scholarly journals Association between cardiometabolic disease multimorbidity and all-cause mortality in 2 million women and men registered in UK general practices

BMC Medicine ◽  
2021 ◽  
Vol 19 (1) ◽  
Author(s):  
Dexter Canoy ◽  
Jenny Tran ◽  
Mariagrazia Zottoli ◽  
Rema Ramakrishnan ◽  
Abdelaali Hassaine ◽  
...  

Abstract Background Myocardial infarction (MI), stroke and diabetes share underlying risk factors and commonalities in clinical management. We examined if their combined impact on mortality is proportional, amplified or less than the expected risk separately of each disease and whether the excess risk is explained by their associated comorbidities. Methods Using large-scale electronic health records, we identified 2,007,731 eligible patients (51% women) and registered with general practices in the UK and extracted clinical information including diagnosis of myocardial infarction (MI), stroke, diabetes and 53 other long-term conditions before 2005 (study baseline). We used Cox regression to determine the risk of all-cause mortality with age as the underlying time variable and tested for excess risk due to interaction between cardiometabolic conditions. Results At baseline, the mean age was 51 years, and 7% (N = 145,910) have had a cardiometabolic condition. After a 7-year mean follow-up, 146,994 died. The sex-adjusted hazard ratios (HR) (95% confidence interval [CI]) of all-cause mortality by baseline disease status, compared to those without cardiometabolic disease, were MI = 1.51 (1.49–1.52), diabetes = 1.52 (1.51–1.53), stroke = 1.84 (1.82–1.86), MI and diabetes = 2.14 (2.11–2.17), MI and stroke = 2.35 (2.30–2.39), diabetes and stroke = 2.53 (2.50–2.57) and all three = 3.22 (3.15–3.30). Adjusting for other concurrent comorbidities attenuated these estimates, including the risk associated with having all three conditions (HR = 1.81 [95% CI 1.74–1.89]). Excess risks due to interaction between cardiometabolic conditions, particularly when all three conditions were present, were not significantly greater than expected from the individual disease effects. Conclusion Myocardial infarction, stroke and diabetes were associated with excess mortality, without evidence of any amplification of risk in people with all three diseases. The presence of other comorbidities substantially contributed to the excess mortality risks associated with cardiometabolic disease multimorbidity.

2020 ◽  
Author(s):  
Kun He ◽  
Wenli Zhang ◽  
Xueqi Hu ◽  
Hao Zhao ◽  
Bingxin Guo ◽  
...  

Abstract Background: Previous studies have evaluated the association of multimorbidity with higher mortality, but epidemiologic data on the association between the combination of multimorbidity and all-cause mortality risk are rare. We aimed to examine the relationship between multimorbidity (number/combination) and all-cause mortality in Chinese older adults. Methods: We conducted a population-based study of 50,100 Chinese participants. Cox regression models were used to estimate the impact of long-term conditions (LTCs) on all-cause mortality. Results: The prevalence of multimorbidity was 31.35% and all-cause mortality was 8.01% (50,100 participants). In adjusted Cox models, the hazard rations (HRs) and 95% confidence intervals (CIs) of all-cause mortality risk for those with 1, 2, and ≥ 3 LTCs compared with those with no LTCs was 1.10 (1.01-1.20), 1.21 (1.10-1.33), and 1.46 (1.27-1.67), respectively (Ptrend <0.001). In the LTCs ≥ 2 category, the combination of chronic diseases that included hypertension, diabetes, CHD, COPD, and stroke had the greatest impact on mortality. In the stratified model by age and sex, absolute all-cause mortality was higher among the ≥ 75 age group with an increasing number of LTCs. However, the relative effect size of the increasing number of LTCs on higher mortality risk was larger among those < 75 years.Conclusions: The risk of all-cause mortality is increased with the number of multimorbidity among Chinese older adults, particularly combinations.


2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
D Canoy ◽  
M Zottoli ◽  
J Tran ◽  
R Ramakrishnan ◽  
A Hasseine ◽  
...  

