Claire Rushton

Preeclampsia and Future Cardiovascular Health: A Systematic Review and Meta-Analysis

Background— Preeclampsia is a pregnancy-specific disorder resulting in hypertension and multiorgan dysfunction. There is growing evidence that these effects persist after pregnancy. We aimed to systematically evaluate and quantify the evidence on the relationship between preeclampsia and the future risk of cardiovascular diseases. Methods and Results— We studied the future risk of heart failure, coronary heart disease, composite cardiovascular disease, death because of coronary heart or cardiovascular disease, stroke, and stroke death after preeclampsia. A systematic search of MEDLINE and EMBASE was performed to identify relevant studies. We used random-effects meta-analysis to determine the risk. Twenty-two studies were identified with >6.4 million women including >258 000 women with preeclampsia. Meta-analysis of studies that adjusted for potential confounders demonstrated that preeclampsia was independently associated with an increased risk of future heart failure (risk ratio [RR], 4.19; 95% confidence interval [CI], 2.09–8.38), coronary heart disease (RR, 2.50; 95% CI, 1.43–4.37), cardiovascular disease death (RR, 2.21; 95% CI, 1.83–2.66), and stroke (RR, 1.81; 95% CI, 1.29–2.55). Sensitivity analyses showed that preeclampsia continued to be associated with an increased risk of future coronary heart disease, heart failure, and stroke after adjusting for age (RR, 3.89; 95% CI, 1.83–8.26), body mass index (RR, 3.16; 95% CI, 1.41–7.07), and diabetes mellitus (RR, 4.19; 95% CI, 2.09–8.38). Conclusions— Preeclampsia is associated with a 4-fold increase in future incident heart failure and a 2-fold increased risk in coronary heart disease, stroke, and death because of coronary heart or cardiovascular disease. Our study highlights the importance of lifelong monitoring of cardiovascular risk factors in women with a history of preeclampsia.

Non-cardiovascular comorbidity, severity and prognosis in non-selected heart failure populations: A systematic review and meta-analysis

Background Non-cardiovascular comorbidities are recognised as independent prognostic factors in selected heart failure (HF) populations, but the evidence on non-selected HF and how comorbid disease severity and change impacts on outcomes has not been synthesised. We identified primary HF comorbidity follow-up studies to compare the impact of non-cardiovascular comorbidity, severity and change on the outcomes of quality of life, all-cause hospital admissions and all-cause mortality. Methods Literature databases (Jan 1990–May 2013) were screened using validated strategies and quality appraisal (QUIPS tool). Adjusted hazard ratios for the main HF outcomes were combined using random effects meta-analysis and inclusion of comorbidity in prognostic models was described. Results There were 68 primary HF studies covering nine non-cardiovascular comorbidities. Most were on diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD) and renal dysfunction (RD) for the outcome of mortality (93%) and hospital admissions (16%), median follow-up of 4 years. The adjusted associations between HF comorbidity and mortality were DM (HR 1.34; 95% CI 1.2, 1.5), COPD (1.39; 1.2, 1.6) and RD (1.52; 1.3, 1.7). Comorbidity severity increased mortality from moderate to severe disease by an estimated 78%, 42% and 80% respectively. The risk of hospital admissions increased up to 50% for each disease. Few studies or prognostic models included comorbidity change. Conclusions Non-cardiovascular comorbidity and severity significantly increases the prognostic risk of poor outcomes in non-selected HF populations but there is a major gap in investigating change in comorbid status over time. The evidence supports a step-change for the inclusion of comorbidity severity in new HF interventions to improve prognostic outcomes.

Comorbidity Cohort (2C) study: cardiovascular disease severity and comorbid osteoarthritis in primary care.

BackgroundTwo of the commonest chronic diseases experienced by older people in the general population are cardiovascular diseases and osteoarthritis. These conditions also commonly co-occur, which is only partly explained by age. Yet, there have been few studies investigating specific a priori hypotheses in testing the comorbid interaction between two chronic diseases and related health and healthcare outcomes. It is also unknown whether the stage or severity of the chronic disease influences the comorbidity impact. The overall plan is to investigate the interaction between cardiovascular severity groups (hypertension, ischaemic heart disease and heart failure) and osteoarthritis comorbidity, and their longitudinal impact on health and healthcare outcomes relative to either condition alone.MethodsFrom ten general practices participating in a research network, adults aged 40 years and over were sampled to construct eight exclusive cohort groups (n = 9,676). Baseline groups were defined on the basis of computer clinical diagnostic data in a 3-year time-period (between 2006 and 2009) as: (i) without cardiovascular disease or osteoarthritis (reference group), (ii) index cardiovascular disease groups (hypertension, ischaemic heart disease and heart failure) without osteoarthritis, (iii) index osteoarthritis group without cardiovascular disease, and (vi) index cardiovascular disease groups comorbid with osteoarthritis. There were three main phases to longitudinal follow-up. The first (survey population) was to invite cohorts to complete a baseline postal health questionnaire, with 10 monthly brief interval health questionnaires, and a final 12-month follow-up questionnaire. The second phase (linkage population) was to link the collected survey data to patient clinical records with consent for the 3-year time-period before baseline, during the 12-month survey period and the 12 months after final questionnaire (total 5 years). The third phase (denominator population) was to construct an anonymised clinical data archive for the study five year period for the total baseline cohorts, linking clinical information such as diagnosis, prescriptions and referrals.DiscussionThe outcomes of the study will result in the determination of the specific interaction between cardiovascular severity and osteoarthritis comorbidity on the change and progression of physical health status in individuals and on the linked and associated clinical-decision making process in primary care.

