Calls for revision of individual care plans after MI due to increased risk of adverse health events

7th March 2024

Patients who have a myocardial infarction (MI) are at significantly increased risk of developing other serious long-term health conditions, according to a new study from the University of Leeds.

The research, published in the journal PLOS Medicine, analysed the records of all individuals aged 18 years and over admitted to one of 229 NHS trusts in England between 1 January 2008 and 31 January 2017 – the largest study of its kind.

This amounted to 145,912,852 hospitalisations among 34,116,257 individuals, with 433,361 reports of people with first-time MI. The average age of patients with MI was 67 years, and 66% of these patients were male.

The study looked at 11 non-fatal health outcomes, plus all-cause mortality, within the nine-year study period and compared the results to a control group of 2,001,310 individuals.

Patients who had an MI went on to develop further conditions at a much higher rate when compared to the control group of patients of the same age and sex who had not had one, with the exception of dementia and cancer.

Adverse health events following MI

Following MI, the most frequent event was all-cause mortality at 37.8% in the study group compared with 35.3% of the control group.

The most likely health outcome washeart failure, with 29.6% of the study group going on to develop the condition within nine years of their MI, compared with 9.8% of the control group over the same period. 

Kidney failure developed in 27.2% of the patients in the study group, compared with 19.8% of the control group, while 22.3% of the study group went on to develop atrial fibrillation, compared with 16.8% of the control group.

In addition, new hospitalisation for diabetes was seen in 17% of the study group, compared with 14.3% of the control group. 

When it came to mental health, the researchers found the hospitalisation records indicated depression occurred in 8.9% of people – which was 6% more likely following a MI than in the control group.

Women were more likely to develop depression after an MI than men, especially those who experienced it at a younger age. Some 21.5% of women who were under the age of 40 at the time of their mi had hospitalisation records for depression compared with 11.5% of men in the same age category.

The study also found that people from more socioeconomically deprived backgrounds were more likely to die or develop serious long-term health conditions following MI – in particular heart and kidney failure – compared to people from less deprived backgrounds of a similar age.

Dementia and cancer risk

However, there was no overall difference in the risk of dementia following a MI compared with the control group. Whilst the risk of vascular dementia was more likely in the study group, the difference observed was small at 2.3% in the study group and 2.1% in the control group.

The research also showed that cancer was less pronounced in the study group than in the control group. Some 13.5% of the study group went on to develop cancer after their MI, compared with 21.5% of the control. However, the researchers stated that there are many likely factors affecting this finding and that the specific reasons ‘remain unclear and require further investigation’. 

Morag Foreman, head of discovery researchers at Wellcome, which part funded the study alongside the British Heart Foundation, said: ‘As survival rates following a myocardial infarction improve, understanding the longer-term impacts on physical and mental health is crucial.

‘This research shows how cohort studies and analysis of large data sets can further our understanding of key health challenges and demonstrates the value to supporting discovery research in the field of population and public health.’

Individual care plans for MI

The researchers noted that as the study included only secondary care data, there is potential for an underestimation of the total burden of disease following MI as diagnoses may be made in other settings.

Nevertheless, with around 1.4 million MI survivors in the UK who are at high risk of developing further serious health conditions, lead author Dr Marlous Hall, associate professor of cardiovascular epidemiology at the Leeds School of Medicine and Multimorbidity Research in the Leeds Institute for Data Analytics, said the study ‘highlights the need for individual care plans to be revised to take into account the higher demand for care’.

She added: ‘Our study provides accessible online information of the risk of these health outcomes for specific age, sex and socioeconomic deprivation groups so that individuals surviving a heart attack can be well informed about their future risks, in order to support informed healthcare decision making with their doctor.

‘Effective communication of the likely course of disease and risk of adverse long-term outcomes between patients and healthcare professionals can promote positive lifestyle changes, encourage patients to stick to treatment, and improve patient understanding and quality of life.’

In 2023, a genetic study revealed that the use of clopidogrel in British patients of south Asian ancestry was less effective at preventing recurrent MI than in those of European descent.

Anti-CD20 therapy increases complication risk in COVID-19 for blood cancer patients

16th January 2023

Anti-CD20 therapy for haematological cancer patients is linked to an increased risk of adverse outcomes despite triple vaccination

Anti-CD20 therapy use in patients with haematological cancers, despite triple vaccination, still poses an increased risk for adverse outcomes following a breakthrough COVID-19 infection, according to the findings of a retrospective population-based cohort study by Canadian researchers.

Although patients with cancer were excluded from the initial clinical trials of COVID-19 vaccines, emerging evidence suggested that adult patients with haematological malignancies, infected with the virus, especially those who were hospitalised and over 60 years of age, were at an increased risk of death. Moreover, once vaccinated, it became clear that patients with haematological cancers displayed an impaired humoral response and the recognition that breakthrough infections were possible and that these infections were correlated with the level of neutralising antibody titers during the peri-infection period, researchers hypothesised that haematological malignancy patients and even those with other types of cancer, might experience a more severe outcomes if infected with COVID-19.

In the present study, the Canadian team set out to examine the relative risk of COVID-19 breakthrough infections and COVID-19-related outcomes in vaccinated patients with cancer (including haematological and solid tumours) compared to matched non-cancer controls. In addition, they considered whether current treatment of cancer, with for example, anti-CD20 therapy, impacted on the risk of COVID-related outcomes. Using a retrospective design, researchers matched patients with haematologic cancer to non-cancer controls (1:4), based on age, sex, type of vaccine, date of vaccine. The primary outcome was COVID-19 breakthrough infection, whereas secondary outcomes were emergency department visits, hospitalisation and death within 4 weeks of infection and the outcomes adjusted for gender, age socioeconomic status and vital status.

