Demystifying Smoker's Paradox: A Propensity Score-Weighted Analysis in Patients Hospitalized With Acute Heart Failure.
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ABSTRACT:
SUBMITTER: Doi SA
PROVIDER: S-EPMC6912958 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:BackgroundMethamphetamines are a common cause of systolic heart failure (HF). There are limited data on the prognosis associated with hospitalizations for decompensated HF in the setting of methamphetamine use. We aimed to evaluate patient characteristics and outcomes among patients admitted with decompensated HF who had positive drug screens for amphetamines as well as to determine whether any parameters from transthoracic echocardiogram (TTE) can predict outcomes in this population.MethodsThis was a retrospective cohort study of consecutive adult patients admitted to the Loma Linda Medical Center who had an active hospital problem of acute on chronic systolic (or systolic and diastolic) HF from 2013 to 2018. Electronic medical records were mined for relevant patient data. Methamphetamine-associated heart failure (MethHF) group was defined as those with an admission urine drug screen (UDS) that was positive for methamphetamines, whereas non-MethHF was defined by patients with negative methamphetamine on UDS or UDS was not done on physician's discretion. The primary outcomes of the study were 30-day composite outcome (defined as combined all-cause readmission and all-cause mortality), 365-day all-cause mortality, and length of stay (LOS). Propensity score weighting for these outcomes was performed using demographics, laboratory and clinical variables, and left ventricular ejection fraction (LVEF) as covariates. TTE parameters from presentation were also evaluated to determine if any had prognostic implications.ResultsA total of 1,655 patients were included (101 patients with positive urine methamphetamine and 1,554 patients without). Patients with MethHF were younger, more likely to be male, had fewer comorbidities, had lower LVEF, and were more likely to have right ventricular systolic dysfunction. In propensity-weighted analyses, there were no significant differences in LOS, 30-day composite outcome, or 365-day mortality between the MethHF and non-MethHF group in (P > 0.05 for all). Presence of at least moderate tricuspid valve regurgitation (TR) was the only TTE predictor of 30-day composite outcome (odds ratio (OR) = 4.67, 95% confidence interval (CI): 1.5 - 14.50, P < 0.01) and 365-day mortality (OR = 4.67, 95% CI: 1.5 - 14.50, P < 0.01) in the MethHF group.ConclusionPatients with MethHF admitted for decompensated HF had similar outcomes compared to non-MethHF after adjusting for baseline characteristics. TR is the only TTE value to predict outcomes in this population.
| S-EPMC8993440 | biostudies-literature
Project description:BackgroundSmokers have been shown to have lower mortality after acute coronary syndrome than non-smokers. This has been attributed to the younger age, lower co-morbidity, more aggressive treatment and lower risk profile of the smoker. Some studies, however, have used multivariate analyses to show a residual survival benefit for smokers; that is, the "smoker's paradox". The aim of this study was, therefore, to perform a systematic review of the literature and evidence surrounding the existence of the "smoker's paradox".MethodsRelevant studies published by September 2010 were identified through literature searches using EMBASE (from 1980), MEDLINE (from 1963) and the Cochrane Central Register of Controlled Trials, with a combination of text words and subject headings used. English-language original articles were included if they presented data on hospitalised patients with defined acute coronary syndrome, reported at least in-hospital mortality, had a clear definition of smoking status (including ex-smokers), presented crude and adjusted mortality data with effect estimates, and had a study sample of > 100 smokers and > 100 non-smokers. Two investigators independently reviewed all titles and abstracts in order to identify potentially relevant articles, with any discrepancies resolved by repeated review and discussion.ResultsA total of 978 citations were identified, with 18 citations from 17 studies included thereafter. Six studies (one observational study, three registries and two randomised controlled trials on thrombolytic treatment) observed a "smoker's paradox". Between the 1980s and 1990s these studies enrolled patients with acute myocardial infarction (AMI) according to criteria similar to the World Health Organisation criteria from 1979. Among the remaining 11 studies not supporting the existence of the paradox, five studies represented patients undergoing contemporary management.ConclusionThe "smoker's paradox" was observed in some studies of AMI patients in the pre-thrombolytic and thrombolytic era, whereas no studies of a contemporary population with acute coronary syndrome have found evidence for such a paradox.