Impact of non-cardiovascular disease comorbidity on cardiovascular disease symptom severity: A population-based study

Objectives Non-cardiovascular comorbidity is common in cardiovascular disease (CVD) populations but its influence on chest pain (CP) and shortness of breath (SOB) symptom-specific physical limitations is unknown. We wanted to test the a priori hypothesis that an unrelated comorbidity would influence symptom-specific physical limitations and to investigate this impact in different severities of CVD. Method and results The study was based on 5426 patients from ten family practices, organised into eight a priori exclusive severity groups: (i) no CVD or osteoarthritis (OA) (reference), (ii) index hypertension, ischaemic heart disease (IHD) and heart failure (HF) without OA, (iii) index OA without CVD and (iv) same CVD groups with comorbid OA. The measure of CP physical limitations was Seattle Angina Questionnaire and for SOB physical limitations was the Kansas City Cardiomyopathy Questionnaire. Adjusted baseline associations between the cohorts and symptom-specific physical limitations were assessed using linear regression methods. In the study population, 1443 (27%) reported CP and 2097 (39%) SOB. CP and SOB physical limitations increased with CVD severity in the index and comorbid groups. Compared with the respective index CVD group, the CP physical limitation scores for comorbid CVD groups with OA were lower by: − 14.7 (95% CI − 21.5, 7.8) for hypertension, − 5.5 (− 10.4, − 0.7) for IHD and − 22.1 (− 31.0, − 6.7) for HF. For SOB physical limitations, comorbid scores were lower by: − 9.2 (− 13.8, − 4.6) for hypertension, − 6.4 (− 11.1, − 1.8) for IHD and − 8.8 (− 19.3, 1.65) for HF. Conclusions CP and SOB are common symptoms, and OA increases the CVD symptom-specific physical limitations additively. Comorbidity interventions need to be developed for CVD specific health outcomes.

Heart Failure and Chronic Obstructive Pulmonary Disease Multimorbidity at Hospital Discharge Transition: a Study of Patient and Carer Experience

Care for patients with multimorbidity represents a major challenge not only for patients and carers but to health‐care systems. Hospital discharge transition is a critical point at which challenges for multimorbidity may amplify.

Ultrafiltration for acute decompensated cardiac failure: A systematic review and meta-analysis.

BACKGROUND Ultrafiltration is a method used to achieve diuresis in acute decompensated heart failure (ADHF) when there is diuretic resistance, but its efficacy in other settings is unclear. We therefore conducted a systematic review and meta-analysis to evaluate the use of ultrafiltration in ADHF. METHODS We searched MEDLINE and EMBASE for studies that evaluated outcomes following filtration compared to diuretic therapy in ADHF. The outcomes of interest were body weight change, change in renal function, length of stay, frequency of rehospitalization, mortality and dependence on dialysis. We performed random effects meta-analyses to pool studies that evaluated the desired outcomes and assessed statistical heterogeneity using the I2 statistic. RESULTS A total of 10 trials with 857 participants (mean age 68years, 71% male) compared filtration to usual diuretic care in ADHF. Nine studies evaluated weight change following filtration and the pooled results suggest a decline in mean body weight -1.8; 95% CI, -4.68 to 0.97 kg. Pooled results showed no difference between the filtration and diuretic group in change in creatinine or estimated glomerular filtration rate. The pooled results suggest longer hospital stay with filtration (mean difference, 3.70; 95% CI, -3.39 to 10.80days) and a reduction in heart failure hospitalization (RR, 0.71; 95% CI, 0.51-1.00) and all-cause rehospitalization (RR, 0.89; 95% CI, 0.43-1.86) compared to the diuretic group. Filtration was associated with a non-significant greater risk of death compared to diuretic use (RR, 1.08; 95% CI, 0.77-1.52). CONCLUSIONS There is insufficient evidence supporting routine use of ultrafiltration in acute decompensated heart failure.