Abstract Background Myocardial infarction (MI), stroke and diabetes are separately associated with increased risk of mortality but it is uncertain if their combined effects are proportional, amplified or less than the expected risk of each disease individually. In addition, patients with these conditions tend to also have other long-term comorbidities. How the relationship between cardiometabolic disease and risk of death is modified by the presence of comorbidity is unclear. Purpose We investigated the separate and combined effects of MI, stroke and diabetes on all-cause mortality, and examined the impact of comorbidity on these associations. Methods We selected a patient cohort of 2,007,731 (51% women) aged ≥16 years at registration with their general practice, using large-scale UK primary care electronic health records that were linked to the national death registry. We identified patients with a recorded diagnosis of MI, stroke, diabetes or none before 2005 (baseline), and classified the patient cohort into mutually exclusive categories of their baseline disease status. For each group, we also extracted information on another major 53 long-term conditions prior to baseline. The cohort was followed until death, deregistration from the practice or censored at the end of study (31 Dec 2014). We used Cox regression, and tested for departure from additivity and multiplicativity to assess interaction. Results At baseline, the mean age of the cohort was 51 (SD=18) years and 7% (N=145,910) had a cardiometabolic disease. Over an average follow-up of 7 (SD=3) years, 270,036 died (mean age of death=79 years). After adjusting for baseline age and sex, the hazard ratio (HR) (95% confidence interval [CI]), relative to those without cardiometabolic disease, were as follows: diabetes=1.53 (1.51 to 1.55), MI=1.54 (1.51 to 1.56), stroke=1.87 (1.84 to 1.90), diabetes and MI=2.16 (2.09 to 2.23), MI and stroke=2.39 (2.28 to 2.49), diabetes and stroke=2.56 (2.47 to 2.65), and all three=3.17 (2.95 to 3.41). After adjusting for the 53 comorbidities, the HR (95% CI) were attenuated: diabetes=1.37 (1.35 to 1.39), MI=1.25 (1.23 to 1.27), stroke=1.49 (1.46 to 1.52), diabetes and MI=1.60 (1.55 to 1.65), MI and stroke=1.52 (1.45 to 1.59), diabetes and stroke=1.91 (1.84 to 1.98), and all three=1.77 (1.64 to 1.91). The results did not materially changed with adjustment for smoking and deprivation level. Test for interaction revealed some minor synergistic effects when cardiometabolic disease co-occurred but excess risks were lower than expected for two combined vs individual disease effects; no significant interaction was seen for all three vs individual disease effects. Conclusion MI, stroke and diabetes are associated with excess mortality, which was partly due to associated chronic conditions. We found no evidence that the co-occurrence of these three conditions contribute to a higher excess mortality than expected from each of them separately. Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): NIHR Oxford Biomedical Research Centre; Oxford Martin School, University of Oxford


2017 ◽  
Vol 210 (5) ◽  
pp. 356-361 ◽  
Author(s):  
Jens Sundbøll ◽  
Morten Schmidt ◽  
Kasper Adelborg ◽  
Lars Pedersen ◽  
Hans Erik Bøtker ◽  
...  

BackgroundThe prognostic impact of previous depression on myocardial infarction survival remains poorly understood.AimsTo examine the association between depression and all-cause mortality following myocardial infarction.MethodUsing Danish medical registries, we conducted a nationwide population-based cohort study. We included all patients with first-time myocardial infarction (1995–2014) and identified previous depression as either a depression diagnosis or use of antidepressants. We used Cox regression to compute adjusted mortality rate ratios (aMRRs) with 95% confidence intervals.ResultsWe identified 170 771 patients with first-time myocardial infarction. Patients with myocardial infarction and a previous depression diagnosis had higher 19-year mortality risks (87% v. 78%). The overall aMRR was 1.11 (95% CI 1.07–1.15) increasing to 1.22 (95% CI 1.17–1.27) when including use of antidepressants in the depression definition.ConclusionsA history of depression was associated with a moderately increased all-cause mortality following myocardial infarction.


Author(s):  
Jessica Schubert ◽  
Bertil Lindahl ◽  
Håkan Melhus ◽  
Henrik Renlund ◽  
Margrét Leosdottir ◽  
...  

