AimsThe objective of the present study is to assess the prognostic value of acute kidney injury (AKI) in the evolution of patients with heart failure (HF) using real-world data. Methods and results Patients with a diagnosis of HF and with serial measurements of renal function collected throughout the study period were included. Estimated glomerular filtration rate (GFR) was calculated with the CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration). AKI was defined when a sudden drop in creatinine with posterior recovery was recorded. According to the Risk, Injury, Failure, Loss, and End-Stage Renal Disease (RIFLE) scale, AKI severity was graded in three categories: risk [1.5-fold increase in serum creatinine (sCr)], injury (2.0-fold increase in sCr), and failure (3.0-fold increase in sCr or sCr > 4.0 mg/dL). AKI incidence and risk of hospitalization and mortality after the first episode were calculated by adjusting for potential confounders. A total of 30 529 patients with HF were included. During an average follow-up of 3.2 years, 5294 AKI episodes in 3970 patients (13.0%) and incidence of 3.3/100 HF patients/year were recorded. One episode was observed in 3161 (10.4%), two in 537 (1.8%), and three or more in 272 (0.9%). They were more frequent in women with diabetes and hypertension. The incidence increases across the GFR levels (Stages 1 to 4: risk 7.6%, 6.8%, 11.3%, and 12.5%; injury 2.1%, 2.0%, 3.3%, and 5.5%; and failure 0.9%, 0.6%. 1.4%, and 8.0%). A total of 3817 patients with acute HF admission were recorded during the follow-up, with incidence of 38.4/100 HF patients/year, 3101 (81.2%) patients without AKI, 545 (14.3%) patients with one episode, and 171 (4.5%) patients with two or more. The number of AKI episodes [one hazard ratio (HR) 1.05 (0.98-1.13); two or more HR 2.01 (1.79-2.25)] and severity [risk HR 1.05 (0.97-1.04); injury HR 1.41 (1.24-1.60); and failure HR 1.90 (1.64-2.20)] increases the risk of hospitalization. A total of 10 560 deaths were recorded, with incidence of 9.3/100 HF patients/year, 8951 (33.7%) of subjects without AKI episodes, 1180 (11.17%) of subjects with one episode, and 429 (4.06%) with two or more episodes. The number of episodes [one HR 1.05 (0.98-1.13); two or more HR 2.01 (1.79-2.25)] and severity [risk 1.05 confidence interval (CI) (0.97-1.14), injury 1.41 (CI 1.24-1.60), and failure 1.90 (CI 1.64-2.20)] increases mortality risk. Conclusions The study demonstrated the worse prognostic value of sudden renal function decline in HF patients and pointed to those with more future risk who require review of treatment and closer follow-up.
Background In contrast with the setting of acute myocardial infarction, there are limited data regarding the impact of diabetes mellitus on clinical outcomes in contemporary cohorts of patients with chronic coronary syndromes. We aimed to investigate the prevalence and prognostic impact of diabetes according to geographical regions and ethnicity. Methods and results CLARIFY is an observational registry of patients with chronic coronary syndromes, enrolled across 45 countries in Europe, Asia, America, Middle East, Australia, and Africa in 2009–2010, and followed up yearly for 5 years. Chronic coronary syndromes were defined by ≥1 of the following criteria: prior myocardial infarction, evidence of coronary stenosis >50%, proven symptomatic myocardial ischaemia, or prior revascularization procedure. Among 32 694 patients, 9502 (29%) had diabetes, with a regional prevalence ranging from below 20% in Northern Europe to ∼60% in the Gulf countries. In a multivariable-adjusted Cox proportional hazards model, diabetes was associated with increased risks for the primary outcome (cardiovascular death, myocardial infarction, or stroke) with an adjusted hazard ratio of 1.28 (95% confidence interval 1.18, 1.39) and for all secondary outcomes (all-cause and cardiovascular mortality, myocardial infarction, stroke, heart failure, and coronary revascularization). Differences on outcomes according to geography and ethnicity were modest. Conclusion In patients with chronic coronary syndromes, diabetes is independently associated with mortality and cardiovascular events, including heart failure, which is not accounted by demographics, prior medical history, left ventricular ejection fraction, or use of secondary prevention medication. This is observed across multiple geographic regions and ethnicities, despite marked disparities in the prevalence of diabetes. ClinicalTrials identifier ISRCTN43070564