Multidrug and optimal heart failure therapy prescribing in older general practice populations: a clinical data linkage study.

Objective To investigate multidrug therapy in the cardiovascular disease (CVD) population and whether it was associated with suboptimal drug prescribing in heart failure (HF). Design A population-based cross-sectional clinical data linkage study. Setting The clinical database populations were registered with three general practices in North Staffordshire that are part of a research network. Participants 3155 patients aged 50 years and over were selected on the basis of a CVD-related prescription and a CVD consultation code applied to their electronic medical record in a 2-year time period. All available diagnostic data were linked to all drugs prescribed data during this time period. Two study groups were: (1) HF and (2) non-HF CVD (reference group). Exposure A standard drug formulary system was used to define four multidrug count categories based on the number of different British National Formulary drug chapters prescribed at the same time. Primary and secondary outcome measures Optimal HF therapy was defined as the prescribing of ACE inhibitor (ACEi) or a combination of ACEi and β-blocker in the 2-year time window. An additional three specific CVD drug categories that are indicated in HF were also measured. Results The HF group, compared with the reference group, had higher non-CVD multidrug therapy (26% with 7 or more counts compared with 14% in the non-HF CVD reference group). For the first-choice optimal drug treatment for HF with ACEi (64%) or ACEi and β-blocker combined therapy (23%), the multidrug-adjusted associations between the HF group and the reference group were OR 3.89; 95% CI 2.8 to 5.5 and 1.99; 1.4 to 2.9, respectively. These estimates were not influenced by adjustment for sociodemographic factors and multidrug counts. Conclusions Multidrug therapy prescribing is much higher in the HF group than in a comparable CVD group but did not influence optimal drug prescribing.

Weekend effect in acute coronary syndrome: A meta-analysis of observational studies

Background: The effect of a weekend compared with a weekday hospital admission on patient outcomes after an acute coronary syndrome is unclear. This study aims to determine whether collectively there is a weekend effect in acute coronary syndrome. Method: We conducted a systematic review and meta-analysis of cohort studies examining the association between weekend compared to weekday admission at any time of the day and early mortality (in-hospital or 30-day). A search was performed on Medline and Embase and relevant studies were pooled using random effects meta-analysis for risk of early mortality. Additional analyses were performed considering only more recent studies (conducted after 2005) and by patient group (ST-elevation myocardial infarction [STEMI] or non-STEMI [NSTEMI]), as well as meta-regression according to starting year and mean year of study. Results: A total of 18 studies were included with over 14 million participants incorporating 3 million weekend and over 11.5 million weekday admissions and the rates of mortality were 19.2% and 23.4%, respectively. The pooled results of all 18 studies suggest that weekend admission was associated with a small increased risk of early mortality (odds ratio [OR] 1.06, 95% confidence interval [CI] 1.03–1.09). The results for subgroups of STEMI and NSTEMI cohorts were not statistically significant and timing of admission after 2005 had minimal influence on the results (OR 1.06, 95% CI 0.95–1.17). Conclusions: There is a small weekend effect for admission with acute coronary syndrome that has persisted over time.

68 The impact of the weekend admission on early mortality after acute coronary syndrome: a meta-analysis of observational studies

Background A weekend effect where outcomes for patients admitted acutely during the weekend are worse than those for patients admitted during the week has been reported in many specialities across medicine. The evidence supporting a weekend effect among patients admitted with an acute coronary syndrome is conflicting. This systematic review and meta-analysis aims to determine if collectively there is a weekend effect in acute coronary syndrome. Methods We searched Medline and EMBASE for cohort studies examining the association between weekend compared to weekday admission at any time of the day and early mortality (in-hospital or 30 day). Relevant studies were pooled using random effects meta-analysis for risk of early mortality. Additional analyses were performed considering only more recent studies (conducted after 2005) and by patient group (STEMI or NSTEMI) as well as meta-regression according to starting year and mean year of study. Results A total of 26 studies were included with over 16 million participants incorporating 3.3 million weekend and over 12.5 million weekday admissions and the rates of mortality rates were 18.3% and 15.7%, respectively. The pooled results of all 26 studies suggest that weekend admission was associated with a small increase in risk of early mortality (OR 1.05 95% CI 1.03–1.07). The results for subgroups of STEMI and NSTEMI cohorts were not statistically significant and timing of admission after 2005 had minimal influence on the results (OR 1.06 95% CI 0.95–1.17). Conclusions There is a small weekend effect for admission with acute coronary syndrome that has persisted over time.