Statins After Ischemic Stroke in the Oldest

Background and Purpose: Statins are frequently initiated in patients aged 80 years and older after an ischemic stroke, even though evidence on prevention of recurrent cardiovascular disease is scarce. In this study, we seek evidence for statin prescription in the oldest old. Methods: We performed a retrospective cohort study in patients aged 65 years and older hospitalized for a first ischemic stroke between 1999 and 2016 without statin prescriptions in the year before hospitalization using the Clinical Practice Research Datalink. The age group 65 to 80 years was included to compare our results to current evidence on statin efficacy. The primary outcome was a composite of recurrent stroke, myocardial infarction, and cardiovascular mortality. The secondary outcome was all-cause mortality. A time-varying Cox model was used to account for statin prescription over time. We compared at least 2 years of statin prescription time with untreated and <2 years of prescription time. Analyses were adjusted for potential confounders. The number needed to treat was calculated based on the adjusted hazard ratios and corrected for deaths during the first 2 years of follow-up. Results: Five thousand nine hundred ten patients, aged 65 years and older were included, of whom 3157 were 80 years and older. Two years of statin prescription in patients aged 80 years and older resulted in both a lower risk of the composite end point (adjusted hazard ratio, 0.80 [95% CI, 0.62–1.02]) and all-cause mortality (adjusted hazard ratio, 0.67 [95% CI, 0.57–0.80]). After correction for the mortality of 23.9% of the patients during the first 2 years, the number needed to treat was 64 for the primary outcome during a median follow-up of 3.9 years and 19 for all-cause mortality. Conclusions: Statins initiated in patients aged 80 and older, discharged home after hospitalization for an ischemic stroke are associated with a reduction in cardiovascular events.

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Stroke Risks in Adult Survivors of Preterm Birth: National Cohort and Cosibling Study

Stroke ◽

10.1161/strokeaha.120.033797 ◽

2021 ◽

Author(s):

Casey Crump ◽

Jan Sundquist ◽

Kristina Sundquist

Keyword(s):

Ischemic Stroke ◽

Preterm Birth ◽

Large Population ◽

Adult Survivors ◽

Small Sample ◽

Hazard Ratio ◽

Adjusted Hazard Ratio ◽

National Cohort

Background and Purpose: Clinicians will increasingly encounter adult patients who were born preterm and will need to understand their long-term sequelae. Adult survivors of preterm birth have been reported to have increased risks of hypertension and other stroke risk factors. However, their stroke risks have seldom been examined and the findings are discrepant, possibly due to small sample sizes, insufficient follow-up, or survivor bias. We examined whether preterm birth is associated with stroke in a large population-based cohort. Methods: A national cohort study was conducted of all 2 140 866 singletons born in Sweden from 1973 to 1994 who survived to age 18 years, who were followed up for first-time stroke through 2015 (maximum age 43 years). Cox regression was used to examine stroke risks associated with gestational age at birth, adjusting for other perinatal and parental factors. Cosibling analyses assessed for potential confounding by shared familial (genetic or environmental) factors. Results: In 28.0 million person-years of follow-up, 4861 (0.2%) people were diagnosed with stroke. At ages 18 to 43 years, the adjusted hazard ratio for stroke associated with preterm birth (<37 weeks) was 1.26 (95% CI, 1.12–1.43; P <0.001), and further stratified was 1.42 (1.11–1.81; P =0.005) for early preterm (22–33 weeks) and 1.22 (1.06–1.40; P =0.004) for late preterm (34–36 weeks), compared with full-term (39–41 weeks). Positive associations were found with both hemorrhagic stroke (early preterm: adjusted hazard ratio, 1.42 [95% CI, 1.04–1.94]; any preterm: 1.15 [0.97–1.35]) and ischemic stroke (early preterm: adjusted hazard ratio, 1.33 [95% CI, 0.87–2.03]; any preterm: 1.31 [1.07–1.60]). These findings were similar in men and women and only partially explained by shared determinants of preterm birth and stroke within families. Conclusions: In this large national cohort, preterm birth was associated with increased risks of both hemorrhagic and ischemic stroke in adulthood. Preterm birth survivors need early preventive evaluation and long-term clinical follow-up to reduce their lifetime risk of stroke.