Artificial Intelligence is creating a paradigm shift in health care, with phenotyping patients through clustering techniques being one of the areas of interest. Objective: To develop a predictive model to classify heart failure (HF) patients according to their left ventricular ejection fraction (LVEF), by using available data from Electronic Health Records (EHR). Subjects and methods: 2854 subjects over 25 years old with a diagnosis of HF and LVEF, measured by echocardiography, were selected to develop an algorithm to predict patients with reduced EF using supervised analysis. The performance of the developed algorithm was tested in heart failure patients from Primary Care. To select the most influentual variables, the LASSO algorithm setting was used, and to tackle the issue of one class exceeding the other one by a large amount, we used the Synthetic Minority Oversampling Technique (SMOTE). Finally, Random Forest (RF) and XGBoost models were constructed. Results: The full XGBoost model obtained the maximum accuracy, a high negative predictive value, and the highest positive predictive value. Gender, age, unstable angina, atrial fibrillation and acute myocardial infarct are the variables that most influence EF value. Applied in the EHR dataset, with a total of 25,594 patients with an ICD-code of HF and no regular follow-up in cardiology clinics, 6170 (21.1%) were identified as pertaining to the reduced EF group. Conclusion: The obtained algorithm was able to identify a number of HF patients with reduced ejection fraction, who could benefit from a protocol with a strong possibility of success. Furthermore, the methodology can be used for studies using data extracted from the Electronic Health Records.
Aims: This study assessed the impact of acute hemoglobin (Hb) falls in heart failure (HF) patients. Methods: HF patients with repeated Hb values over time were included. Falls in Hb greater than 30% were considered to represent an acute episode of anemia and the risk of hospitalization and all-cause mortality after the first episode was assessed. Results: In total, 45,437 HF patients (54.9% female, mean age 74.3 years) during a follow-up average of 2.9 years were analyzed. A total of 2892 (6.4%) patients had one episode of Hb falls, 139 (0.3%) had more than one episode, and 342 (0.8%) had concomitant acute kidney injury (AKI). Acute heart failure occurred in 4673 (10.3%) patients, representing 3.6/100 HF patients/year. The risk of hospitalization increased with one episode (Hazard Ratio = 1.30, 95% confidence interval (CI) 1.19–1.43), two or more episodes (HR = 1.59, 95% CI 1.14–2.23, and concurrent AKI (HR = 1.61, 95% CI 1.27–2.03). A total of 10,490 patients have died, representing 8.1/100 HF patients/year. The risk of mortality was HR = 2.20 (95% CI 2.06–2.35) for one episode, HR = 3.14 (95% CI 2.48–3.97) for two or more episodes, and HR = 3.20 (95% CI 2.73–3.75) with AKI. In the two or more episodes and AKI groups, Hb levels at the baseline were significantly lower (10.2–11.4 g/dL) than in the no episodes group (12.8 g/dL), and a higher and significant mortality in these subgroups was observed. Conclusions: Hb falls in heart failure patients identified those with a worse prognosis requiring a more careful evaluation and follow-up.
Objective: To assess the impact of hypertension in the risk of cardiovascular events and mortality in a population of diabetic patients from a Mediterranean population based in Real World Evidence. Design and method: The sample was recruited from beneficiaries of the Valencian Health Agency's health care system, with a population of 3799884 people older than 25 years in 2012. The observational study was undertaken as part of routine clinical practice from January 2012 to December 2016. Diabetes was defined as a non-fasting glucose higher or equal to 200 mg/dl, a recorded physician diagnosis, medication use or an HbA1c higher or equal to 6.5%. Hypertension was defined by a recorded physician diagnosis or antihypertensive medication use. Estimated glomerular filtration rate (eGFR) was calculated from calibrated creatinine, age and sex using the CKD-EPI and CKD was defined when eGFR < 60 ml/min/1.73m2. Vital status was determined by matching records and death certificates from the Spanish National Death Index. Results: Among the total population of 3799884, DM was present in 510922 (13%) patients (12% in women and 15% in men), Average of HbA1c was 6.9% + 1.4%. Hypertension was recorded in 387590 (75%) with a rate of BP < 140/90 mmHg of 45% and CKD in 125441 (24%). The incidence rates for DM, with and without diagnostic of HTN, of acute myocardial infarction, heart failure and stroke, as well all-cause mortality by age and sex rates are in the figure, in which the times of increment of risk due to the presence of HTN is presented. Conclusions: Presence of HTN in patients of diabetes largely increases the risk of MI, stroke, HF and all-cause mortality. The impact even it is higher in more younger patients, it still until the last decade of life.