Abstract Aims Clinical trials have demonstrated that a reduction in low-density lipoprotein cholesterol (LDL-C) reduces cardiovascular (CV) events. This has, however, not yet been shown in a real-world setting. We aimed to investigate the association between LDL-C changes and statin intensity with prognosis after a myocardial infarction (MI). Methods and results Patients admitted with MI were followed for mortality and major CV events. Changes in LDL-C between the MI and a 6- to 10-week follow-up visit were analysed. The associations between quartiles of LDL-C change and statin intensity with outcomes were assessed using adjusted Cox regression analyses. A total of 40 607 patients were followed for a median of 3.78 years. The median change in LDL-C was a 1.20 mmol/L reduction. Patients with larger LDL-C reduction (1.85 mmol/L, 75th percentile) compared with a smaller reduction (0.36 mmol/L, 25th percentile) had lower hazard ratios (HR) for all outcomes (95% confidence interval): composite of CV mortality, MI, and ischaemic stroke 0.77 (0.70–0.84); all-cause mortality 0.71 (0.63–0.80); CV mortality 0.68 (0.57–0.81); MI 0.81 (0.73–0.91); ischaemic stroke 0.76 (0.62–0.93); heart failure hospitalization 0.73 (0.63–0.85), and coronary artery revascularization 0.86 (0.79–0.94). Patients with ≥50% LDL-C reduction using high-intensity statins at discharge had a lower incidence of all outcomes compared with those using a lower intensity statin. Conclusions Larger early LDL-C reduction and more intensive statin therapy after MI were associated with a reduced hazard of all CV outcomes and all-cause mortality. This supports clinical trial data suggesting that earlier lowering of LDL-C after an MI confers the greatest benefit.


2017 ◽  
Vol 13 (1) ◽  
pp. 91-99 ◽  
Author(s):  
Bethany J. Foster ◽  
Mark M. Mitsnefes ◽  
Mourad Dahhou ◽  
Xun Zhang ◽  
Benjamin L. Laskin

Background and objectivesIndividuals with ESRD have a very high risk of death. Although mortality rates have decreased over time in ESRD, it is unknown if improvements merely reflect parallel increases in general population survival. We, therefore, examined changes in the excess risk of all-cause mortality—over and above the risk in the general population—among people treated for ESRD in the United States from 1995 to 2013. We hypothesized that the magnitude of change in the excess risk of death would differ by age and RRT modality.Design, setting, participants, & measurementsWe used time-dependent relative survival models including data from persons with incident ESRD as recorded in the US Renal Data System and age-, sex-, race-, and calendar year–specific general population mortality rates from the Centers for Disease Control and Prevention. We calculated relative excess risks (analogous to hazard ratios) to examine the association between advancing calendar time and the primary outcome of all-cause mortality.ResultsWe included 1,938,148 children and adults with incident ESRD from 1995 to 2013. Adjusted relative excess risk per 5-year increment in calendar time ranged from 0.73 (95% confidence interval, 0.69 to 0.77) for 0–14 year olds to 0.88 (95% confidence interval, 0.88 to 0.88) for ≥65 year olds, meaning that the excess risk of ESRD-related death decreased by 12%–27% over any 5-year interval between 1995 and 2013. Decreases in excess mortality over time were observed for all ages and both during treatment with dialysis and during time with a functioning kidney transplant (year by age and year by renal replacement modality interactions were both P<0.001), with the largest relative improvements observed for the youngest persons with a functioning kidney transplant. Absolute decreases in excess ESRD-related mortality were greatest for the oldest persons.ConclusionsThe excess risk of all-cause mortality among people with ESRD, over and above the risk in the general population, decreased significantly between 1995 and 2013 in the United States.


2020 ◽  
Vol 9 (12) ◽  
pp. 3952
Author(s):  
Elias Haj-Yehia ◽  
Robert Werner Mertens ◽  
Florian Kahles ◽  
Marcia Viviane Rückbeil ◽  
Matthias Rau ◽  
...  

Aims: Recent studies have found circulating concentrations of the gastrointestinal hormone GLP-1 to be an excellent predictor of cardiovascular risk in patients with myocardial infarction. This illustrates a yet not appreciated crosstalk between the gastrointestinal and cardiovascular systems, which requires further investigation. The gut-derived hormone Peptide YY (PYY) is secreted from the same intestinal L-cells as GLP-1. Relevance of PYY in the context of cardiovascular disease has not been explored. In this study, we aimed to investigate PYY serum concentrations in patients with acute myocardial infarction and to evaluate their association with cardiovascular events. Material and Methods: PYY levels were assessed in 834 patients presenting with acute myocardial infarction (553 Non-ST-Elevation Myocardial Infarction (NSTEMI) and 281 ST-Elevation Myocardial Infarction (STEMI)) at the time of hospital admission. The composite outcomes of first occurrence of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke (3-P-MACE), and all-cause mortality were assessed with a median follow-up of 338 days. Results: PYY levels were significantly associated with age and cardiovascular risk factors, including hypertension, diabetes, and kidney function in addition to biomarkers of heart failure (NT-pro BNP) and inflammation (hs-CRP). Further, PYY was significantly associated with 3-P-MACE (HR: 1.7; 95% CI: 1–2.97; p = 0.0495) and all-cause mortality (HR: 2.69; 95% CI: 1.61–4.47; p = 0.0001) by univariable Cox regression analyses, which was however lost after adjusting for multiple confounders. Conclusions: PYY levels are associated with parameters of cardiovascular risk as well as cardiovascular events and mortality in patients presenting with acute myocardial infarction. However, this significant association is lost after adjustment for further confounders.