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Left Atrial Functional Assessment and Mortality in Patients with Severe Aortic Stenosis

10.21203/rs.3.rs-52491/v1 ◽

2020 ◽

Author(s):

João Ferreira ◽

Valdirene Gonçalves ◽

Patrícia Marques-Alves ◽

Rui Martins ◽

Sílvia Monteiro ◽

...

Keyword(s):

Aortic Valve ◽

Left Atrial ◽

Primary Outcome ◽

Severe Aortic Stenosis ◽

Hazard Ratio ◽

Heart Team ◽

Pump Function ◽

Volumetric Assessment ◽

All Cause Mortality

Abstract Background: Aortic valve stenosis (AS) is the most common primary valvular heart disease leading to surgical or percutaneous aortic valve replacement (AVR) in Europe and its prevalence is growing. While other risk factors in severe AS are well documented, less is known about the association between left atrial (LA) function and prognosis in AS. Our aim is to clarify the relationship between LA function measured at severe AS diagnosis (evaluated by means of volumetric assessment) and all-cause mortality during follow-up.Methods: We retrospectively evaluated patients diagnosed with severe AS for the first time at our echocardiography laboratory. We evaluated LA reservoir, conduit and pump function by measuring LA volumes at different timings of cardiac cycle. Treatment strategy was decided according to heart team consensus and patient decision. We divided patients into groups according to terciles of LA reservoir, conduit and pump function. Primary outcome was defined by the occurrence of all-cause mortality during follow-up.Results: A total of 451 patients were included in the analysis, with a median follow-up time of 73 months (interquartile range 44.5). 55.8% of patients underwent AVR and 45.5% of patients registered the primary outcome during follow-up. Left atrial emptying fraction (LAEF) was the best LA functional parameter and the best overall parameter in discriminating primary outcome (AUC 0.840, 95% CI 0.803-0.872, p<0.001). After adjustment for clinical, demographic and echocardiographic variables, cumulative survival of patients with LAEF <37% and LAEF 37 to 53% relative to patients with LAEF ≥54% remained significantly lower (hazard ratio 19.04, 95% CI 8.30-43.67, P<0.001 and hazard ratio 4.09, 95% CI 1.85-9.06, p=0.001, respectively). After adjustment for AVR, excess risk of LAEF <37% and LAEF 37 to 53% relative to LAEF ≥54% remained significant (hazard ratio 13.95, 95% CI 5.98-32.54, P<0.001 and hazard ratio 3.97, 95% CI 1.80-8.78, P=0.001, respectively).Conclusions: In patients with a first diagnosis of severe AS, LA function, evaluated by means of volumetric assessment, is an independent predictor of all-cause mortality and a more potent predictor of death compared to classical severity parameters. These data can be useful to identify high-risk patients who might benefit of AVR.

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Risk of ischemic stroke in patients with acute myocardial infarction and new atrial fibrillation: a nationwide analysis

European Heart Journal ◽

10.1093/ehjci/ehaa946.0514 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

L Fauchier ◽

A Bisson ◽

A Bodin ◽

J Herbert ◽

T Genet ◽

...

Keyword(s):

