Background: Carbohydrate antigen-125 (CA125) is an ovarian cancer marker, but recent work has examined its role in risk stratification in heart failure. A recent meta-analysis examined its prognostic value in heart failure generally. However, there has been no systematic evaluation of its role specifically in acute heart failure (AHF).
Methods: PubMed and EMBASE databases were searched until 11 May 2018 for studies that evaluated the prognostic value of CA125 in AHF.
Results: A total of 129 and 179 entries were retrieved from PubMed and EMBASE. Sixteen studies (15 cohort studies, 1 randomised trial) including 8401 subjects with AHF (mean age 71 years old, 52% male, mean follow-up 13 months, range of patients 525.1±598.2) were included. High CA125 levels were associated with a 68% increase in all-cause mortality (8 studies, HRs: 1.68, 95% CI 1.36 to 2.07; p<0.0001; I2: 74%) and 77% increase in heart failure-related readmissions (5 studies, HRs: 1.77, 95% CI 1.22 to 2.59; p<0.01; I2: 73%). CA125 levels were higher in patients with fluid overload symptoms and signs compared with those without them, with a mean difference of 54.8 U/mL (5 studies, SE: 13.2 U/mL; p<0.0001; I2: 78%).
Conclusion: Our meta-analysis found that high CA125 levels are associated with AHF symptoms, heart failure-related hospital readmissions and all-cause mortality. Therefore, CA125 emerges as a useful risk stratification tool for identifying high-risk patients with more severe fluid overload, as well as for monitoring following an AHF episode.
Currently, the choice of whether or not to electively operate on current smokers is varied among cardiothoracic surgeons. This meta-analysis aims to determine whether preoperative current versus ex-smoking status is related to short-term postoperative morbidity and mortality in cardiac surgical patients. Systematic literature searches of the PubMed, MEDLINE and Cochrane databases were carried out to identify all studies in cardiac surgery that investigated the relationship between smoking status and postoperative outcomes. Extracted data were analysed by random effects models. Primary outcomes included 30-day or in-hospital all-cause mortality and pulmonary morbidity. Overall, 13 relevant studies were identified, with 34 230 patients in current or ex-smoking subgroups. There was no difference in mortality (p=0.93). Current smokers had significantly higher risk of overall pulmonary complications (OR 1.44; 95% CI 1.27 to 1.64; p<0.001) and postoperative pneumonia (OR 1.62; 95% CI 1.27 to 2.06; p<0.001) as well as lower risk of postoperative renal complications (OR 0.82; 95% CI 0.70 to 0.96; p=0.01) compared with ex-smokers. There was a trend towards an increased risk of postoperative MI (OR 1.29; 95% CI 0.95 to 1.75; p=0.10). No difference in postoperative neurological complications (p=0.15), postoperative sternal surgical site infections (p=0.20) or postoperative length of intensive care unit stay (p=0.86) was seen. Cardiac surgical patients who are current smokers at the time of operation do not have an increased 30-day mortality risk compared with ex-smokers, although they are at significantly increased risk of postoperative pulmonary complications.
Objective: Our objective was to assess the relations between apparent temperature and incidence of acute coronary syndrome (ACS) in Rasht, Iran.
Methods: We used a time-series analysis to investigate the relationship between apparent temperature and hospital admission from 2005 to 2014. Distributed lag non-linear models were used to estimate the association between ACS hospitalisation and apparent temperature. To examine the high-temperature effect on ACS hospital admission, the relative risk of ACS hospital admission associated with high temperature, the 99th percentile of temperature (34.7°C) compared with the 75th percentile of temperature (26.9°C), was calculated. To assess the cold effect on ACS hospital admission, the relative risk of ACS hospital admission associated with cold temperature, the first percentile of temperature (-0.2°C) compared with the 25th percentile of temperature (8.2°C), was evaluated.