2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
J Lopez Pais ◽  
M J Espinosa Pascual ◽  
B Izquierdo Coronel ◽  
D Galan Gil ◽  
B Alcon Duran ◽  
...  

Abstract Background Despite all the recent publications, including new guidelines, myocardial infarction with non-obstructive coronary arteries (MINOCA) is still a controversy “working diagnosis”. MINOCA patients have a characteristic risk profile, with a lower prevalence of classical risk factors (CVRF). The aim of this study is to analyze the relationship between known proinflammatory conditions and MINOCA. Methods Analytical and observational study developed in a University Hospital, which covers 220.000 individuals. We analyzed data of 109 consecutive MINOCA patients admitted to our center during a 3 years period (2016–2018). We used the definitions and the clinical management of the 2016 European Society of Cardiology Working Group Position Paper on MINOCA. The composite of proinflammatory conditions (PIC) includes vasculitis and other autoimmune pathologies; connective tissue diseases, the presence of active cancer and the fact of presenting the myocardial infarction as a complication during admission for a non-cardiovascular pathology. Follow up analysis included death from any cause and major adverse cardiovascular events (MACE). Survival analysis is based on Cox regression and represented by Kaplan Meier curves. Median follow up was 17 months. Results Around one-third of the MINOCA patients had PIC (34.8%). They tended to be older (67.9±14 vs 62.8±15, p 0.08), with no differences in rate of female sex (55.3 vs 49.3%, p 0.55) neither in traditional CVRF: Tobacco (40.5 vs 42.6%), diabetes (18.4 vs 26.8%), dyslipidaemia (39.5 vs 48.6%) or hypertension (55.3 vs 64.8%). Patients with PIC had a higher proportion of ischemic ECG at presentation (75.7 vs 53.5%, p 0.03), a tendency to worse ejection fraction (45.9 vs 28.2%, p 0.07) and higher in-hospital mortality (2.6 vs 0.0%, p 0.17). Levels of troponin were similar (4.0±6.0 vs 6.6±10.4, p 0.2) During follow-up (Figure 1), PIC was related to a higher all-cause-mortality (16.2 vs 1.5%, Hazard Ratio (HR) 10.7 (95% Confidence Interval [CI]: 1.3–89.0, p 0.03). Patients with PIC also showed a non-significant higher cardiovascular mortality (5.3 vs 1.4%, HR 3.5 [CI: 0.3–38.5], p 0.3) and higher rate of MACE (13.5 vs 9.2%, HR 1.6 [CI: 0.5–5.1], p 0.4). Conclusion In this study, MINOCA patients had a high prevalence of PIC, being present in more than one-third of them. They are linked to worse prognosis, with higher all-cause mortality and a non-significant increase in cardiovascular mortality and MACE, which could be significant with the appropriate number of patients.


Open Heart ◽  
2020 ◽  
Vol 7 (2) ◽  
pp. e001286
Author(s):  
Rubina Attar ◽  
Axel Wester ◽  
Sasha Koul ◽  
Svend Eggert ◽  
Christoffer Polcwiartek ◽  
...  

BackgroundPatients with schizophrenia are a high-risk population due to higher prevalences of cardiovascular risk factors and comorbidities that contribute to shorter life expectancy.PurposeTo investigate patients with and without schizophrenia experiencing an acute myocardial infarction (AMI) in relation to guideline recommended in-hospital management, discharge medications and 5-year major adverse cardiac events (MACE: composite of all-cause mortality, rehospitalisation for reinfarction, stroke or heart failure).MethodsAll patients with schizophrenia who experienced AMI during 2000–2018 were identified (n=1008) from the nationwide Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies registry and compared with AMI patients without schizophrenia (n=2 85 325). Kaplan-Meier survival curves and multivariable Cox regression models were used to compare the populations.ResultsPatients with schizophrenia presented with AMI approximately 10 years earlier (median age 64 vs 73 years), and had higher prevalences of diabetes, heart failure and chronic obstructive pulmonary disease. They were less likely to be invasively investigated or discharged with aspirin, P2Y12 inhibitors, ACE inhibitors/angiotensin II receptor blockers, beta-blockers and statins (all p<0.005). AMI patients with schizophrenia had higher adjusted risk of MACE (aHR=2.05, 95% CI 1.63 to 2.58), mortality (aHR=2.38, 95% CI 1.84 to 3.09) and hospitalisation for heart failure (aHR=1.39, 95% CI 1.04 to 1.86) compared with AMI patients without schizophrenia.ConclusionPatients with schizophrenia experienced an AMI almost 10 years earlier than patients without schizophrenia. They less often underwent invasive procedures and were less likely to be treated with guideline recommended medications at discharge, and had more than doubled risk of MACE and all-cause mortality. Improved primary and secondary preventive measures, including adherence to guideline recommendations, are warranted and may improve outcome.


