Death Registry. Risk of re-hospitalization was compared with sub-hazard ratios (SHR) from competing risk regression with death as competing event, and mortality was compared using hazard ratios (HR) from Cox regression. All models were adjusted for age. Results Risk of re-hospitalization was 2-fold increased both for AMI [SHR=2.53 (95% CI: 1.88–3.41)] and CHD [SHR=1.82 (95% CI: 1.44–2.28)]. However, persons with FH did not have increased 28-day mortality following an incident AMI (HR=1.05 (95% CI: 0.62–1.78), but the longer-term (>28 days) mortality after first AMI was increased in FH [HR=1.45 (95% CI: 1.07–1.95]. Conclusion This study yields the important finding that persons with FH have increased risk of re-hospitalization of both AMI and CHD after incident AMI. These findings call for more intensive follow-up of individuals with FH after an AMI. Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): University of Oslo and Oslo University Hospital

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Effects of long-term anti-seizure medication monotherapy on all-cause death in patients with post-stroke epilepsy: a nationwide population-based study in Taiwan

BMC Neurology ◽

10.1186/s12883-021-02241-5 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Chia-Yu Hsu ◽

Chun-Yu Cheng ◽

Jiann-Der Lee ◽

Meng Lee ◽

Bruce Ovbiagele

Keyword(s):

Valproic Acid ◽

Ischemic Stroke ◽

Cox Regression ◽

Population Based ◽

Primary Diagnosis ◽

Research Database ◽

Post Stroke ◽

Risk Of Death ◽

Index Stroke

Abstract Objective We aim to compare the effect of long-term anti-seizure medication (ASM) monotherapy on the risk of death and new ischemic stroke in patients with post-stroke epilepsy (PSE). Patients and methods We identified all hospitalized patients (≥ 20 years) with a primary diagnosis of ischemic or hemorrhagic stroke from 2001 to 2012 using the National Health Insurance Research Database in Taiwan. The PSE cohort were defined as the stroke patients (1) who had no epilepsy and no ASMs use before the index stroke, and (2) who had epilepsy and ASMs use after 14 days from the stroke onset. The patients with PSE receiving ASM monotherapy were enrolled and were categorized into phenytoin, valproic acid, carbamazepine, and new ASM groups. We employed the Cox regression model to estimate the unadjusted and adjusted hazard ratios (HRs) with 95 % confidence intervals (CIs) of death and new ischemic stroke within 5 years across all groups, using the new ASM group as the reference. Results Of 6962 patients with PSE using ASM monotherapy, 3917 (56 %) were on phenytoin, 1623 (23 %) on valproic acid, 457 (7 %) on carbamazepine, and 965 (14 %) on new ASMs. After adjusting for confounders, compared with new ASM users, phenytoin users had a higher risk of death in 5 years (HR: 1.64; 95 % CI: 1.06–2.55). On the other hand, all ASM groups showed a similar risk of new ischemic stroke in 5 years. Conclusions Among patients with PSE on first-line monotherapy, compared to new ASMs, use of phenytoin was associated with a higher risk of death in 5 years.

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Fast-Track Programs in Total Hip and Knee Replacement at Swedish Hospitals—Influence on 2-Year Risk of Revision and Mortality

Journal of Clinical Medicine ◽

10.3390/jcm10081680 ◽

2021 ◽

Vol 10 (8) ◽

pp. 1680

Author(s):

Urban Berg ◽

Annette W-Dahl ◽

Anna Nilsdotter ◽

Emma Nauclér ◽

Martin Sundberg ◽

...

Keyword(s):

Fast Track ◽

Cox Regression ◽

Cox Regression Analysis ◽

Total Hip ◽

Total Knee Replacements ◽

Risk Of Death ◽

Kaplan Meier ◽

Increased Risk ◽

Hip And Knee Arthroplasty ◽

Total Knee

Purpose: We aimed to study the influence of fast-track care programs in total hip and total knee replacements (THR and TKR) at Swedish hospitals on the risk of revision and mortality within 2 years after the operation. Methods: Data were collected from the Swedish Hip and Knee Arthroplasty Registers (SHAR and SKAR), including 67,913 THR and 59,268 TKR operations from 2011 to 2015 on patients with osteoarthritis. Operations from 2011 to 2015 Revision and mortality in the fast-track group were compared with non-fast-track using Kaplan–Meier survival analysis and Cox regression analysis with adjustments. Results: The hazard ratio (HR) for revision within 2 years after THR with fast-track was 1.19 (CI: 1.03–1.39), indicating increased risk, whereas no increased risk was found in TKR (HR 0.91; CI: 0.79–1.06). The risk of death within 2 years was estimated with a HR of 0.85 (CI: 0.74–0.97) for TKR and 0.96 (CI: 0.85–1.09) for THR in fast-track hospitals compared to non-fast-track. Conclusions: Fast-track programs at Swedish hospitals were associated with an increased risk of revision in THR but not in TKR, while we found the mortality to be lower (TKR) or similar (THR) as compared to non-fast track.

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