Myocardial Infarction ◽

Atrial Fibrillation ◽

Acute Myocardial Infarction ◽

Ischemic Stroke ◽

Hazard Ratio ◽

Adjusted Hazard Ratio ◽

Risk Of Death ◽

Increased Risk ◽

History Of

Abstract Background In patients with acute myocardial infarction (AMI), history of atrial fibrillation (AF) and new onset AF during the early phase may be associated with a worse prognosis. Whether both conditions are associated with a similar risk of stroke and should be similarly managed is a matter of debate. Methods Based on the administrative hospital-discharge database, we collected information for all patients treated with AMI between 2010 and 2019 in France. The adverse outcomes were investigated during follow-up. Results Among 797,212 patients with STEMI or NSTEMI, 146,922 (18.4%) had history of AF, and 11,824 (1.5%) had new AF diagnosed between day 1 and day 30 after AMI. Patients with new AF were older and had more comorbidities than those with no AF but were younger and had less comorbidities than those with history of AF. Both groups with history of AF or new AF had less frequent STEMI and anterior MI, less frequent use of percutaneous coronary intervention but more frequent HF at the acute phase than patients with no AF. During follow-up (mean [SD] 1.8 [2.4] years, median [interquartile range] 0.7 [0.1–3.1] years), 163,845 deaths and 20,168 ischemic strokes were recorded. Using Cox multivariable analysis, compared to patients with no AF, history of AF was associated with a higher risk of death during follow-up (adjusted hazard ratio HR 1.06 95% CI 1.05–1.08) while this was not the case for patients with new AF (adjusted HR 0.98 95% CI 0.95–1.02). By contrast, both history of AF and new AF were associated with a higher risk of ischemic stroke during follow-up compared to patients with no AF: adjusted hazard ratio HR 1.29 95% CI 1.25–1.34 for history of AF, adjusted HR 1.72 95% CI 1.59–1.85 for new AF. New AF was associated with a higher risk of ischemic stroke than history of AF (adjusted HR 1.38 95% CI 1.27–1.49). Conclusion In a large and systematic nationwide analysis, AF first recorded in the first 30 days after AMI was associated with an increased risk of ischemic stroke. Specific management should be considered in order to improve outcomes in these patients after AMI. Funding Acknowledgement Type of funding source: None

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Occupational Class Differences in Outcomes After Ischemic Stroke: A Prospective Observational Study

10.21203/rs.3.rs-292925/v1 ◽

2021 ◽

Author(s):

Yinwei Zhu ◽

Yaling Lu ◽

Mo Zhou ◽

Ping Huang ◽

Peipei Zhang ◽

...

Keyword(s):

Ischemic Stroke ◽

Cardiovascular Events ◽

White Collar ◽

Hazard Ratio ◽

Adjusted Hazard Ratio ◽

Blue Collar ◽

Occupational Class ◽

Blue Collar Workers ◽

All Cause Mortality ◽

White Collar Workers

Abstract Background Occupational class is an integral part of socioeconomic status. The studies focused on the occupational difference in ischemic stroke outcome in a Chinese population are limited. We aimed to investigate the associations between occupational class and the prognosis of patients with ischemic stroke in China. Methods We included 1484 ischemic stroke participants (mean age: 63.42 ± 11.26 years) from the prospective cohort study: Infectious Factors, Inflammatory Markers, and Prognosis of Acute Ischemic Stroke (IIPAIS). Occupational class was categorized into white-collar workers, blue-collar workers and farmers in our study. Study outcomes were cardiovascular events, all-cause mortality and the composite outcome of cardiovascular events and all-cause mortality within 12 months after ischemic stroke onset. We applied Cox proportional hazard model to evaluate the associations between the occupational class and study outcomes after ischemic stroke. Results Within 12 months after ischemic stroke, there were 106 (7.5%) cardiovascular events, 69 (4.9%) all-cause deaths and 155 (10.4%) composite outcomes. The Kaplan–Meier plots showed that white-collar workers had highest risk of cardiovascular events after 12-month follow-up (Log-rank P = 0.02). Multivariate adjusted hazard ratio and 95% confidence intervals (CIs) of farmers versus white-collar workers was 0.57 (95% CIs, 0.34–0.96) for cardiovascular events. No significant difference showed in blue-collar workers versus white-collar workers, with fully adjusted hazard ratio 0.74 (95% CIs, 0.47–1.18). Conclusions Compared with white-collar workers, farmers are associated with less risk of cardiovascular events at 12 months after ischemic stroke, while there are no significant differences in blue-collar workers.

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Use of Statins After Ischemic Stroke in Young Adults and Its Association With Long-Term Outcome

Stroke ◽

10.1161/strokeaha.119.026992 ◽

2019 ◽

Vol 50 (12) ◽

pp. 3385-3392 ◽

Cited By ~ 10

Author(s):

Myrna Marita Elisabeth van Dongen ◽

Karoliina Aarnio ◽

Nicolas Martinez-Majander ◽

Jani Pirinen ◽

Juha Sinisalo ◽

...