2020 ◽  
Vol 9 (20) ◽  
Author(s):  
Cosme García‐García ◽  
Teresa Oliveras ◽  
Jordi Serra ◽  
Joan Vila ◽  
Ferran Rueda ◽  
...  

Background Coronary artery disease remains a major cause of death despite better outcomes of ST‐segment–elevation myocardial infarction (STEMI). We aimed to analyze data from the Ruti‐STEMI registry of in‐hospital, 28‐day, and 1‐year events in patients with STEMI over the past 3 decades in Catalonia, Spain, to assess trends in STEMI prognosis. Methods and Results Between February 1989 and December 2017, a total of 7589 patients with STEMI were admitted consecutively. Patients were grouped into 5 periods: 1989 to 1994 (period 1), 1995 to 1999 (period 2), 2000 to 2004 (period 3), 2005 to 2009 (period 4), and 2010 to 2017 (period 5). We used Cox regression to compare 28‐day and 1‐year STEMI mortality and in‐hospital complication trends across these periods. Mean patient age was 61.6±12.6 years, and 79.3% were men. The 28‐day all‐cause mortality declined from period 1 to period 5 (10.4% versus 6.0%; P <0.001), with a 40% reduction after multivariable adjustment (hazard ratio [HR], 0.6; 95% CI, 0.46–0.80; P <0.001). One‐year all‐cause mortality declined from period 1 to period 5 (11.7% versus 9.0%; P =0.001), with a 24% reduction after multivariable adjustment (HR, 0.76; 95% CI, 0.60–0.98; P =0.036). A significant temporal reduction was observed for in‐hospital complications including postinfarct angina (−78%), ventricular tachycardia (−57%), right ventricular dysfunction (−48%), atrioventricular block (−45%), pericarditis (−63%), and free wall rupture (−53%). Primary ventricular fibrillation showed no significant downslope trend. Conclusions In‐hospital STEMI complications and 28‐day and 1‐year mortality rates have dropped markedly in the past 30 years. Reducing ischemia‐driven primary ventricular fibrillation remains a major challenge.


2021 ◽  
Vol 116 (1) ◽  
Author(s):  
Thomas M. Hofbauer ◽  
Andreas Mangold ◽  
Anna S. Ondracek ◽  
Adelheid Panzenböck ◽  
Thomas Scherz ◽  
...  

AbstractUpon activation, neutrophils release neutrophil extracellular traps (NETs), which contribute to circulating DNA burden and thrombosis, including ST-segment elevation myocardial infarction (STEMI). Deoxyribonuclease (DNase) 1 degrades circulating DNA and NETs. Lower DNase activity correlates with NET burden and infarct size. The DNase 1 Q222R single nucleotide polymorphism (SNP), impairing DNase 1 function, is linked with myocardial infarction. We assessed whether the Q222R SNP is connected to increased NET burden in STEMI and influences long-term outcomes. We enrolled 711 STEMI patients undergoing primary percutaneous coronary intervention (pPCI), and 1422 controls. Genotyping was performed for DNase 1 Q222R SNP. DNase activity, double-stranded (ds)DNA and citrullinated histone H3 were determined in culprit site and peripheral plasma during pPCI. The association of the Q222R variant on cardiovascular and all-cause mortality was assessed by multivariable Cox regression adjusted for cardiovascular risk factors. Homozygous Q222R DNase 1 variant was present in 64 (9.0%) STEMI patients, at the same frequency as in controls. Patients homozygous for Q222R displayed less DNase activity and increased circulating DNA burden. In overall patients, median survival was 60 months. Homozygous Q222R variant was independently associated with cardiovascular and all-cause mortality after STEMI. dsDNA/DNase ratio independently predicted cardiovascular and all-cause mortality. These findings highlight that the Q222R DNase 1 SNP is associated with increased NET burden and decreased compensatory DNase activity, and may serve as an independent risk factor for poor outcome after STEMI.


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