Results: The cumulative effect of hot exposure on ACS admissions was statistically significant, with a relative risk of 2.04 (95% CI 1.06 to 4.16). The cumulative effect of cold temperature on ACS admissions was found to be non-significant. The highest risk of ACS admission in women was in 38°C (RR, 2.03, 95% CI 1.04 to 4.18). The effect of hot temperature on ACS admission occurred immediately (lag 0) (RR, 1.09, 95% CI 1.001 to 1.19).
Conclusions: The high apparent temperature is correlated with a higher ACS admission especially on the same day. These findings may have implications for developing intervention strategies to reduce and prevent temperature-related morbidity especially in the elderly.
Objectives: Hospitalisation for congestive heart failure (CHF) was reported to be 1648 cases for every 100 000 patient claims in 2014 in the Philippines; however, there are no data regarding its economic impact. This study determined CHF hospitalisation cost and its total economic burden. It compared the healthcare-related hospitalisation cost from the societal perspective with the payer's perspective, the Philippine Health Insurance Corporation (PhilHealth).
Methods: This is a cost analysis study. Data were obtained from representative government/private hospitals and a drugstore in all regions of the country. Healthcare costs included cost of diagnostics/treatment, professional fees and other CHF-related hospital charges, while non-healthcare costs included production losses, transportation and food expenses.
Results: The overall mean healthcare-related cost for CHF hospitalisation (class III) in government hospitals in the Philippines in 2014 was PHP19 340-PHP28 220 (US$436-US$636). In private hospitals, it was PHP28 370-PHP41 800 (US$639-US$941). In comparison, PhilHealth's coverage/CHF case rate payment is PHP15 700 (US$354). The mean non-healthcare cost was PHP10 700-PHP14 600 (US$241-US$329). Using PhilHealth's case rate payment and the prevalence of CHF hospitalisation in 2014, the total economic burden was PHP691 522 200 (US$15 574 824). Using the study results on healthcare-related cost meant that the total economic burden for CHF hospitalisation would instead be PHP851 850 000-PHP1 841 563 000 (US$19 185 811-US$41 476 644).
Conclusions: The calculated healthcare-related hospitalisation cost for CHF in the Philippines in 2014 demonstrates the disparity between the actual cost and PhilHealth's coverage. This implies a need for policymakers to review its coverage to make healthcare delivery affordable.
Objective: Estimate the incidence and outcomes of in-hospital cardiac arrest (IHCA) in a tertiary-care hospital in Abu Dhabi emirate, United Arab Emirates (UAE).
Methods: Retrospective data from 685 inpatients who experienced an IHCA at a hospital in Abu Dhabi (UAE) between 1 January 2013 and 31 December 2015 were analysed. Sociodemographic variables were age and gender, and IHCA event variables were shift, day, event location, initial cardiac rhythm and the total number of IHCA events. Outcome variables were the return of spontaneous circulation (ROSC) and survival to discharge (StD).
Results: The incidence of IHCA was 11.7 (95% CI 10.8 to 12.6) per 1000 hospital admissions. Non-shockable rhythms were 91.1% of the cardiac rhythms at presentation. The majority of IHCA cases occurred in the intensive care unit (46.1%) and on weekdays (74.6%). More than a third (38.3%) of patients who experienced an IHCA achieved ROSC and 7.7% StD. Both ROSC and StD were significantly higher in patients who were younger and presenting with a shockable rhythm (all p's≤0.05). Survival outcomes were not significantly different between dayshifts and nightshifts or weekdays and weekends.
Conclusions: The incidence of IHCA was higher and its outcomes were lower compared with other high-income/developed countries. Survival outcomes were better for patients who were younger and had a shockable rhythm, and similar between time of day and days of the week. These findings may help to inform health managers about the magnitude and quality of IHCA care in the UAE.
Objective: Hypertension is a significant and rising burden in Nepal. The disease remains undetected and inadequately managed. However, no studies have been conducted to understand the inhibiting and facilitating factors to hypertension treatment among newly diagnosed cases. This qualitative study aimed to explore barriers and facilitators to treatment among patients with newly diagnosed hypertension aged ≥18 years in Dhulikhel, Nepal.