Keyword(s):

Young Adults ◽

Ischemic Stroke ◽

Propensity Score ◽

Lower Risk ◽

Recurrent Stroke ◽

Hazard Ratio ◽

Vascular Events ◽

Preventive Medication ◽

All Cause Mortality

Background and Purpose— Knowledge of the use of secondary preventive medication in young adults is limited. We studied the use of statins and its association with subsequent vascular events in young adults with ischemic stroke—a patient group with a known low burden of atherosclerosis. Methods— The study population included 935 first-ever 30-day ischemic stroke survivors aged 15 to 49 years from the Helsinki Young Stroke Registry, 1994 to 2007. Follow-up data until 2012 were obtained from the Social Insurance Institution of Finland (Drug Prescription Register), the Finnish Care Register, and Statistics Finland. The association of the use of statins (defined as at least 2 purchases) with all-cause mortality, recurrent stroke, and other recurrent vascular events was assessed through adjusted Cox regression analyses. We further compared propensity score–matched statin users with nonusers. Results— Of our 935 patients, 46.8% used statins at some point during follow-up. Higher age, dyslipidemia, heavy alcohol use, and hypertension were significantly associated with purchasing statins. Statin users exhibited lower risk of all-cause mortality (hazard ratio, 0.38 [95% CI, 0.25–0.58]) and recurrent stroke (hazard ratio, 0.29 [95% CI, 0.19–0.44]) than nonusers, after adjustment for dyslipidemia, stroke subtype, and other confounders. These results remained unchanged after propensity score–matched comparison. Conclusions— Less than half of young ischemic stroke patients used statins; use was affected by age and risk factor profile. Statin use was independently associated with lower risk of all-cause mortality and recurrent stroke.

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Comparative study of intracranial access in thrombectomy using next generation 0.088 inch guide catheter technology

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2021-017341 ◽

2021 ◽

pp. neurintsurg-2021-017341

Author(s):

Devin V Bageac ◽

Blake S Gershon ◽

Jan Vargas ◽

Maxim Mokin ◽

Zeguang Ren ◽

...

Keyword(s):

Primary Outcome ◽

Primary Outcome Measure ◽

Secondary Outcome ◽

Control Group ◽

Anterior Circulation ◽

Guide Catheter ◽

Catheter Failure ◽

Catheter Technology ◽

Intracranial Vasculature

BackgroundMost conventional 0.088 inch guide catheters cannot safely navigate intracranial vasculature. The objective of this study is to evaluate the safety of stroke thrombectomy using a novel 0.088 inch guide catheter designed for intracranial navigation.MethodsThis is a multicenter retrospective study, which included patients over 18 years old who underwent thrombectomy for anterior circulation large vessel occlusions. Technical outcomes for patients treated using the TracStar Large Distal Platform (TracStar LDP) or earlier generation TRX LDP were compared with a matched cohort of patients treated with other commonly used guide catheters. The primary outcome measure was device-related complications. Secondary outcome measures included guide catheter failure and time between groin puncture and clot engagement.ResultsEach study arm included 45 patients. The TracStar group was non-inferior to the control group with regard to device-related complications (6.8% vs 8.9%), and the average time to clot engagement was 8.89 min shorter (14.29 vs 23.18 min; p=0.0017). There were no statistically significant differences with regard to other technical outcomes, including time to recanalization (modified Thrombolysis In Cerebral Infarction (mTICI) ≥2B). The TracStar was successfully advanced into the intracranial internal carotid artery in 33 cases (73.33%); in three cases (6.67%), it was swapped for an alternate catheter. Successful reperfusion (mTICI 2B-3) was achieved in 95.56% of cases. Ninety-day follow-up data were available for 86.67% of patients, among whom 46.15% had an modified Rankin Score of 0–2%, and 10.26% were deceased.ConclusionsTracstar LDP is safe for use during stroke thrombectomy and was associated with decreased time to clot engagement. Intracranial access was regularly achieved.

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Left atrial functional assessment and mortality in patients with severe aortic stenosis with sinus rhythm

Cardiovascular Ultrasound ◽

10.1186/s12947-020-00231-0 ◽

2021 ◽

Vol 19 (1) ◽

Author(s):

João Ferreira ◽

Valdirene Gonçalves ◽

Patrícia Marques-Alves ◽

Rui Martins ◽

Sílvia Monteiro ◽

...