Introduction The objective of this study was to investigate the changes in men’s and women’s measured height in response to weight gain above standards for the U.S. Navy and to quantify associated distortions in body mass index (BMI). We expected that some servicemembers would manipulate their measured height to comply with service standards. Materials and Methods The study was a retrospective observational study. The data were housed in the Person-Event Data Environment, an individual-level administrative registry from the United States Department of Defense. All participants were active-duty U.S. Navy sailors aged 21–50 during the years 2010–2019. The main outcomes were height and weight as recorded during twice-yearly physical fitness assessments and BMI calculated as: height in pounds × 703/(height in inches)2. We assessed whether weight gain above standards was associated with an increase in height at the subsequent height–weight assessment. Results Among the 489,020 sailors, individuals were nearly 1.5 times as likely to measure taller when they gained weight that put them above military height–weight standards as compared to those who continued to remain within standards. Men were more often out of standards and therefore their measured height increased during subsequent assessments more often than women. Increases in height depressed measures of BMI slightly. Conclusions Among U.S. sailors, taller height was correlated with surpassing height-based weight limits, where taller individuals were allowed to weigh more and still meet professional weight standards. Results underscore that current height–weight accountability standards may distort behavior, leading servicemembers to manipulate measurements rather than improve job-relevant fitness. Instead, greater reliance on fitness-based measures of health, such as fitness tests, may hold promise for upholding servicemember readiness. Our results highlight that when stakes are attached to a measure, individuals may work to raise their performance using strategies that are misaligned with the policy intent.
Objective: Hypertension is the most relevant risk factor of mortality over the world. Assessment of the impact has been analysed in a great variety of studies, but the Electronic Health Recordings, including hole populations, provide a more precise information. The objective was to assess the mortality associated to adult hypertensive patients from a Mediterranean population. The associated impact of diabetes (DM) and chronic kidney disease (CKD) has been presented. Design and method: The sample was recruited from beneficiaries of the Valencian Health Agency's health care system, with a population of 3799884 people older than 25 years in 2012. The observational study was undertaken as part of routine clinical practice from 2012 until 2016. Hypertension was defined by a recorded physician diagnosis or antihypertensive medication use. Diabetes was defined as a non-fasting glucose higher or equal to 200 mg/dl, a recorded physician diagnosis, medication use or an HbA1c higher or equal to 6.5%. Estimated glomerular filtration rate (eGFR) was calculated from calibrated creatinine, age and sex using the CKD-EPI and CKD was defined when eGFR <60 ml/min/1.73m2. Participants were followed for all-cause mortality until 31st December 2016. Vital status was determined by matching records and death certificates from the Spanish National Death Index. Results: Among the total population, 1247467 hypertensives were included. Among them, 387590 (%) were diabetics and 272800 (%) CKD. A total de 204629 casualties were recorded (crude rate of 2.2% in the GP and 12% in HTN, 16% in DM and 23% in CKD. Mortality incidence per 10000 patients/year of general population and the hypertensives, in each decade of age and by sex, with and without diabetes and CKD are in the Table. Conclusions: The increment of mortality risk due to the presence of HTN increases in all age groups. Although the higher increment in risk occurs in population beyond 60 yr, the number of subjects in risk largely increases over 60 and extent until the ninety decade. Diabetes, and more CKD, further increases the risk in hypertensive subjects.
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