| S-EPMC3179733 | biostudies-literature
Project description:BackgroundThe clinical efficiency of routine oxygen therapy is uncertain in patients with acute heart failure (AHF) who do not have hypoxemia. The aim of this study was to investigate the association between oxygen therapy and clinical outcomes in normoxemic patients hospitalized with AHF using real-world data.MethodsNormoxemic patients diagnosed with AHF on ICU admission from the electronic ICU (eICU) Collaborative Research Database were included in the current study, in which the study population was divided into the oxygen therapy group and the ambient-air group. Propensity score matching (PSM) was applied to create a balanced covariate distribution between patients receiving supplemental oxygen and those exposed to ambient air. Linear regression and logistic regression models were performed to assess the associations between oxygen therapy and length of stay (LOS), and all-cause in-hospital as well as ICU mortality rates, respectively. A series of sensitivity and subgroup analyses were conducted to further validate the robustness of our findings.ResultsA total of 2922 normoxemic patients with AHF were finally included in the analysis. Overall, 42.1% (1230/2922) patients were exposed to oxygen therapy, and 57.9% (1692/2922) patients did not receive oxygen therapy (defined as the ambient-air group). After PSM analysis, 1122 pairs of patients were matched: each patient receiving oxygen therapy was matched with a patient without receiving supplemental oxygen. The multivariable logistic model showed that there was no significant interaction between the ambient air and oxygen group for all-cause in-hospital mortality [odds ratio (OR) 1.30; 95% confidence interval (CI) 0.92-1.82; P = 0.138] or ICU mortality (OR 1.39; 95% CI 0.83-2.32; P = 0.206) in the post-PSM cohorts. In addition, linear regression analysis revealed that oxygen therapy was associated with prolonged ICU LOS (OR 1.11; 95% CI 1.06-1.15; P < 0.001) and hospital LOS (OR 1.06; 95% CI 1.01-1.10; P = 0.009) after PSM. Furthermore, the absence of an effect of supplemental oxygen on mortality was consistent in all subgroups.ConclusionRoutine use of supplemental oxygen in AHF patients without hypoxemia was not found to reduce all-cause in-hospital mortality or ICU mortality.
| S-EPMC8268364 | biostudies-literature
Project description:Recent work has demonstrated that propensity score matching may lead to increased covariate imbalance, even with the corresponding decrease in propensity score distance between matched units. The extent to which this paradoxical phenomenon might harm causal inference in real epidemiologic studies has not been explored. We evaluated the effect of this phenomenon using insurance claims data from the Pharmaceutical Assistance Contract for the Elderly (1999-2002) and Medicaid Analytic eXtract (2000-2007) databases in the United States. For each data set, we created several 1:1 propensity-score-matched data sets by manipulating the size of the covariate set used to generate propensity scores, the index exposure prevalence in the prematched data set, and the matching algorithm. We matched all index units, then progressively pruned matched sets in order of decreasing propensity score distance, calculating covariate imbalance after each pruning. Although covariate imbalance sometimes increased after progressive pruning of matched sets, the application of commonly used propensity score calipers for defining an acceptable match stopped pruning near the lowest region of the imbalance trend and resulted in an improvement over the imbalance in the prematched data set. Thus, propensity score matching does not appear to induce increased covariate imbalance when standard propensity score calipers are applied in these types of pharmacoepidemiologic studies.
| S-EPMC6118075 | biostudies-literature
Project description:ObjectiveThe aim of this study was to investigate the effect of dapagliflozin (DAPA) on the rate of heart failure rehospitalization in patients with acute myocardial infarction (AMI) and type 2 diabetes mellitus (T2DM).MethodsAMI patients with T2DM from CZ-AMI registry between January 2017 and January 2021 were enrolled in this study. Patients were stratified into DAPA users and non-DAPA users. The primary outcome was the incidence of heart failure rehospitalization. Kaplan-Meier analysis and Cox regressions were performed to evaluate the prognostic significance of DAPA. Propensity score matching (PSM) was performed to minimize the bias of confounding factors and facilitate the comparability between groups. The enrolled patients were matched with a propensity score of 1:1.ResultsA total of 961 patients were included, and 132 (13.74%) heart failure rehospitalizations occurred during a median follow-up of 540 days. In the Kaplan-Meier analysis, DAPA users had a statistically significantly lower rate of heart failure rehospitalization than non-DAPA users (p < 0.0001). Multivariate Cox analysis showed that DAPA was an independent protective factor for heart failure rehospitalization risk after discharge (HR = 0.498, 95% CI = 0.296 ~ 0.831, p = 0.001). After 1:1 propensity score matching, survival analysis showed a lower cumulative risk of heart failure rehospitalization in DAPA users than in non-DAPA users (p = 0.0007). In-hospital and continued use of DAPA remained significantly associated with a reduced risk of heart failure rehospitalization (HR = 0.417, 95% CI = 0.417 ~ 0.838, p = 0.001). Results were consistent across sensitivity and subgroup analyses.ConclusionIn patients with diabetic AMI, in-hospital and continued use of DAPA after discharge were associated with a significant lower risk of heart failure rehospitalization.