Keyword(s):

Aortic Valve ◽

Left Atrial ◽

Primary Outcome ◽

Severe Aortic Stenosis ◽

Heart Team ◽

Pump Function ◽

Volumetric Assessment ◽

All Cause Mortality ◽

Echocardiography Laboratory

Abstract Background Aortic valve stenosis (AS) is the most common primary valvular heart disease leading to surgical or percutaneous aortic valve replacement (AVR) in Europe and its prevalence keeps growing. While other risk factors in severe AS are well documented, little is known about the prognostic value of left atrial (LA) function in AS. Our aim is to clarify the relationship between LA function measured at severe AS diagnosis (evaluated by means of volumetric assessment) and all-cause mortality during follow-up. Methods We retrospectively evaluated patients diagnosed with severe AS for the first time at our echocardiography laboratory. We evaluated LA reservoir, conduit and pump function by measuring LA volumes at different timings of cardiac cycle. Treatment strategy was decided according to heart team consensus and patient decision. We divided patients into groups according to terciles of LA reservoir, conduit and pump function. Primary outcome was defined by the occurrence of all-cause mortality during follow-up. Results A total of 408 patients were included in the analysis, with a median follow-up time of 45 months (interquartile range 54 months). 57.9% of patients underwent AVR and 44.9% of patients registered the primary outcome during follow-up. Left atrial emptying fraction (LAEF) was the best LA functional parameter and the best overall parameter in discriminating primary outcome (AUC 0.845, 95%CI 0.81–0.88, P < 0.001). After adjustment for clinical, demographic and echocardiographic variables, cumulative survival of patients with LAEF < 37% and LAEF 37 to 53% relative to patients with LAEF ≥54% remained significantly lower (HR 13.91, 95%CI 6.20–31.19, P < 0.001 and HR 3.40, 95%CI 1.57–7.37, P = 0.002, respectively). After adjustment for AVR, excess risk of LAEF < 37% and LAEF 37 to 53% relative to LAEF ≥54% remained significant (HR 11.71, 95%CI 5.20–26.40, P < 0.001 and HR 3.59, 95%CI 1.65–7.78, P = 0.001, respectively). Conclusions In patients with a first diagnosis of severe AS, LA function, evaluated by means of volumetric assessment, is an independent predictor of all-cause mortality and a more potent predictor of death compared to classical severity parameters. These data can be useful to identify high-risk patients who might benefit of AVR.

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Using Ultrasound and Inflammation to Improve Prediction of Ischemic Stroke: A Secondary Analysis of the Multi-Ethnic Study of Atherosclerosis

Cerebrovascular Diseases Extra ◽

10.1159/000514373 ◽

2021 ◽

pp. 37-43

Author(s):

Hediyeh Baradaran ◽

Alen Delic ◽

Ka-Ho Wong ◽

Nazanin Sheibani ◽

Matthew Alexander ◽

...

Keyword(s):

Ischemic Stroke ◽

Goodness Of Fit ◽

Primary Outcome ◽

Stroke Risk ◽

Secondary Analysis ◽

Predictor Variables ◽

Baseline Model ◽

Fit Statistics ◽

Ischemic Stroke Risk

Introduction: Current ischemic stroke risk prediction is primarily based on clinical factors, rather than imaging or laboratory markers. We examined the relationship between baseline ultrasound and inflammation measurements and subsequent primary ischemic stroke risk. Methods: In this secondary analysis of the Multi-Ethnic Study of Atherosclerosis (MESA), the primary outcome is the incident ischemic stroke during follow-up. The predictor variables are 9 carotid ultrasound-derived measurements and 6 serum inflammation measurements from the baseline study visit. We fit Cox regression models to the outcome of ischemic stroke. The baseline model included patient age, hypertension, diabetes, total cholesterol, smoking, and systolic blood pressure. Goodness-of-fit statistics were assessed to compare the baseline model to a model with ultrasound and inflammation predictor variables that remained significant when added to the baseline model. Results: We included 5,918 participants. The primary outcome of ischemic stroke was seen in 105 patients with a mean follow-up time of 7.7 years. In the Cox models, we found that carotid distensibility (CD), carotid stenosis (CS), and serum interleukin-6 (IL-6) were associated with incident stroke. Adding tertiles of CD, IL-6, and categories of CS to a baseline model that included traditional clinical vascular risk factors resulted in a better model fit than traditional risk factors alone as indicated by goodness-of-fit statistics. Conclusions: In a multiethnic cohort of patients without cerebrovascular disease at baseline, we found that CD, CS, and IL-6 helped predict the occurrence of primary ischemic stroke. Future research could evaluate if these basic ultrasound and serum measurements have implications for primary prevention efforts or clinical trial inclusion criteria.