Anti-CD20 therapy and COVID-19 outcomes

A total of 289,400 vaccinated cancer patients with a mean age of 66.05 years (65.4% female) were matched with 1,157,600 non-cancer controls. During the period of the study, there were 3118 and 12 150 breakthrough infections in the cancer and non-cancer groups, respectively.

Overall, the risk of a COVID-19 breakthrough infection was significantly higher among cancer patients compared to non-cancer controls (adjusted Hazard ratio, aHR = 1.05, 95% CI, 1.01 – 1.09, p = 0.02). However, the risk was significantly greater among patients with haematologic cancers (aHR = 1.33, 95% CI 1.20 – 1.46, p < 0.01) compared to controls. There were also significantly elevated risks for haematological cancer patients (compared to controls) for emergency department visits, hospitalisation and death. However, when researchers looked at patients who had received a third COVID-19 vaccine dose, this was associated with lower risk of breakthrough infection for blood cancer patients (aHR = 0.61, 95% CI 0.54. – 0.69, p < 0.01). 

Among haematological cancer patients in receipt of anti-CD20 therapy, there remained an elevated risk of breakthrough infection (aHR = 1.88, 95% CI 1.27 – 2.78, p =0.02) as well as for emergency department visits, hospitalisation and death. Although a third vaccine dose was associated with a lower risk of infection and COVID-19 complications for all cancer patients, this did not significantly reduce the risk among haematological cancer patients receiving anti-CD20 therapy. For example, the adjusted hazard ratio for death was 0.49 (p = 0.24) and 1.19 (p = 0.46) for severe outcomes.

The authors concluded that patients with haematological cancer had the highest risk for breakthrough infections and adverse COVID-19 outcomes, particularly for those who received anti-CD20 therapy.

Citation
Gong IY et al. Association of COVID-19 Vaccination With Breakthrough Infections and Complications in Patients With Cancer. JAMA Oncol 2022.

Acute COPD exacerbation in ED commonly associated with non-harmful dysnatraemia and dyskalaemia

1st April 2022

Among patients with an acute exacerbation of COPD seen at ED, both dysnatraemia and dyskalaemia are common but unharmful clinical disorders

Both dysnatraemia and dyskalaemia, especially, hyponatraemia and hypokalaemia are common electrolyte disorders among emergency department patients with an acute exacerbation of chronic obstructive pulmonary disease (COPD). However, the presence of these disturbances do not negatively impact on outcomes such as re-admission, the need for intensive care treatment or mortality.

This was the conclusion of a study by a team from the Department of Internal and Emergency Medicine, Solothurn, Switzerland.

Electrolyte disorders often affect patients prescribed diuretics attending an emergency department (ED). For example, one study found that 4% of patients had hyponatraemia on admission, 12% hypernatraemia, 11% hypokalaemia and 4% hyperkalaemia.

Furthermore, the presence of dysnatraemia upon on admission to an intensive care unit, is an independent risk factors for poor prognosis. Equally, dyskalaemia has been found to occur in 1 of 11 ED patients and is associated with both inpatient admission and mortality.

Although dysnatraemia, in particular, hyponatraemia at discharge is associated with an increased risk of recurrence in hospitalised patients with pneumonia, much less is known about the effect of both dysnatraemia and dyskalemia in patients admitted to an ED with an acute exacerbation of COPD.

Consequently in the present study, the Swiss team retrospectively examined the prevalence and extent of both dysnatraemia and dyskalemia and the associated outcomes in patients visiting an ED with an acute exacerbation of COPD.

For the purposes of the study, baseline hyponatraemia and hypernatraemia were defined by a serum sodium level of below 135mmol/l and above 145mmol/L respectively. Similarly, hypokalaemia and hyperkalaemia were defined as < 3.5mmol/l and > 5mmol/l respectively. Additional clinical and demographic data were also collected from hospital charts.

For comparative purposes, similar data were collected for a sample of patients with community-acquired pneumonia. The outcomes of interest were intensive care unit (ICU) admission, the need for mechanical ventilation, length of hospital stay, 30- and 180-day re-admission rates and hospital mortality.

Dysnatraemia and dyskalemia and outcomes for those with acute COPD

A total of 19,846 consultations for which serum sodium and potassium levels were available were used in the analysis, of which 102 patients, with a mean age of 73 years (46.1% male), had an acute exacerbation of COPD. The mean baseline serum sodium and potassium levels were 137mmol/l and 4.0mmol/l respectively.

Overall, upon admission, 23% of patients had hyponatraemia and 5% hypernatraemia, whereas 16% and 4% had hypokalaemia and hyperkalaemia, respectively. Compared with those without COPD, hyponatraemia was significantly more common (p = 0.001) as was hypernatraemia (p < 0.001) although levels of dyskalaemia were non-significant.

In regression analysis neither dysnatraemia or dyskalaemia were significantly associated any of the outcomes of interest such as the need for ICU admission, invasive or non-invasive mechanical ventilation, re-admission or mortality.

The authors concluded that while dysnatraemia and dyskalaemia were commonly encountered in those presenting at an ED with acute exacerbations of COPD, neither disorder was associated with adverse outcomes.

Citation
Lindner G et al. Sodium and potassium disorders in patients with COPD exacerbation presenting to the emergency department BMC Emerg Med 2022