| S-EPMC10276777 | biostudies-literature
Project description:BackgroundHypercoagulability may contribute to COVID-19 pathogenicity. The role of anticoagulation (AC) at therapeutic (tAC) or prophylactic doses (pAC) is unclear.ObjectivesWe evaluated the impact on survival of different AC doses in COVID-19 patients.MethodsRetrospective, multi-center cohort study of consecutive COVID-19 patients hospitalized between March 13 and May 5, 2020.ResultsA total of 3480 patients were included (mean age, 64.5 years [17.0]; 51.5% female; 52.1% black and 40.6% white). 18.5% (n = 642) required intensive care unit (ICU) stay. 60.9% received pAC (n = 2121), 28.7% received ≥3 days of tAC (n = 998), and 10.4% (n = 361) received no AC. Propensity score (PS) weighted Kaplan-Meier plot demonstrated different 25-day survival probability in the tAC and pAC groups (57.5% vs 50.7%). In a PS-weighted multivariate proportional hazards model, AC was associated with reduced risk of death at prophylactic (hazard ratio [HR] 0.35 [95% confidence interval {CI} 0.22-0.54]) and therapeutic doses (HR 0.14 [95% CI 0.05-0.23]) compared to no AC. Major bleeding occurred more frequently in tAC patients (81 [8.1%]) compared to no AC (20 [5.5%]) or pAC (46 [2.2%]) subjects.ConclusionsHigher doses of AC were associated with lower mortality in hospitalized COVID-19 patients. Prospective evaluation of efficacy and risk of AC in COVID-19 is warranted.
| S-EPMC7675265 | biostudies-literature
Project description:Background and purpose The effects of therapy and patient characteristics on rehabilitation outcomes in patients with acute stroke are unclear. We investigated the effects of intensive occupational therapy (OT) on patients with acute stroke. Methods We performed a retrospective cohort study using the 2005–2016 Japan Rehabilitation Database, from which we identified patients with stroke (n = 10,270) who were admitted to acute care hospitals (n = 37). We defined active OT (AOT) and non-AOT as OT intervention times (total intervention time/length of hospital stay) longer or shorter than the daily physical therapy intervention time, respectively. The outcomes assessed were the Functional Independence Measure (FIM) and National Institutes of Health Stroke Scale (NIHSS) scores, duration of hospitalization, and rate of discharge. Propensity scores and inverse probability of treatment weighting analyses adjusted for patient characteristics were performed to investigate the effects of AOT on patient outcomes. Results We enrolled 3,501 patients (1,938 and 1,563 patients in the AOT and non-AOT groups, respectively) in the study. After inverse probability of treatment weighting, the AOT group had a shorter length of hospitalization (95% confidence interval: −3.7, −1.3, p < 0.001), and the FIM (95% confidence interval: 2.0, 5.7, p < 0.001) and NIHSS (95% confidence interval; 0.3, 1.1, p < 0.001) scores improved significantly. Subgroup analysis showed that lower NHISS scores for aphasia, gaze, and neglect and lower overall NIHSS and FIM scores on admission led to a greater increase in FIM scores in the AOT group. Conclusions AOT improved the limitations in performing activities of daily living (ADL) and physical function in patients with acute stroke and reduced the length of hospitalization. Additionally, subgroup analysis suggested that the increase in FIM score was greater in patients with severe limitations in performing ADLs and worse cognitive impairment, such as neglect, on admission.
