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Demystifying Smoker's Paradox: A Propensity Score-Weighted Analysis in Patients Hospitalized With Acute Heart Failure.

ABSTRACT: Background Smoker's paradox has been observed with several vascular disorders, yet there are limited data in patients with acute heart failure (HF). We examined the effects of smoking in patients with acute HF using data from a large multicenter registry. The objective was to determine if the design and analytic approach could explain the smoker's paradox in acute HF mortality. Methods and Results The data were sourced from the acute HF registry (Gulf CARE [Gulf Acute Heart Failure Registry]), a multicenter registry that recruited patients over 10 months admitted with a diagnosis of acute HF from 47 hospitals in 7 Middle Eastern countries. The association between smoking and mortality (in hospital) was examined using covariate adjustment, making use of mortality risk factors. A parallel analysis was performed using covariate balancing through propensity scores. Of 5005 patients hospitalized with acute HF, 1103 (22%) were current smokers. The in-hospital mortality rates were significantly lower in current smoker's before (odds ratio, 0.71; 95% CI, 0.52-0.96) and more so after (odds ratio, 0.47; 95% CI, 0.31-0.70) covariate adjustment. With the propensity score-derived covariate balance, the smoking effect became much less certain (odds ratio, 0.63; 95% CI, 0.36-1.11). Conclusions The current study illustrates the fact that the smoker's paradox is likely to be a result of residual confounding as covariate adjustment may not resolve this if there are many competing prognostic confounders. In this situation, propensity score methods for covariate balancing seem preferable. Clinical Trial Registration URL: https://www.clinicaltrials.gov/. Unique identifier: NCT01467973.

SUBMITTER: Doi SA

PROVIDER: S-EPMC6912958 | biostudies-literature | 2019 Dec

REPOSITORIES: biostudies-literature

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Demystifying Smoker's Paradox: A Propensity Score-Weighted Analysis in Patients Hospitalized With Acute Heart Failure.

Doi Suhail A SA Islam Nazmul N Sulaiman Kadhim K Alsheikh-Ali Alawi A AA Singh Rajvir R Al-Qahtani Awad A Asaad Nidal N AlHabib Khalid F KF Al-Zakwani Ibrahim I Al-Jarallah Mohammed M AlMahmeed Wael W Bulbanat Bassam B Bazargani Nooshin N Amin Haitham H Al-Motarreb Ahmed A AlFaleh Husam H Panduranga Prashanth P Shehab Abdulla A Al Suwaidi Jassim J Salam Amar M AM

Journal of the American Heart Association 20191129 23

Background Smoker's paradox has been observed with several vascular disorders, yet there are limited data in patients with acute heart failure (HF). We examined the effects of smoking in patients with acute HF using data from a large multicenter registry. The objective was to determine if the design and analytic approach could explain the smoker's paradox in acute HF mortality. Methods and Results The data were sourced from the acute HF registry (Gulf CARE [Gulf Acute Heart Failure Registry]), a ...[more]

PMID: 31779564

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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.

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.

Project description:BackgroundPatients with heart failure frequently present with kidney dysfunction. Kidney function is relevant, as prognosis declines with reduced kidney function and potentially beneficial drugs like levosimendan are contraindicated for missing safety data.Materials and methodsA single-center retrospective registry study was conducted including all patients receiving levosimendan on a medical intensive care unit between January 2010 and December 2019. Exclusion criteria were a follow-up less than 24 h or missing glomerular filtration rate (eGFR) before administration of levosimendan. The first course of treatment was evaluated. Patients were stratified by eGFR before drug administration and the primary endpoint was a composite of supraventricular-, ventricular tachycardia and death within 7 days after administration of levosimendan. An internal control group was created by propensity score matching.ResultsA total of 794 patients receiving levosimendan were screened and 368 unique patients were included. Patients were predominantly male (73.6%) and median age was 63 years. Patients were divided by eGFR into three groups: >60 ml/min/1.73 m2 (n = 110), 60-30 ml/min/1.73 m2 (n = 130), and <30 ml/min/1.73 m2 (n = 128). ICU survival was significantly lower in patients with lower eGFR (69.1, 57.7, and 50.8%, respectively, p = 0.016) and patients with lower eGFR were significantly older and had significantly more comorbidities. The primary combined endpoint was reached in 61.8, 63.1, and 69.5% of subjects, respectively (p = 0.396). A multivariate logistic regression model suggested only age (p < 0.020), extracorporeal membrane oxygenation (p < 0.001) or renal replacement therapy (p = 0.028) during day 1-7 independently predict the primary endpoint while kidney function did not (p = 0.835). A propensity score matching of patients with eGFR < 30 and >30 ml/min/1.73 m2 based on these predictors of outcome confirmed the primary endpoint (p = 0.886).ConclusionThe combined endpoint of supraventricular-, ventricular tachycardia and death within 7 days was reached at a similar rate in patients independently of kidney function. Prospective randomized trials are warranted to clarify if levosimendan can be used safely in severely reduced kidney function.

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.

Dataset Information

Demystifying Smoker's Paradox: A Propensity Score-Weighted Analysis in Patients Hospitalized With Acute Heart Failure.

Publications

Demystifying Smoker's Paradox: A Propensity Score-Weighted Analysis in Patients Hospitalized With Acute Heart Failure.

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