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Routine colonoscopy may be needed for uncomplicated acute right colonic diverticulitis

BMC Gastroenterology ◽

10.1186/s12876-021-01672-1 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Kil-yong Lee ◽

Jaeim Lee ◽

Youn Young Park ◽

Seong Taek Oh

Keyword(s):

Computed Tomography ◽

Colon Cancer ◽

Detection Rate ◽

Primary Outcome ◽

Advanced Adenoma ◽

Secondary Outcome ◽

Colonic Diverticulitis ◽

Right Colon ◽

Colon Diverticulitis

Abstract Background Routine colonoscopy is recommended to determine the coexistence of colon cancer after medical treatment for colon diverticulitis. However, in the case of uncomplicated diverticulitis diagnosed by computed tomography, the clinical relevance of routine follow-up colonoscopy has recently been debated. Yet, the role of follow-up colonoscopy for right colon diverticulitis, which tends to develop at a younger age than left colon diverticulitis, has not been specifically evaluated. Therefore, we aimed to evaluate the incidence of right colon cancer or colonic adenomatous polyps, detected by routine colonoscopy, after conservative management of acute uncomplicated right colon diverticulitis. Methods Patients with uncomplicated right colon diverticulitis (modified Hinchey stage Ia) diagnosed by computed tomography imaging, between 2011 and 2017, and who underwent follow-up colonoscopy surveillance after treatment were included. The primary outcome was the incidence of colon cancer, with the detection rate of adenoma being the secondary outcome. Information for analysis was retrieved retrospectively from patients’ medical records. Results The study group included 330 consecutive patients, with a mean age of 41.9 years, and 51.9% being men. For the primary outcome, the rate of colon cancer on follow-up colonoscopy was 0.3% (1/330 cases). The rate of adenoma detection was 20.9% (69/330 cases) and advanced adenoma (> 10 mm in diameter; or exhibiting a > 25% villous component or severe dysplasia), including colon cancer, was observed in 9 patients (2.7%). Conclusions In patients with acute uncomplicated right colonic diverticulitis, routine colonoscopy after conservative treatment may be necessary because although the colon cancer detection rate is low, it is possible to detect advanced colon adenoma.

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Canadian Registry of Electronic Device Outcomes: remote monitoring outcomes in the Abbott battery performance alert—a multicentre cohort

EP Europace ◽

10.1093/europace/euab025 ◽

2021 ◽

Author(s):

Sharath Kumar ◽

Jason Davis ◽

Bernard Thibault ◽

Iqwal Mangat ◽

Benoit Coutu ◽

...

Keyword(s):

Remote Monitoring ◽

Primary Outcome ◽

Electronic Device ◽

Electronic Devices ◽

Cardiac Resynchronization ◽

Device Performance ◽

Cardiac Implantable Electronic Devices ◽

All Cause Mortality ◽

Multicentre Cohort

Abstract Aims Cardiac implantable electronic devices with device advisories have the potential of device malfunction. Remote monitoring (RM) of devices has been suggested to allow the identification of abnormal device performance and permit early intervention. We sought to describe the outcomes of patients with and without RM in devices subject to the Abbott Premature Battery Depletion (PBD) advisory with data from a Canadian registry. Methods and results Patients with an Abbott device subject to the PBD advisory from nine implantable cardioverter defibrillator (ICD) implanting centres in Canada were included in the registry. The use of RM was identified from baseline and follow-up data in the registry. The primary outcome was detection of PBD and all-cause mortality. A total of 2666 patients were identified with a device subject to the advisory. In all, 1687 patients (63.2%) had RM at baseline. There were 487 deaths during follow-up. At a mean follow-up of 5.7 ± 0.7 years, mortality was higher in those without a remote monitor compared with RM at baseline (24.7% vs. 14.5%; P < 0.001). Pre-mature battery depletion was identified in 36 patients (2.1%) with RM vs. 7 (0.7%) without RM (P = 0.004). Time to battery replacement was significantly reduced in patients on RM (median 5 vs. 13 days, P = 0.001). Conclusion The use of RM in patients with ICD and cardiac resynchronization therapy under advisory improved detection of PBD, time to device replacement, and was associated with a reduction in all-cause mortality. The factors influencing the association with mortality are unknown and deserve further study.

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