Methods: We conducted seven focus group discussions with 35 patients with newly diagnosed hypertension identified through community surveillance of the Dhulikhel Heart Study, an observational cohort of Dhulikhel Hospital, Kathmandu University. Audiotaped discussions were transcribed, inductively coded and analysed by the thematic framework method using Atlas.ti V.7.
Results: Hypertension was viewed as a rising problem in the community. Participants had limited knowledge and many misbeliefs regarding hypertension and its treatment. The major barriers included absence of symptoms, reluctance to take medicine, low perceived seriousness of the disease, challenges in behaviour change (diet and exercise), lack of family support, and lack of communication and trust with the provider. The major reported facilitating factors were fear of consequences of the disease, and family support in controlling diet and adhering to treatment.
Conclusions: A number of factors emerged as barriers and facilitators to hypertension treatment. This information can be useful in designing appropriate health interventions to improve hypertension management.
Case presentation: A middle-aged patient presented to the emergency department with intermittent chest pain of 4-hour duration. The patient had been recently diagnosed with metastatic adenocarcinoma of the colon and was receiving 5-fluorouracil (5-FU)-based chemotherapy at the time of presentation. The ECG at presentation showed 1 mm ST segment elevation in leads II, III and aVF, with reciprocal changes in leads aVL, V1 and V2 (figure 1A). Serum cardiac troponin I level was elevated at 0.11 ng/mL (normal: 0.00-0.02 ng/mL). The patient was given sublingual nitrate and loading doses of aspirin, clopidogrel and atorvastatin, and was taken up for coronary angiography with an intent to perform primary percutaneous coronary intervention.Figure 1(A) 12-lead ECG done at presentation to the emergency department. (B) 12-lead ECG done 30 min after coronary angiography.The images of the coronary angiogram are shown in figure 2. The patient was angina-free by this time. A repeat ECG done 30 min after coronary angiography is shown in figure 1B. Two-dimensional transthoracic echocardiogram revealed normal left ventricle (LV) systolic function and no regional wall motion abnormality.Figure 2Images of the coronary angiogram of the patient. (A) Right anterior oblique view with a caudal angulation showing left anterior descending (LAD) artery and left circumflex (LCx) artery. (B) Left anterior oblique view with a cranial angulation showing right coronary artery (RCA).
Question: What is the likely mechanism of myocardial infarction in this patient?In situ coronary artery thrombosis with spontaneous recanalisation.Epicardial coronary artery vasospasm.Coronary artery embolism.Coronary microvascular dysfunction.
Introduction: Life-threatening emergencies are not limited to the emergency department. Any delay in intervention during an emergency often culminates into a poor outcome. Early electrical defibrillation is one of the most important interventions in patients with cardiac arrest. This study aimed to conduct a clinical audit of defibrillator devices at an urban public sector hospital in Johannesburg.
Methods: All defibrillator devices within various areas of the hospital were assessed. Device characteristics were recorded into a data collection sheet and subjected to further analysis.
Results: This study assessed 112 out of 123 areas in the hospital with a total of 143 defibrillators comprising 139(97.2%) manual external defibrillators (MED) and four(2.8%) automated external defibrillators (AED). MEDs were located in the general wards (n=52, 37.4%), theatre complex (n=25, 17.9%), high dependency areas (n=27, 19.4%) and non-sleepover areas (n=35, 25.2%). Daily checklist books were available for 101 (72.7%) MEDs, 26 (18.7%) had at least once daily documented checks over a 5-day period while 57 (41.0%) had been serviced in the last 12 months. Seven MEDs (4.9%) and one AED (0.7%) had critical problems.
Conclusion: Compliance with regard to the availability of defibrillator checklist books, conducting and recording of daily defibrillator checks, timely service maintenance of defibrillators and identification of critical device problems was suboptimal in this study. There is a need for ongoing training of hospital staff as well as the establishment of systems to prevent potential adverse consequences due to device failure.
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