| S-EPMC9849931 | biostudies-literature
Project description:Regression adjustment for the propensity score is a statistical method that reduces confounding from measured variables in observational data. A Bayesian propensity score analysis extends this idea by using simultaneous estimation of the propensity scores and the treatment effect. In this article, we conduct an empirical investigation of the performance of Bayesian propensity scores in the context of an observational study of the effectiveness of beta-blocker therapy in heart failure patients. We study the balancing properties of the estimated propensity scores. Traditional Frequentist propensity scores focus attention on balancing covariates that are strongly associated with treatment. In contrast, we demonstrate that Bayesian propensity scores can be used to balance the association between covariates and the outcome. This balancing property has the effect of reducing confounding bias because it reduces the degree to which covariates are outcome risk factors.
| S-EPMC2758880 | biostudies-other
Project description:BackgroundA structure and staffing model similar to that in general intensive care unit (ICUs) is applied to cardiac intensive care unit (CICUs) for patients with acute heart failure. However, there is limited evidence on the structure and staffing model of CICUs. The present study aimed to assess whether critical care for patients with acute heart failure in the ICUs is associated with improved outcomes than care in the high-dependency care units (HDUs), the hospital units in which patient care levels and costs are between the levels found in the ICU and general ward.MethodsThis nationwide, propensity score-matched, retrospective cohort study was performed using a national administrative inpatient database in Japan. We identified all patients who were hospitalized for acute heart failure and admitted to the ICU or HDU on the day of hospital admission from April 2014 to March 2019. Propensity score-matching analysis was performed to compare the in-hospital mortality between acute heart failure patients treated in the ICU and HDU on the day of hospital admission.ResultsOf 202,866 eligible patients, 78,646 (39%) and 124,220 (61%) were admitted to the ICU and HDU, respectively, on the day of admission. After propensity score matching, there was no statistically significant difference in in-hospital mortality between patients who were admitted to the ICU and HDU on the day of admission (10.7% vs. 11.4%; difference, - 0.6%; 95% confidence interval, - 1.5% to 0.2%). In the subgroup analyses, there was a statistically significant difference in in-hospital mortality between the ICU and HDU groups among patients receiving noninvasive ventilation (9.4% vs. 10.5%; difference, - 1.0%; 95% confidence interval, - 1.9% to - 0.1%) and patients receiving intubation (32.5% vs. 40.6%; difference, - 8.0%; 95% confidence interval, - 14.5% to - 1.5%). There were no statistically significant differences in other subgroup analyses.ConclusionsCritical care in ICUs was not associated with lower in-hospital mortality than critical care in HDUs among patients with acute heart failure. However, critical care in ICUs was associated with lower in-hospital mortality than critical care in HDUs among patients receiving noninvasive ventilation and intubation.
| S-EPMC8686245 | biostudies-literature
Project description:BackgroundThyroid hormones (TH) are crucial for cardiovascular homeostasis. Recent evidence suggests that acute cardiovascular conditions, particularly acute heart failure (AHF), significantly impair the thyroid axis. Our aim was to evaluate the association of thyroid function with cardiovascular parameters and short- and long-term clinical outcomes in AHF patients.MethodsWe performed a single-centre retrospective cohort study including patients hospitalized for AHF between January 2012 and December 2017. We used linear, logistic, and Cox proportional hazard regression models to analyse the association of thyroid-stimulating hormone (TSH) and free thyroxine (FT4) with inpatient cardiovascular parameters, in-hospital mortality, short-term adverse clinical outcomes, and long-term mortality. Two models were used: (1) unadjusted, and (2) adjusted for age and sex.ResultsOf the 235 patients included, 59% were female, and the mean age was 77.5 (SD 10.4) years. In the adjusted model, diastolic blood pressure was positively associated with TSH [β = 2.68 (0.27 to 5.09); p = 0.030]; left ventricle ejection fraction (LVEF) was negatively associated with FT4 [β = -24.85 (-47.87 to -1.82); p = 0.035]; and a nonsignificant trend for a positive association was found between 30-day all-cause mortality and FT4 [OR = 3.40 (0.90 to 12.83); p = 0.071]. Among euthyroid participants, higher FT4 levels were significantly associated with a higher odds of 30-day all-cause death [OR = 4.40 (1.06 to 18.16); p = 0.041]. Neither TSH nor FT4 levels were relevant predictors of long-term mortality in the adjusted model.ConclusionsThyroid function in AHF patients is associated with blood pressure and LVEF during hospitalization. FT4 might be useful as a biomarker of short-term adverse outcomes in these patients.
| S-EPMC8026290 | biostudies-literature